Select Plan Premium Kids - 54965VA0020005 Health Insurance Plan

Dominion National health insurance plan with the Plan ID 54965VA0020005. The plan is called Select Plan Premium Kids.

Health Insurance Plan ID 54965VA0020005
Health Insurance Plan Year 2022
State Virginia
Health Insurance Issuer Dominion National
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 54965VA0020005-00
Provider Network(s) ['VAN001']
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 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 - 54965VA0020005-00

Standard On Exchange Plan - 54965VA0020005-01

Last Plan Update Date Mon, 16 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Select Plan Premium Kids Health Insurance Plan Variant 54965VA0020005-00 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 2022
Child-Only Offering Allows 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 54965VA002
Import Date 8/16/2021 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 High
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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 54965VA0020005-00
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 Premium Kids
Plan Type EPO
Plan Variant Marketing Name Select Plan Premium Kids
QHP/Non QHP Both
Service Area ID VAS001
Source Name SERFF
Plan ID 54965VA0020005
State Code VA

Copay & Coinsurance of Select Plan Premium Kids Health Insurance Plan, 54965VA0020005

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

Frequently Asked Questions(FAQ) about Select Plan Premium Kids, 54965VA0020005 Health Insurance Plan, 54965VA0020005

  • Does Select Plan Premium Kids Health Insurance Plan, 54965VA0020005 support Mail Ordering?

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

  • Does (54965VA0020005) Health Insurance Plan, Variant (54965VA0020005-00) have Out Of Country Coverage?

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

    Does (54965VA0020005) Health Insurance Plan, Variant (54965VA0020005-00) 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: 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