| Field | Data |
|---|---|
| Health Insurance Plan ID | 58883MO0010004 |
| Health Insurance Plan Year | 2022 |
| State | Missouri |
| Health Insurance Issuer | DSM USA Insurance Company, Inc. |
| Plan Marketing Materials URL | Marketing URL |
| Last Plan Update Date | Tue, 18 May 2021 00:00 GMT |
| Last Import Date | Sun, 24 Sep 2023 09:34 GMT |
| Health Insurance Plan Variant | 58883MO0010004-00 |
| Available Variants of the Health Plan | |
| 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 | 2022 |
| 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 | 58883MO001 |
| Import Date | 5/18/2021 1:00 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 58883 |
| Issuer Marketplace Marketing Name | DentaQuest Insurance Company-MO |
| 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 | $150 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 | $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 | Low |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MON001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Only. In excess of 50 miles from nearest provider. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 58883MO0010004-00 |
| Plan Marketing Name | DentaQuest PPO Family Low |
| Plan Type | PPO |
| Plan Variant Marketing Name | DentaQuest PPO Family Low |
| QHP/Non QHP | Both |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 58883MO0010004 |
| State Code | MO |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about DentaQuest PPO Family Low, 58883MO0010004 Health Insurance Plan, 58883MO0010004
Does DentaQuest PPO Family Low Health Insurance Plan, 58883MO0010004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58883MO0010004) Health Insurance Plan, Variant (58883MO0010004-00) have Out Of Country Coverage?
No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).
Does (58883MO0010004) Health Insurance Plan, Variant (58883MO0010004-00) have Out of Service Area Coverage?
Yes. Details: Emergency Only. In excess of 50 miles from nearest provider.
Disclaimer: This is based on the import(Date: Sun, 24 Sep 2023 09:34 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