Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/22

HMO - OFF EXCHANGE with Dental SOB SBC
ElevateHealth HMO Gold 1500 MD0000100279
ElevateHealth HMO Silver 3500 MD0000100282
ElevateHealth HMO Silver 4000 MD0000100284
ElevateHealth HMO Silver 5500 MD0000100286
ElevateHealth HMO Silver 6500 MD0000100288
ElevateHealth HMO Bronze 6500 MD0000100289
ElevateHealth HMO Bronze 7200 MD0000100290
ElevateHealth HMO Bronze 8700 MD0000100291
ElevateHealth HMO HSA Silver 4500 MD0000100294
ElevateHealth HMO HSA Bronze 7000 MD0000100295
ElevateHealth Options HMO Gold 1000 MD0000100296
ElevateHealth Options HMO Silver 3000 MD0000100298
ElevateHealth Options HMO Gold 500 MD0000100300
HMO - OFF EXCHANGE without Dental SOB SBC
ElevateHealth HMO Gold 1500 MD0000100279
ElevateHealth HMO Silver 3500 MD0000100281
ElevateHealth HMO Silver 4000 MD0000100283
ElevateHealth HMO Silver 5500 MD0000100285
ElevateHealth HMO Silver 6500 MD0000100287
ElevateHealth HMO Bronze 6500 MD0000100289
ElevateHealth HMO Bronze 7200 MD0000100290
ElevateHealth HMO Bronze 8700 MD0000100291
ElevateHealth HMO Catastrophic MD0000100292
ElevateHealth HMO HSA Silver 4500 MD0000100293
ElevateHealth HMO HSA Bronze 7000 MD0000100295
ElevateHealth Options HMO Gold 1000 MD0000100296
ElevateHealth Options HMO Silver 3000 MD0000100298
ElevateHealth Options HMO Gold 500 MD0000100300
HMO - ON EXCHANGE without Dental SOB SBC
ElevateHealth HMO Gold 1500 MD0000100279
ElevateHealth HMO Silver 3500 MD0000100281
ElevateHealth HMO Silver 4000 MD0000100283
ElevateHealth HMO Silver 5500 MD0000100285
ElevateHealth HMO Silver 6500 MD0000100287
ElevateHealth HMO Bronze 6500 MD0000100289
ElevateHealth HMO Bronze 7200 MD0000100290
ElevateHealth HMO Bronze 8700 MD0000100291
ElevateHealth HMO Catastrophic MD0000100292
ElevateHealth HMO HSA Silver 4500 MD0000100293
ElevateHealth HMO HSA Bronze 7000 MD0000100295
HMO - ON EXCHANGE without Dental - AI/AN - Limited SOB SBC
ElevateHealth HMO Gold 1500 MD0000100279
ElevateHealth HMO Silver 3500 MD0000100281
ElevateHealth HMO Silver 4000 MD0000100283
ElevateHealth HMO Silver 5500 MD0000100285
ElevateHealth HMO Silver 6500 MD0000100287
ElevateHealth HMO Bronze 6500 MD0000100289
ElevateHealth HMO Bronze 7200 MD0000100290
ElevateHealth HMO Bronze 8700 MD0000100291
ElevateHealth HMO HSA Silver 4500 MD0000100293
ElevateHealth HMO HSA Bronze 7000 MD0000100295
HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
ElevateHealth HMO MD0000100280
HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
ElevateHealth HMO Silver 4500 MD0000100304
ElevateHealth HMO Silver 3500 MD0000100307
ElevateHealth HMO Silver 4000 MD0000100310
ElevateHealth HMO Silver 5500 MD0000100313
ElevateHealth HMO Silver 6500 MD0000100316
HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
ElevateHealth HMO Silver 4500 MD0000100305
ElevateHealth HMO Silver 3500 MD0000100308
ElevateHealth HMO Silver 4000 MD0000100311
ElevateHealth HMO Silver 5500 MD0000100314
ElevateHealth HMO Silver 6500 MD0000100317
HMO - ON EXCHANGE without Dental - CSR - 94% SOB SBC
ElevateHealth HMO Silver 4500 MD0000100306
ElevateHealth HMO Silver 3500 MD0000100309
ElevateHealth HMO Silver 4000 MD0000100312
ElevateHealth HMO Silver 5500 MD0000100315
ElevateHealth HMO Silver 6500 MD0000100318