Choice Bronze HSA + Vision + Adult Dental

Ambetter from NH Healthy Families

Expanded BronzeHSA eligible

Ind. deductible: $7,250
Family deductible: $7,250
Ind. OOP max: $7,250
Family OOP max: $7,250

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Bronze Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$322	—
30	$365	—
40	$411	—
50	$575	—
60	$873	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	No Charge after deductible

Specialist

Benefit	In-network
Specialist Visit	No Charge after deductible

Hospital

Benefit	In-network
Emergency Room Services	No Charge after deductible
Substance Use Disorder Urgent Care	No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	No Charge after deductible
Mental/Behavioral Health Emergency Room	No Charge after deductible
Mental/Behavioral Health Urgent Care	No Charge after deductible
Outpatient Surgery Physician/Surgical Services	No Charge after deductible
Substance Use Disorder Emergency Room	$0.00
Urgent Care Centers or Facilities	No Charge after deductible

Pharmacy

Benefit	In-network
Generic Drugs	No Charge after deductible
Non-Preferred Brand Drugs	No Charge after deductible
Preferred Brand Drugs	$0.00
Specialty Drugs	No Charge after deductible
Tier 1b Generic Drugs	No Charge after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Emergency Transportation/Ambulance	No Charge after deductible
Mental/Behavioral Health ER Physician Fee	No Charge after deductible
Mental/Behavioral Health Inpatient Services	No Charge after deductible
Mental/Behavioral Health Outpatient Other Services	No Charge after deductible
Mental/Behavioral Health Outpatient Services	No Charge after deductible
Substance Use Disorder Emergency Transportation/Ambulance	No Charge after deductible
Substance Use Disorder ER Physician Fee	No Charge after deductible
Substance Use Disorder Outpatient Other Services	No Charge after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	No Charge after deductible
Acupuncture	No Charge after deductible
Allergy Testing	No Charge after deductible
Bariatric Surgery	$0.00
Basic Dental Care - Adult	50.00%
Basic Dental Care - Child	Not covered
Chemotherapy	No Charge after deductible
Chiropractic Care	No Charge after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	$0.00
Dental Check-Up for Children	Not covered
Diabetes Education	No Charge after deductible
Dialysis	No Charge after deductible
Durable Medical Equipment	No Charge after deductible
Emergency Transportation/Ambulance	No Charge after deductible
Eye Glasses for Children	No charge
Habilitation Services	$0.00
Hearing Aids	$0.00
Home Health Care Services	No Charge after deductible
Hospice Services	No Charge after deductible
Imaging (CT/PET Scans, MRIs)	$0.00
Infertility Treatment	$0.00
Infusion Therapy	No Charge after deductible
Inpatient Physician and Surgical Services	No Charge after deductible
Laboratory Outpatient and Professional Services	No Charge after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	50.00%
Major Dental Care - Child	Not covered
Nutritional Counseling	No Charge after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	No Charge after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	No Charge after deductible
Outpatient Rehabilitation Services	No Charge after deductible
Prenatal and Postnatal Care	No Charge after deductible
Private-Duty Nursing	Not covered
Prosthetic Devices	No Charge after deductible
Radiation	No Charge after deductible
Reconstructive Surgery	No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$0.00
Rehabilitative Speech Therapy	No Charge after deductible
Routine Dental Services (Adult)	$0.00
Routine Eye Exam (Adult)	No charge
Routine Eye Exam for Children	No charge
Routine Foot Care	No Charge after deductible
Skilled Nursing Facility	No Charge after deductible
Substance Abuse Disorder Inpatient Services	No Charge after deductible
Substance Abuse Disorder Outpatient Services	$0.00
Transplant	$0.00
Treatment for Temporomandibular Joint Disorders	No Charge after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	No Charge after deductible

Plan rules

Service area

This plan covers 1 geographic area.