EssentialSmil411 - 33626TX0010001 Health Insurance Plan
Solstice Healthplans of Texas, Inc. health insurance plan with the Plan ID 33626TX0010001. The plan is called EssentialSmil411.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 84.50% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 15.50% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 33626TX0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Solstice Healthplans of Texas, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 33626TX0010001-00 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 21 Jul 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of EssentialSmil411 Health Insurance Plan, 33626TX0010001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Includes Coverage for White Fillings, Deep Cleanings, Extractions and Other Minor Restorative Procedures |
YES | $56.00 |
100.00% |
| Basic Dental Care - Child
|
YES | $56.00 |
100.00% |
| Dental Check-Up for Children
|
YES | No Charge |
100.00% |
| Major Dental Care - Adult
Includes Coverage for Crowns, Bridges, Dentures, Root Canals and Surgical Implants |
YES | $260.00 |
100.00% |
| Major Dental Care - Child
|
YES | $350.00 |
100.00% |
| Orthodontia - Adult
|
YES | $3,700.00 |
100.00% |
| Orthodontia - Child
|
YES | $350.00 |
100.00% |
| Routine Dental Services (Adult)
Includes Coverage For Routine Cleanings, Exams, Fluoride, Sealants and X-Rays |
YES | $10.00 |
100.00% |
EssentialSmil411 Health Insurance Plan Variant 33626TX0010001-00 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 | 33626TX001 |
| Import Date | 7/21/2022 1:01 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 84.50% |
| Issuer ID | 33626 |
| Issuer Marketplace Marketing Name | Solstice Healthplans of Texas, Inc. |
| 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 | 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 | $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 | No |
| Network ID | TXN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Only for palliative care where a network provider is not available. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 33626TX0010001-00 |
| Plan Marketing Name | EssentialSmil411 |
| Plan Type | EPO |
| Plan Variant Marketing Name | EssentialSmil411 |
| QHP/Non QHP | Both |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 33626TX0010001 |
| State Code | TX |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
Copay & Coinsurance of EssentialSmil411 Health Insurance Plan, 33626TX0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about EssentialSmil411, 33626TX0010001 Health Insurance Plan, 33626TX0010001
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Does EssentialSmil411 Health Insurance Plan, 33626TX0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33626TX0010001) Health Insurance Plan, Variant (33626TX0010001-00) have Out Of Country Coverage?
Does (33626TX0010001) Health Insurance Plan, Variant (33626TX0010001-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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