Schedules of Benefits and SBCs: Maine

Individual Market effective 1/1/21

HMO - OFF EXCHANGE with Dental SOB SBC
HMO Gold 1500 MD0000100117
HMO Bronze 7000 MD0000100119
HMO Bronze 8550 MD0000100120
HMO Catastrophic MD0000100121
HMO 5000 MD0000100122
HMO HSA Bronze 6000 MD0000100123
HMO Silver 3000 MD0000100124
Maine's Choice PlusSM HMO HSA Bronze 6000 MD0000100129
Maine's Choice PlusSM HMO Gold 1200 MD0000100131
HMO HSA 3000 MD0000100133
HMO 1000 MD0000100134
Maine's Choice PlusSM HMO Silver 2700 MD0000100175
Maine's Choice PlusSM HMO Silver 4800 MD0000100180
Maine's Choice PlusSM HMO Silver 6500 MD0000100185
HMO - OFF EXCHANGE without Dental SOB SBC
HMO Gold 1500 MD0000100117
HMO Bronze 7000 MD0000100119
HMO Bronze 8550 MD0000100120
HMO Catastrophic MD0000100121
HMO 5000 MD0000100122
HMO HSA Bronze 6000 MD0000100123
HMO Silver 3000 MD0000100125
Maine's Choice PlusSM HMO HSA Bronze 6000 MD0000100129
Maine's Choice PlusSM HMO Gold 1200 MD0000100131
HMO HSA 3000 MD0000100133
HMO 1000 MD0000100134
Maine's Choice PlusSM HMO Silver 2700 MD0000100176
Maine's Choice PlusSM HMO Silver 4800 MD0000100181
Maine's Choice PlusSM HMO Silver 6500 MD0000100186
HMO - ON EXCHANGE without Dental SOB SBC
HMO Gold 1500 MD0000100117
HMO Bronze 7000 MD0000100119
HMO Bronze 8550 MD0000100120
HMO Catastrophic MD0000100121
HMO HSA Bronze 6000 MD0000100123
HMO Silver 3000 MD0000100125
Maine's Choice PlusSM HMO HSA Bronze 6000 MD0000100129
Maine's Choice PlusSM HMO Gold 1200 MD0000100131
Maine's Choice PlusSM HMO Silver 2700 MD0000100176
Maine's Choice PlusSM HMO Silver 4800 MD0000100181
Maine's Choice PlusSM HMO Silver 6500 MD0000100186
HMO - ON EXCHANGE without Dental - AI/AN - Limited SOB SBC
HMO Gold 1500 MD0000100117
HMO Bronze 7000 MD0000100119
HMO Bronze 8550 MD0000100120
HMO HSA Bronze 6000 MD0000100123
HMO Silver 3000 MD0000100125
Maine's Choice PlusSM HMO HSA Bronze 6000 MD0000100129
Maine's Choice PlusSM HMO Gold 1200 MD0000100131
Maine's Choice PlusSM HMO Silver 2700 MD0000100176
Maine's Choice PlusSM HMO Silver 4800 MD0000100181
Maine's Choice PlusSM HMO Silver 6500 MD0000100186
HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
HMO MD0000100118
HMO MD0000100118
HMO MD0000100118
HMO MD0000100118
HMO MD0000100118
Maine's Choice PlusSM HMO MD0000100130
Maine's Choice PlusSM HMO MD0000100130
Maine's Choice PlusSM HMO MD0000100130
Maine's Choice PlusSM HMO MD0000100130
Maine's Choice PlusSM HMO MD0000100130
HMO - ON EXCHANGE without Dental - CSR - 94% SOB SBC
HMO Silver 3000 CSR94 MD0000100126
Maine's Choice PlusSM HMO Silver 2700 CSR94 MD0000100177
Maine's Choice PlusSM HMO Silver 4800 CSR94 MD0000100182
Maine's Choice PlusSM HMO Silver 6500 CSR94 MD0000100187
HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
HMO Silver 3000 CSR87 MD0000100127
Maine's Choice PlusSM HMO Silver 2700 CSR87 MD0000100178
Maine's Choice PlusSM HMO Silver 4800 CSR87 MD0000100183
Maine's Choice PlusSM HMO Silver 6500 CSR87 MD0000100188
HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
HMO Silver 3000 CSR73 MD0000100128
Maine's Choice PlusSM HMO Silver 2700 CSR73 MD0000100179
Maine's Choice PlusSM HMO Silver 4800 CSR73 MD0000100184
Maine's Choice PlusSM HMO Silver 6500 CSR73 MD0000100189