Choice PPO Premium Kids - 64357GA0010004 Health Insurance Plan

Dominion Dental Services, Inc. health insurance plan with the Plan ID 64357GA0010004. The plan is called Choice PPO Premium Kids.

Health Insurance Plan ID 64357GA0010004
Health Insurance Plan Year 2023
State Georgia
Health Insurance Issuer Dominion Dental Services, Inc.
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 64357GA0010004-00
Provider Network(s) ['GAN001']
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 Georgia 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 - 64357GA0010004-00

Standard On Exchange Plan - 64357GA0010004-01

Last Plan Update Date Fri, 19 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Choice PPO Premium Kids Health Insurance Plan, 64357GA0010004-00

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Limit: 60.0 Months per Procedure

Limitations applies to prefabricated crowns

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

0.00%

0.00%
Major Dental Care - Adult
NO
Major Dental Care - Child

Limit: 60.0 Months per Procedure

Limitations vary by procedure type

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Exclusions: Orthodontia require medical necessity

YES

$375.00, 50.00%

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO

Choice PPO Premium Kids Health Insurance Plan Variant 64357GA0010004-00 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 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 64357GA001
Import Date 8/19/2022 1:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 64357
Issuer Marketplace Marketing Name Dominion National
Market Coverage Individual
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group $750 per group
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person $375 per person
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out $375
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $100 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $50 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $50
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 Not Applicable
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 $750 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $375 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $375
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 GAN001
Out of Country Coverage Yes
Out of Country Coverage Description Standard Out of Network PPO Benefits
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Standard Out of Network PPO Benefits
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 64357GA0010004-00
Plan Marketing Name Choice PPO Premium Kids
Plan Type PPO
Plan Variant Marketing Name Choice PPO Premium Kids
QHP/Non QHP Both
Service Area ID GAS001
Source Name HIOS
Plan ID 64357GA0010004
State Code GA

Copay & Coinsurance of Choice PPO Premium Kids Health Insurance Plan, 64357GA0010004

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

Frequently Asked Questions(FAQ) about Choice PPO Premium Kids, 64357GA0010004 Health Insurance Plan, 64357GA0010004

  • Does Choice PPO Premium Kids Health Insurance Plan, 64357GA0010004 support Mail Ordering?

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

  • Does (64357GA0010004) Health Insurance Plan, Variant (64357GA0010004-00) have Out Of Country Coverage?

    Yes. Details: Standard Out of Network PPO Benefits

    Does (64357GA0010004) Health Insurance Plan, Variant (64357GA0010004-00) have Out of Service Area Coverage?

    Yes. Details: Standard Out of Network PPO 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