Chorus Dental - Standard - 14630WI0020002 Health Insurance Plan
Chorus Community Health Plans health insurance plan with the Plan ID 14630WI0020002. The plan is called Chorus Dental - Standard.
| Health Insurance Plan ID | 14630WI0020002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Chorus Community Health Plans | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 14630WI0020002-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 07 Nov 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Chorus Dental - Standard Health Insurance Plan, 14630WI0020002-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Prior Authorization may be required for certain services. Balance billing may apply. Some exclusions apply, see contract for details. |
YES | 50.00% Coinsurance after deductible |
75.00% Coinsurance after deductible |
| Basic Dental Care - Adult
6 month waiting period applies. Prior Authorization may be required for certain services. Out-of-network providers may balance bill. Some exclusions apply, see contract for details. |
YES | 20.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Basic Dental Care - Child
Out-of-network providers may balance bill. Some exclusions apply, see contract for details. |
YES | 20.00% Coinsurance after deductible |
60.00% Coinsurance after deductible |
| Dental Check-Up for Children
2 visits per year |
YES | No Charge |
50.00% Coinsurance after deductible |
| Major Dental Care - Adult
12 month waiting period applies. Prior Authorization may be required for certain services. Out-of-network providers may balance bill. Some exclusions apply, see contract for details. |
YES | 50.00% Coinsurance after deductible |
75.00% Coinsurance after deductible |
| Major Dental Care - Child
Prior Authorization may be required for certain services. Out-of-network providers may balance bill. Some exclusions apply, see contract for details. |
YES | 50.00% Coinsurance after deductible |
75.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Medically necessary orthodontia coverage only. Prior Authorization required. Out-of-network providers may balance bill. Some exclusions apply, see contract for details. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
2 visits per year |
YES | No Charge |
50.00% Coinsurance after deductible |
Chorus Dental - Standard Health Insurance Plan Variant 14630WI0020002-00 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 |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 100% |
| HIOS Product ID | 14630WI002 |
| Import Date | 2024-11-07 00:02:00 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 14630 |
| Issuer Marketplace Marketing Name | Chorus Community Health Plans |
| 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 | $225 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $75 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $75 |
| Medical EHB Deductible, Out of Network, Family Per Group | $450 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $150 per person |
| Medical EHB Deductible, Out of Network, Individual | $150 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $375 |
| 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 | No |
| Network ID | WIN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Service coverage for general or emergent care. Balance billing may apply. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 14630WI0020002-00 |
| Plan Marketing Name | Chorus Dental - Standard |
| Plan Type | PPO |
| Plan Variant Marketing Name | Chorus Dental - Standard |
| QHP/Non QHP | Both |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Plan ID | 14630WI0020002 |
| State Code | WI |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of Chorus Dental - Standard Health Insurance Plan, 14630WI0020002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Chorus Dental - Standard, 14630WI0020002 Health Insurance Plan, 14630WI0020002
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Does Chorus Dental - Standard Health Insurance Plan, 14630WI0020002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14630WI0020002) Health Insurance Plan, Variant (14630WI0020002-00) have Out Of Country Coverage?
Does (14630WI0020002) Health Insurance Plan, Variant (14630WI0020002-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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