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Home > Members > NH 2019 Individual Market

Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/19

HMO - ON EXCHANGE without Dental SOB SBC
ElevateHealth HMO Silver 3500 MD0000004832
ElevateHealth HMO Gold 1500 MD0000004834
ElevateHealth HMO Silver 5000 MD0000004839
ElevateHealth HMO MD0000004848

HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
ElevateHealth HMO MD0000004833
ElevateHealth HMO MD0000004833
ElevateHealth HMO MD0000004833

HMO - ON EXCHANGE without Dental - AI/AN - LIMITED SOB SBC
ElevateHealth HMO Silver 3500 MD0000004832
ElevateHealth HMO Gold 1500 MD0000004834
ElevateHealth HMO Silver 5000 MD0000004839

HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
ElevateHealth HMO Silver 5000 MD0000004840
ElevateHealth HMO Silver 3500 MD0000004843

HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
ElevateHealth HMO Silver 5000 MD0000004841
ElevateHealth HMO Silver 3500 MD0000004844

HMO - ON EXCHANGE without Dental - CSR - 94% SOB SBC
ElevateHealth HMO Silver 5000 MD0000004842
ElevateHealth HMO Silver 3500 MD0000004845

HMO - OFF EXCHANGE with Dental SOB SBC
ElevateHealth HMO Silver 3500 MD0000004832
ElevateHealth HMO Gold 1500 MD0000004834
ElevateHealth HMO Silver 3250 MD0000004835
ElevateHealth HMO Silver 4750 MD0000004836
ElevateHealth Options HMO Gold 1000 MD0000004837
ElevateHealth Options HMO Silver 3000 MD0000004838
ElevateHealth HMO Silver 5000 MD0000004839
ElevateHealth HMO HSA Silver 3750 MD0000004846
ElevateHealth HMO Bronze 6000 MD0000004847

HMO - OFF EXCHANGE without Dental SOB SBC
ElevateHealth HMO Silver 3500 MD0000004832
ElevateHealth HMO Gold 1500 MD0000004834
ElevateHealth HMO Silver 3250 MD0000004835
ElevateHealth HMO Silver 4750 MD0000004836
ElevateHealth Options HMO Gold 1000 MD0000004837
ElevateHealth Options HMO Silver 3000 MD0000004838
ElevateHealth HMO Silver 5000 MD0000004839
ElevateHealth HMO HSA Silver 3750 MD0000004846
ElevateHealth HMO Bronze 6000 MD0000004847