Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/21

HMO - OFF EXCHANGE with Dental SOB SBC
ElevateHealth HMO Gold 1500 MD0000100001
ElevateHealth HMO Silver 3500 MD0000100003
ElevateHealth HMO Silver 4000 MD0000100005
ElevateHealth HMO Silver 5000 MD0000100007
ElevateHealth HMO Silver 6300 MD0000100009
ElevateHealth HMO Bronze 6000 MD0000100011
ElevateHealth HMO Bronze 7200 MD0000100012
ElevateHealth HMO HSA Silver 3750 MD0000100014
ElevateHealth HMO HSA Bronze 6250 MD0000100016
ElevateHealth Options HMO Gold 1000 MD0000100017
ElevateHealth Options HMO Silver 3000 MD0000100038
ElevateHealth Options HMO Gold 500 MD0000100039
HMO - OFF EXCHANGE without Dental SOB SBC
ElevateHealth HMO Gold 1500 MD0000100001
ElevateHealth HMO Silver 3500 MD0000100004
ElevateHealth HMO Silver 4000 MD0000100006
ElevateHealth HMO Silver 5000 MD0000100008
ElevateHealth HMO Silver 6300 MD0000100010
ElevateHealth HMO Bronze 6000 MD0000100011
ElevateHealth HMO Bronze 7200 MD0000100012
ElevateHealth HMO Catastrophic MD0000100013
ElevateHealth HMO HSA Silver 3750 MD0000100015
ElevateHealth HMO HSA Bronze 6250 MD0000100016
ElevateHealth Options HMO Gold 1000 MD0000100017
ElevateHealth Options HMO Silver 3000 MD0000100019
ElevateHealth Options HMO Gold 500 MD0000100039
HMO - ON EXCHANGE without Dental SOB SBC
ElevateHealth HMO Gold 1500 MD0000100001
ElevateHealth HMO Silver 3500 MD0000100004
ElevateHealth HMO Silver 4000 MD0000100006
ElevateHealth HMO Silver 5000 MD0000100008
ElevateHealth HMO Silver 6300 MD0000100010
ElevateHealth HMO Bronze 6000 MD0000100011
ElevateHealth HMO Bronze 7200 MD0000100012
ElevateHealth HMO Catastrophic MD0000100013
ElevateHealth HMO HSA Silver 3750 MD0000100015
ElevateHealth HMO HSA Bronze 6250 MD0000100016
ElevateHealth Options HMO Gold 1000 MD0000100017
ElevateHealth Options HMO Silver 3000 MD0000100019
HMO - ON EXCHANGE without Dental - AI/AN - Limited SOB SBC
ElevateHealth HMO Gold 1500 MD0000100001
ElevateHealth HMO Silver 3500 MD0000100004
ElevateHealth HMO Silver 4000 MD0000100006
ElevateHealth HMO Silver 5000 MD0000100008
ElevateHealth HMO Silver 6300 MD0000100010
ElevateHealth HMO Bronze 6000 MD0000100011
ElevateHealth HMO Bronze 7200 MD0000100012
ElevateHealth HMO HSA Silver 3750 MD0000100015
ElevateHealth HMO HSA Bronze 6250 MD0000100016
ElevateHealth Options HMO Gold 1000 MD0000100017
ElevateHealth Options HMO Silver 3000 MD0000100019
HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth HMO MD0000100002
ElevateHealth Options HMO MD0000100018
ElevateHealth Options HMO MD0000100018
HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
ElevateHealth HMO Silver 3500 MD0000100020
ElevateHealth HMO Silver 4000 MD0000100023
ElevateHealth HMO Silver 5000 MD0000100026
ElevateHealth HMO Silver 6300 MD0000100029
ElevateHealth HMO Silver 3750 MD0000100032
ElevateHealth Options HMO Silver 3000 MD0000100035
HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
ElevateHealth HMO Silver 3500 MD0000100021
ElevateHealth HMO Silver 4000 MD0000100024
ElevateHealth HMO Silver 5000 MD0000100027
ElevateHealth HMO Silver 6300 MD0000100030
ElevateHealth HMO Silver 3750 MD0000100033
ElevateHealth Options HMO Silver 3000 MD0000100036
HMO - ON EXCHANGE without Dental - CSR - 94% SOB SBC
ElevateHealth HMO Silver 3500 MD0000100022
ElevateHealth HMO Silver 4000 MD0000100025
ElevateHealth HMO Silver 5000 MD0000100028
ElevateHealth HMO Silver 6300 MD0000100031
ElevateHealth HMO Silver 3750 MD0000100034
ElevateHealth Options HMO Silver 3000 MD0000100037