Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible - 97176LA0390001 Health Insurance Plan

Louisiana Health Service & Indemnity Company health insurance plan with the Plan ID 97176LA0390001. The plan is called Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible.

Health Insurance Plan ID 97176LA0390001
Health Insurance Plan Year 2023
State Louisiana
Health Insurance Issuer Louisiana Health Service & Indemnity Company
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 97176LA0390001-00
Provider Network(s) ['LAN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Louisiana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 97176LA0390001-00

Standard On Exchange Plan - 97176LA0390001-01

Last Plan Update Date Fri, 16 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan, 97176LA0390001-00

Benefit Covered In Network Out Of Network
Accidental Dental

Emergency Palliative Treatment. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

20.00%

20.00%
Accidental Dental - Child

Emergency Palliative Treatment. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

No Charge

No Charge
Basic Dental Care - Adult

Amalgam Restorations (Metal Fillings) and Resin-Based Composite Restorations (White Fillings), Endodontics (6-month waiting period applies). Periodontics and Oral Surgery (12-month waiting period applies). OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Basic Dental Care - Child

Amalgam Restorations (Metal Fillings) and Resin-Based Composite Restorations (White Fillings), Endodontics, Periodontics, Oral Surgery, Adjustments and Repairs of Prosthodontics and Other Prosthodontic Services (including Relining and Rebasing of Dentures). No waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

One periodic, limited problem-focused, or comprehensive oral exam every 6 months. Oral cleanings (Prophylaxis) limited to one every 6 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

No Charge

No Charge
Major Dental Care - Adult

Inlays, Onlays and Crowns are limited to one per tooth every 60 months. 12-month waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Major Dental Care - Child

Inlays, Onlays and Crowns are limited to one per tooth every 60 months. Prosthetic Dentures are limited to one every 60 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult

Not Covered

NO
Orthodontia - Child

All orthodontic services require Authorization, a written plan of care, and must be rendered by a Provider. Orthodontic treatment must be considered medically necessary. Orthodontic services for cosmetic purposes are not covered. No waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Routine Dental Services (Adult)

Oral Cleanings (Prophylaxis) limited to two every 12 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. Two periodic or comprehensive oral exams every 12 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount.

YES

No Charge

No Charge

Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan Variant 97176LA0390001-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard High Off Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1
First Tier Utilization 100%
HIOS Product ID 97176LA039
Import Date 9/16/2022 1:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 97176
Issuer Marketplace Marketing Name Blue Cross and Blue Shield of Louisiana
Market Coverage Individual
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Not Applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Group per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person per person not applicable
Medical EHB Deductible, In Network (Tier 1), Individual $75
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group $700 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $350 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $350
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual Not Applicable
Metal Level High
Multiple In Network Tiers No
National Network Yes
Network ID LAN002
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Coverage available for covered benefits
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 97176LA0390001-00
Plan Marketing Name Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible
Plan Type PPO
Plan Variant Marketing Name Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible
QHP/Non QHP Both
Service Area ID LAS002
Source Name HIOS
Plan ID 97176LA0390001
State Code LA

Copay & Coinsurance of Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan, 97176LA0390001

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible, 97176LA0390001 Health Insurance Plan, 97176LA0390001

  • Does Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan, 97176LA0390001 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (97176LA0390001) Health Insurance Plan, Variant (97176LA0390001-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (97176LA0390001) Health Insurance Plan, Variant (97176LA0390001-00) have Out of Service Area Coverage?

    Yes. Details: Coverage available for covered benefits

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API