Choice PPO Preventive - 66759NC0010004 Health Insurance Plan

Dominion Dental Services, Inc. health insurance plan with the Plan ID 66759NC0010004. The plan is called Choice PPO Preventive.

Health Insurance Plan ID 66759NC0010004
Health Insurance Plan Year 2024
State North Carolina
Health Insurance Issuer Dominion Dental Services, Inc.
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 66759NC0010004-00
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 North Carolina 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 - 66759NC0010004-00

Standard On Exchange Plan - 66759NC0010004-01

Last Plan Update Date Thu, 02 Nov 2023 00:00 GMT
Last Import Date Thu, 21 Nov 2024 00:44 GMT

Benefits of Choice PPO Preventive Health Insurance Plan, 66759NC0010004-00

Benefit Covered In Network Out Of Network
Accidental Dental
YES

0.00% Coinsurance after deductible

 20.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

65.00% Coinsurance after deductible

 80.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Benefit Period

YES

100.00%

 80.00%
Major Dental Care - Adult
NO
Major Dental Care - Child
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)

Subject to deductible of $50/individual and $150/three or more adults. Benefit limitations may apply to individual services.

YES

0.00% Coinsurance after deductible

 20.00% Coinsurance after deductible

Choice PPO Preventive Health Insurance Plan Variant 66759NC0010004-00 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 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Low Off Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1.0
First Tier Utilization 100%
HIOS Product ID 66759NC001
Import Date 2023-11-02 01:01:23
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 66759
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 NCN001
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) 66759NC0010004-00
Plan Marketing Name Choice PPO Preventive
Plan Type PPO
Plan Variant Marketing Name Choice PPO Preventive
QHP/Non QHP Both
Service Area ID NCS001
Source Name HIOS
Plan ID 66759NC0010004
State Code NC

Copay & Coinsurance of Choice PPO Preventive Health Insurance Plan, 66759NC0010004

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

Frequently Asked Questions(FAQ) about Choice PPO Preventive, 66759NC0010004 Health Insurance Plan, 66759NC0010004

  • Does Choice PPO Preventive Health Insurance Plan, 66759NC0010004 support Mail Ordering?

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

    • Does (66759NC0010004) Health Insurance Plan, Variant (66759NC0010004-00) have Out Of Country Coverage?

    Yes. Details: Standard Out of Network PPO Benefits

    Does (66759NC0010004) Health Insurance Plan, Variant (66759NC0010004-00) have Out of Service Area Coverage?

    Yes. Details: Standard Out of Network PPO Benefits

 

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