Choice PPO Plus - 65736WI0020003 Health Insurance Plan

Dominion Dental Services, Inc. health insurance plan with the Plan ID 65736WI0020003. The plan is called Choice PPO Plus.

Health Insurance Plan ID

65736WI0020003

Health Insurance Plan Year

2024

State

Wisconsin

Health Insurance Issuer

Dominion Dental Services, Inc.

Plan Marketing Materials URL

Marketing URL

Health Insurance Plan Variant

65736WI0020003-01

Provider Network(s)

CHOICE

In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT).

Providers	Wisconsin	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 - 65736WI0020003-00

Standard On Exchange Plan - 65736WI0020003-01

Last Plan Update Date

Wed, 01 Nov 2023 00:00 GMT

Last Import Date

Thu, 21 Nov 2024 00:44 GMT

Benefits of Choice PPO Plus Health Insurance Plan, 65736WI0020003-01

Benefit	Covered	In Network	Out Of Network
Accidental Dental	NO
Basic Dental Care - Adult Limit: 1.0 Procedure(s) per 2 Years	YES	50.00% Coinsurance after deductible	60.00% Coinsurance after deductible
Basic Dental Care - Child Benefit limitations may apply to individual services.	YES	65.00% Coinsurance after deductible	80.00% Coinsurance after deductible
Dental Check-Up for Children Limit: 2.0 Visit(s) per Year 2 visits per year Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208.	YES	0.00%	20.00%
Major Dental Care - Adult	NO
Major Dental Care - Child Benefit limitations may apply to individual services.	YES	75.00% Coinsurance after deductible	90.00% Coinsurance after deductible
Orthodontia - Adult	NO
Orthodontia - Child	YES	50.00% Coinsurance after deductible	70.00% Coinsurance after deductible
Routine Dental Services (Adult) Limit: 2.0 Visit(s) per Year	YES	0.00% Coinsurance after deductible	10.00% Coinsurance after deductible

Choice PPO Plus Health Insurance Plan Variant 65736WI0020003-01 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 Adult and 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	65736WI002
Import Date	2023-11-01 01:02:11
Inpatient Copayment Maximum Days	0
Guaranteed Rate	Guaranteed Rate
New/Existing Plan	New
Issuer ID	65736
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	$200 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person	$100 per person
Medical EHB Deductible, Combined In/Out of Network, Individual	$100
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	$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	WIN001
Out of Country Coverage	Yes
Out of Country Coverage Description	Standard Out of Network PPO Benefits
Out of Service Area Coverage	Yes
Out of Service Area Coverage Description	Standard Out of Network PPO Benefits
Plan Brochure	URL
Plan Effective Date	2024-01-01
Plan Expiration Date	2024-12-31
Plan ID (Standard Component ID with Variant)	65736WI0020003-01
Plan Level Exclusions	Out of Pocket Maximum applies to children only. Adults have separate deductible and plan payment maximum, refer to plan document for details.
Plan Marketing Name	Choice PPO Plus
Plan Type	PPO
Plan Variant Marketing Name	Choice PPO Plus
QHP/Non QHP	Both
Service Area ID	WIS001
Source Name	HIOS
Plan ID	65736WI0020003
State Code	WI

Copay & Coinsurance of Choice PPO Plus Health Insurance Plan, 65736WI0020003

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

Frequently Asked Questions(FAQ) about Choice PPO Plus, 65736WI0020003 Health Insurance Plan, 65736WI0020003

Does Choice PPO Plus Health Insurance Plan, 65736WI0020003 support Mail Ordering?

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

Does (65736WI0020003) Health Insurance Plan, Variant (65736WI0020003-01) have Out Of Country Coverage?

Yes. Details: Standard Out of Network PPO Benefits

Does (65736WI0020003) Health Insurance Plan, Variant (65736WI0020003-01) have Out of Service Area Coverage?