Select Plan Basic Kids - 54965VA0020001 Health Insurance Plan

Dominion National health insurance plan with the Plan ID 54965VA0020001. The plan is called Select Plan Basic Kids.

Health Insurance Plan ID

54965VA0020001

Health Insurance Plan Year

2023

State

Virginia

Health Insurance Issuer

Dominion National

Plan Marketing Materials URL

Marketing URL

Health Insurance Plan Variant

54965VA0020001-00

Provider Network(s)

['VAN001']

In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT).

Providers	Virginia	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 - 54965VA0020001-00

Standard On Exchange Plan - 54965VA0020001-01

Last Plan Update Date

Thu, 15 Sep 2022 00:00 GMT

Last Import Date

Tue, 16 Apr 2024 06:19 GMT

Benefits of Select Plan Basic Kids Health Insurance Plan, 54965VA0020001-00

Benefit	Covered	In Network	Out Of Network
Accidental Dental	YES	38.00%	100.00%
Basic Dental Care - Adult	NO
Basic Dental Care - Child Benefit limitations may apply to individual services. Max Out of Pocket is $375 per child up to $750 per family	YES	38.00%	100.00%
Dental Check-Up for Children Limit: 1.0 Visit(s) per 6 Months 1 per 6 months Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208.	YES	$10.00	100.00%
Major Dental Care - Adult	NO
Major Dental Care - Child Benefit limitations may apply to individual services.	YES	50.00%	100.00%
Orthodontia - Adult	NO
Orthodontia - Child Limit: 1.0 Treatment(s) per Lifetime Limit applies to one comprehensive orthodontic treatment of the adolescent dentition. Orthodontia services are only provided for severe, dysfunctional, handicapping maloclussion.	YES	$375.00	100.00%
Routine Dental Services (Adult)	NO

Select Plan Basic Kids Health Insurance Plan Variant 54965VA0020001-00 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 Low Off Exchange Plan
Dental Only Plan	Yes
EHB Apportionment for Pediatric Dental	1
First Tier Utilization	100%
HIOS Product ID	54965VA002
Import Date	9/15/2022 20:01
Inpatient Copayment Maximum Days	0
Guaranteed Rate	Guaranteed Rate
New/Existing Plan	Existing
Issuer ID	54965
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	VAN001
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)	54965VA0020001-00
Plan Level Exclusions	Co-insurance equivalent percentages displayed except for orthodontic services; copay for orthodontic services will not equal more than out of pocket maximum. Discount provided for non-medically necessary orthodontia. Must choose participating Select Plan dentist.
Plan Marketing Name	Select Plan Basic Kids
Plan Type	EPO
Plan Variant Marketing Name	Select Plan Basic Kids
QHP/Non QHP	Both
Service Area ID	VAS001
Source Name	SERFF
Plan ID	54965VA0020001
State Code	VA

Copay & Coinsurance of Select Plan Basic Kids Health Insurance Plan, 54965VA0020001

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

Frequently Asked Questions(FAQ) about Select Plan Basic Kids, 54965VA0020001 Health Insurance Plan, 54965VA0020001

Does Select Plan Basic Kids Health Insurance Plan, 54965VA0020001 support Mail Ordering?

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

Does (54965VA0020001) Health Insurance Plan, Variant (54965VA0020001-00) have Out Of Country Coverage?

Yes. Details: Emergency pain treatment only if 50 miles away from home zip code, up to $100

Does (54965VA0020001) Health Insurance Plan, Variant (54965VA0020001-00) have Out of Service Area Coverage?