Choice PPO Premium - 15676MI0020002 Health Insurance Plan
Dominion Dental Services, Inc. health insurance plan with the Plan ID 15676MI0020002. The plan is called Choice PPO Premium.
| Health Insurance Plan ID | 15676MI0020002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Dominion Dental Services, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 15676MI0020002-01 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Tue, 15 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Choice PPO Premium Health Insurance Plan, 15676MI0020002-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Limit: 1.0 Procedure(s) per 2 Years |
YES | 20.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Basic Dental Care - Child
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | 0.00% |
20.00% |
| Major Dental Care - Adult
Limit: 84.0 Months per Procedure |
YES | 50.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Major Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year |
YES | 0.00% |
10.00% |
Choice PPO Premium Health Insurance Plan Variant 15676MI0020002-01 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 High On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 100% |
| HIOS Product ID | 15676MI002 |
| Import Date | 2023-08-15 20:02:25 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | New |
| Issuer ID | 15676 |
| 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 | $100 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $50 |
| 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 | High |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MIN001 |
| 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) | 15676MI0020002-01 |
| 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 Premium |
| Plan Type | PPO |
| Plan Variant Marketing Name | Choice PPO Premium |
| QHP/Non QHP | Both |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 15676MI0020002 |
| State Code | MI |
Copay & Coinsurance of Choice PPO Premium Health Insurance Plan, 15676MI0020002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Choice PPO Premium, 15676MI0020002 Health Insurance Plan, 15676MI0020002
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Does Choice PPO Premium Health Insurance Plan, 15676MI0020002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15676MI0020002) Health Insurance Plan, Variant (15676MI0020002-01) have Out Of Country Coverage?
Does (15676MI0020002) Health Insurance Plan, Variant (15676MI0020002-01) 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