Blue Dental PPO Pediatric 80/50/50 - 15560MI0740001 Health Insurance Plan
Blue Cross Blue Shield of Michigan Mutual Insurance Company health insurance plan with the Plan ID 15560MI0740001. The plan is called Blue Dental PPO Pediatric 80/50/50.
| Health Insurance Plan ID | 15560MI0740001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Michigan Mutual Insurance Company | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 15560MI0740001-01 | ||||||||||||||||||
| Provider Network(s) | ['MIN007'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Blue Dental PPO Pediatric 80/50/50 Health Insurance Plan, 15560MI0740001-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Emergency palliative treatment for temporary pain relief. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 1.0 Procedure(s) per 3 Years Sealants - 1x per permanent molars, every 3 years. Fillings - 1x per 24 months for primary teeth, 1x per 48 months for permanent teeth. Periodontal maintenance - 3x per calendar year in combination with routine prohylaxis (cleaning). Simple extractions - 1x per lifetime. Root canals - 1x per lifetime per tooth. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 3.0 Procedure(s) per Year Prophylaxis (Cleaning) - 3x per calendar year. Exams - 2x per calendar year. Bitewing X-rays - One set (up to 4) per calendar year. Fluoride - 2x per calendar year. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 20.00% |
50.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Limit: 1.0 Procedure(s) per 2 Years Exclusions: Implants are not covered. Scaling and root planing - 1x per quadrant, per 24 months. Onlays, crowns, veneers - 1x every 60 months. Bridges and dentures - 1x every 84 months. Implants - not covered. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Routine Dental Services (Adult)
|
NO |
Blue Dental PPO Pediatric 80/50/50 Health Insurance Plan Variant 15560MI0740001-01 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 | 2024 |
| Child-Only Offering | Allows Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Low On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 100% |
| HIOS Product ID | 15560MI074 |
| Import Date | 2023-08-16 20:01:48 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 15560 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Michigan Mutual Insurance Company |
| 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 | $75 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $25 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $25 |
| Medical EHB Deductible, Out of Network, Family Per Group | $150 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Out of Network, Individual | $50 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $400 |
| 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 | Yes |
| Network ID | MIN007 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Any licensed dentist in the US can participate in the Tier 2 par per claim Blue Par Select arrangement. Similar to PPO, dentists accept Blue Cross' approved amount for covered services as payment in full, less deductible or any coinsurance. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 15560MI0740001-01 |
| Plan Marketing Name | Blue Dental PPO Pediatric 80/50/50 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Dental PPO Pediatric 80/50/50 |
| QHP/Non QHP | Both |
| Service Area ID | MIS004 |
| Source Name | SERFF |
| Plan ID | 15560MI0740001 |
| State Code | MI |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of Blue Dental PPO Pediatric 80/50/50 Health Insurance Plan, 15560MI0740001
| 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 PPO Pediatric 80/50/50, 15560MI0740001 Health Insurance Plan, 15560MI0740001
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Does Blue Dental PPO Pediatric 80/50/50 Health Insurance Plan, 15560MI0740001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15560MI0740001) Health Insurance Plan, Variant (15560MI0740001-01) have Out Of Country Coverage?
Does (15560MI0740001) Health Insurance Plan, Variant (15560MI0740001-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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