Chorus Dental - Essential - 14630WI0020003 Health Insurance Plan

Chorus Community Health Plans health insurance plan with the Plan ID 14630WI0020003. The plan is called Chorus Dental - Essential.

Health Insurance Plan ID 14630WI0020003
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer Chorus Community Health Plans
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 14630WI0020003-00
Provider Network(s) ['WIN002']
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 Wisconsin 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 - 14630WI0020003-00

Standard On Exchange Plan - 14630WI0020003-01

Last Plan Update Date Thu, 26 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Chorus Dental - Essential Health Insurance Plan, 14630WI0020003-00

Benefit Covered In Network Out Of Network
Accidental Dental

Prior Authorization may be required for certain services. Balance billing may apply. Some exclusions apply, see contract for details.

YES

50.00% Coinsurance after deductible

75.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Out-of-network providers may balance bill. Some exclusions apply, see contract for details.

YES

50.00% Coinsurance after deductible

60.00% Coinsurance after deductible
Dental Check-Up for Children

2 visits per year

YES

No Charge

50.00% Coinsurance after deductible
Major Dental Care - Adult
NO
Major Dental Care - Child

Prior Authorization may be required for certain services. Out-of-network providers may balance bill. Some exclusions apply, see contract for details.

YES

50.00% Coinsurance after deductible

75.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Medically necessary orthodontia coverage only. Prior Authorization required. Out-of-network providers may balance bill. Some exclusions apply, see contract for details.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Routine Dental Services (Adult)

2 visits per year

YES

No Charge

50.00% Coinsurance after deductible

Chorus Dental - Essential Health Insurance Plan Variant 14630WI0020003-00 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 Low Off Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1
First Tier Utilization 100%
HIOS Product ID 14630WI002
Import Date 1/26/2023 1:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan New
Issuer ID 14630
Issuer Marketplace Marketing Name Chorus Community Health Plans
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 $225 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $75 per person
Medical EHB Deductible, In Network (Tier 1), Individual $75
Medical EHB Deductible, Out of Network, Family Per Group $450 per group
Medical EHB Deductible, Out of Network, Family Per Person $150 per person
Medical EHB Deductible, Out of Network, Individual $150
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 Low
Multiple In Network Tiers No
National Network No
Network ID WIN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergency
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out of Service coverage for general or emergent care. Balance billing may apply.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 14630WI0020003-00
Plan Marketing Name Chorus Dental - Essential
Plan Type PPO
Plan Variant Marketing Name Chorus Dental - Essential
QHP/Non QHP Both
Service Area ID WIS002
Source Name HIOS
Plan ID 14630WI0020003
State Code WI
URL for Enrollment Payment URL

Copay & Coinsurance of Chorus Dental - Essential Health Insurance Plan, 14630WI0020003

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

Frequently Asked Questions(FAQ) about Chorus Dental - Essential, 14630WI0020003 Health Insurance Plan, 14630WI0020003

  • Does Chorus Dental - Essential Health Insurance Plan, 14630WI0020003 support Mail Ordering?

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

  • Does (14630WI0020003) Health Insurance Plan, Variant (14630WI0020003-00) have Out Of Country Coverage?

    Yes. Details: Emergency

    Does (14630WI0020003) Health Insurance Plan, Variant (14630WI0020003-00) have Out of Service Area Coverage?

    Yes. Details: Out of Service coverage for general or emergent care. Balance billing may apply.

 

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