Select Plan Basic - 67775DE0010004 Health Insurance Plan
Dominion Dental Services, Inc. health insurance plan with the Plan ID 67775DE0010004. The plan is called Select Plan Basic.
| Health Insurance Plan ID | 67775DE0010004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Delaware | ||||||||||||||||||
| Health Insurance Issuer | Dominion Dental Services, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 67775DE0010004-00 | ||||||||||||||||||
| Provider Network(s) | ['DEN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 18 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of Select Plan Basic Health Insurance Plan, 67775DE0010004-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Limit: 1.0 Procedure(s) per 2 Years |
YES | 30.00% |
100.00% |
| Basic Dental Care - Child
Limit: 1.0 Procedure(s) per 2 Years |
YES | 28.00% |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | $20.00 |
100.00% |
| Major Dental Care - Adult
Limit: 84.0 Months per Procedure |
YES | 43.00% |
100.00% |
| Major Dental Care - Child
Limit: 60.0 Months per Procedure |
YES | 39.00% |
100.00% |
| Orthodontia - Adult
Limit: 1.0 Treatment(s) per Lifetime |
YES | 54.00% |
100.00% |
| Orthodontia - Child
Orthodontia services are only provided for severe, dysfunctional, handicapping maloclussion. |
YES | $350.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year |
YES | $10.00 |
100.00% |
Select Plan Basic Health Insurance Plan Variant 67775DE0010004-00 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 | 67775DE001 |
| Import Date | 8/18/2022 20:01 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 67775 |
| Issuer Marketplace Marketing Name | Dominion National |
| 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 | $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 | DEN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency pain treatment only if 50 miles away from home ZIP code, up to $100 |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency pain treatment only if 50 miles away from home ZIP code, up to $100 |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 67775DE0010004-00 |
| Plan Level Exclusions | Out of Pocket Maximum applies to children only. Co-insurance equivalent percentages displayed. Discount provided for non-medically necessary orthodontia. Must choose participating Select Plan dentist. |
| Plan Marketing Name | Select Plan Basic |
| Plan Type | HMO |
| Plan Variant Marketing Name | Select Plan Basic |
| QHP/Non QHP | Both |
| Service Area ID | DES001 |
| Source Name | SERFF |
| Plan ID | 67775DE0010004 |
| State Code | DE |
Copay & Coinsurance of Select Plan Basic Health Insurance Plan, 67775DE0010004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select Plan Basic, 67775DE0010004 Health Insurance Plan, 67775DE0010004
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Does Select Plan Basic Health Insurance Plan, 67775DE0010004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (67775DE0010004) Health Insurance Plan, Variant (67775DE0010004-00) have Out Of Country Coverage?
Yes. Details: Emergency pain treatment only if 50 miles away from home ZIP code, up to $100
Does (67775DE0010004) Health Insurance Plan, Variant (67775DE0010004-00) have Out of Service Area Coverage?
Yes. Details: Emergency pain treatment only if 50 miles away from home ZIP code, up to $100
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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