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Home > Members > NH 2017 Individual Market

Schedules of Benefits and SBCs: New Hampshire

Individual Market effective 1/1/17

HMO - ON EXCHANGE without Dental SOB SBC
ElevateHealth Silver 3500 MD0000004175
ElevateHealth Gold HSA 1500 MD0000004176
ElevateHealth Bronze 5750 MD0000004177
ElevateHealth Silver HSA 3000 MD0000004178
ElevateHealth Bronze HSA 6300 MD0000004179
New Hampshire Network Gold 1000 MD0000004180
New Hampshire Network Silver 2500 MD0000004181
New Hampshire Network Bronze HSA 5100 MD0000004182

HMO - ON EXCHANGE without Dental - AI/AN - $0 SOB SBC
New Hampshire Network MD0000004194
New Hampshire Network MD0000004194
ElevateHealth MD0000004195
ElevateHealth MD0000004195
ElevateHealth MD0000004195
ElevateHealth MD0000004195
New Hampshire Network MD0000004196
ElevateHealth MD0000004197

HMO - ON EXCHANGE without Dental - AI/AN - LIMITED SOB SBC
ElevateHealth Silver 3500 MD0000004175
ElevateHealth Gold HSA 1500 MD0000004176
ElevateHealth Bronze 5750 MD0000004177
ElevateHealth Silver HSA 3000 MD0000004178
ElevateHealth Bronze HSA 6300 MD0000004179
New Hampshire Network Gold 1000 MD0000004180
New Hampshire Network Silver 2500 MD0000004181
New Hampshire Network Bronze HSA 5100 MD0000004182

HMO - ON EXCHANGE without Dental - CSR - 73% SOB SBC
ElevateHealth Silver 3000 MD0000004185
ElevateHealth Silver HSA 2500 MD0000004186
New Hampshire Network Silver 2250 MD0000004189

HMO - ON EXCHANGE without Dental - CSR - 87% SOB SBC
ElevateHealth Silver 1250 MD0000004183
ElevateHealth Silver HSA 750 MD0000004187
New Hampshire Network Silver 750 MD0000004190

HMO - ON EXCHANGE without Dental - CSR - 94% SOB SBC
ElevateHealth Silver 350 MD0000004184
ElevateHealth Silver HSA 200 MD0000004188
New Hampshire Network Silver 350 MD0000004191

HMO - OFF EXCHANGE with Dental SOB SBC
ElevateHealth Options Gold 1000 MD0000004202
ElevateHealth Options Silver 3000 MD0000004203
ElevateHealth Silver 3500 MD0000004175
ElevateHealth Gold HSA 1500 MD0000004176
ElevateHealth Bronze 5750 MD0000004177
ElevateHealth Silver HSA 3000 MD0000004178
ElevateHealth Bronze HSA 6300 MD0000004179
New Hampshire Network Gold 1000 MD0000004180
New Hampshire Network Silver 2500 MD0000004181
New Hampshire Network Bronze HSA 5100 MD0000004182

HMO - OFF EXCHANGE without Dental SOB SBC
ElevateHealth Options Gold 1000 MD0000004202
ElevateHealth Options Silver 3000 MD0000004203
ElevateHealth Silver 3500 MD0000004175
ElevateHealth Gold HSA 1500 MD0000004176
ElevateHealth Bronze 5750 MD0000004177
ElevateHealth Silver HSA 3000 MD0000004178
ElevateHealth Bronze HSA 6300 MD0000004179
New Hampshire Network Gold 1000 MD0000004180
New Hampshire Network Silver 2500 MD0000004181
New Hampshire Network Bronze HSA 5100 MD0000004182

HMO - OFF EXCHANGE without Dental - AI/AN - $0 PAP SOB SBC
New Hampshire Network MD0000004198
ElevateHealth MD0000004199

HMO - OFF EXCHANGE without Dental - CSR - 94% PAP SOB SBC
ElevateHealth Silver Premium Assistance Plan MD0000004192
New Hampshire Network Silver Premium Assistance Plan MD0000004193