Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible - 97176LA0400001 Health Insurance Plan
Louisiana Health Service & Indemnity Company health insurance plan with the Plan ID 97176LA0400001. The plan is called Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible.
| Health Insurance Plan ID | 97176LA0400001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Louisiana | ||||||||||||||||||
| Health Insurance Issuer | Louisiana Health Service & Indemnity Company | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 97176LA0400001-00 | ||||||||||||||||||
| Provider Network(s) | NOT-APPLICABLE | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 11 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan, 97176LA0400001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Emergency Palliative Treatment. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | 20.00% |
20.00% |
| Accidental Dental - Child
Emergency Palliative Treatment. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | No Charge |
No Charge |
| Basic Dental Care - Adult
Amalgam Restorations (Metal Fillings) (6-month waiting period applies) and Resin-Based Composite Restorations (White Fillings) (6-month waiting period applies), Endodontics (6-month waiting period applies). Periodontics and Oral Surgery (12-month waiting period applies). OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Child
Amalgam Restorations (Metal Fillings) and Resin-Based Composite Restorations (White Fillings), Endodontics, Periodontics, Oral Surgery, Adjustments and Repairs of Prosthodontics and Other Prosthodontic Services (including Relining and Rebasing of Dentures). No waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months One periodic, limited problem-focused, or comprehensive oral exam every 6 months. Oral cleanings (Prophylaxis) limited to one every 6 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | No Charge |
No Charge |
| Major Dental Care - Adult
Inlays, Onlays and Crowns are limited to one per tooth every 60 months. Prosthetic Dentures are limited to one every 60 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Major Dental Care - Child
Inlays, Onlays and Crowns are limited to one per tooth every 60 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
Not Covered |
NO | ||
| Orthodontia - Child
All orthodontic services require Authorization, a written plan of care, and must be rendered by a Provider. Orthodontic treatment must be considered medically necessary. Orthodontic services for cosmetic purposes are not covered. No waiting period applies. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Oral Cleanings (Prophylaxis) limited to two every 12 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. Two periodic or comprehensive oral exams every 12 months. OON coinsurance, member is responsible for any difference between the charge and the paid amount. |
YES | No Charge |
No Charge |
Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan Variant 97176LA0400001-00 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 | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 97176LA040 |
| Import Date | 2024-09-11 01:01:35 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 97176 |
| Issuer Marketplace Marketing Name | Blue Cross and Blue Shield of Louisiana |
| Market Coverage | SHOP (Small Group) |
| 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 | $75 |
| 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 | Yes |
| Network ID | LAN003 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage available for covered benefits |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 97176LA0400001-00 |
| Plan Marketing Name | Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | LAS022 |
| Source Name | HIOS |
| Plan ID | 97176LA0400001 |
| State Code | LA |
Copay & Coinsurance of Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan, 97176LA0400001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible, 97176LA0400001 Health Insurance Plan, 97176LA0400001
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Does Blue Dental Essential Certified- $1,000 Annual Benefit Maximum per Adult, 100%/50%/50% coinsurance, $75 deductible Health Insurance Plan, 97176LA0400001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (97176LA0400001) Health Insurance Plan, Variant (97176LA0400001-00) have Out Of Country Coverage?
Does (97176LA0400001) Health Insurance Plan, Variant (97176LA0400001-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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