Delta Dental Family Low Plan - 50165ME0170001 Health Insurance Plan
50165 health insurance plan with the Plan ID 50165ME0170001. The plan is called Delta Dental Family Low Plan.
| Health Insurance Plan ID | 50165ME0170001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Maine | ||||||||||||||||||
| Health Insurance Issuer | 50165 | ||||||||||||||||||
| Health Insurance Plan Variant | 50165ME0170001-01 | ||||||||||||||||||
| Provider Network(s) | ['MEN001'] | ||||||||||||||||||
| 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 | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Delta Dental Family Low Plan Health Insurance Plan Variant 50165ME0170001-01 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | 99.35% |
| First Tier Utilization | 100% |
| HIOS Product ID | 50165ME017 |
| Import Date | 2/12/2024 |
| Guaranteed Rate | Guaranteed Rate |
| IsItANewPlan | Existing |
| Issuer ID | 50165 |
| Market Coverage | Individual |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family | $150 per person | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $150 |
| Medical EHB Deductible, In Network (Tier 1), Family | $150 per person | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | $150 |
| Medical EHB Deductible, Out of Network, Family | $150 per person | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | $150 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $400 per person | $800 per group |
| 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 person not applicable | per group 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 | MEN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Same Coverage |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Same Coverage |
| Plan Effective Date | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 50165ME0170001-01 |
| Plan Level Exclusions | Many covered services, including but not limited to oral evaluations, x-rays, cleanings, fluoride treatments, sealants, restorations, periodontal treatment and surgery, tissue conditioning, crowns, inlays, onlays, dentures, implants, and root canal therapy, are subject to age, time, and frequency limitations. Covered services containing time and frequency limitations are available for more frequent treatment for pediatric enrollees with prior authorization. Medically necessary orthodontia is a covered benefit for pediatric enrollees only. Certain covered services apply to treatment for specified teeth. Certain procedures performed on the same date by the same dentist are not separately chargeable by the dentist. Certain covered services are considered part of the complete treatment and not separately chargeable by the dentist. Many dental repairs, replacements, and retreatments are time limited and not separately chargeable by the dentist. Other exclusions and limitations may apply. Please refer to your Policy for details. |
| Plan Marketing Name | Delta Dental Family Low Plan |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental Family Low Plan |
| QHP/Non QHP | Both |
| Service Area ID | MES001 |
| Source Name | SERFF |
| Plan ID | 50165ME0170001 |
| State Code | ME |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Delta Dental Family Low Plan Health Insurance Plan, 50165ME0170001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Delta Dental Family Low Plan, 50165ME0170001 Health Insurance Plan, 50165ME0170001
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Does Delta Dental Family Low Plan Health Insurance Plan, 50165ME0170001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (50165ME0170001) Health Insurance Plan, Variant (50165ME0170001-01) have Out Of Country Coverage?
Does (50165ME0170001) Health Insurance Plan, Variant (50165ME0170001-01) 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