Delta Dental Family Low Plan - 87701NH0080001 Health Insurance Plan
Delta Dental Plan of New Hampshire, Inc. health insurance plan with the Plan ID 87701NH0080001. The plan is called Delta Dental Family Low Plan.
| Health Insurance Plan ID | 87701NH0080001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental Plan of New Hampshire, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 87701NH0080001-00 | ||||||||||||||||||
| Provider Network(s) | DELTA-DENTAL-PPO-AND-DELTA-DENTAL-PREMIER | ||||||||||||||||||
| 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, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Delta Dental Family Low Plan Health Insurance Plan, 87701NH0080001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Exclusions: For more detail, please refer to the Outline of Coverage and your plan documents Periodontal maintenance 4 times in 12 months; periodontal scaling and root planing once in 2 years; restorations once in 2 years per tooth; resin restorations on anterior teeth and the buccal surface of bicuspids only; anesthesia only in conjunction with covered services; stainless steel crowns once in 2 years per tooth. |
YES | $30.00 Copay after deductible, 40.00% Coinsurance after deductible |
$30.00 Copay after deductible, 40.00% Coinsurance after deductible |
| Basic Dental Care - Child
Exclusions: For more detail, please refer to the Outline of Coverage and your plan documents Periodontal maintenance 4 times in 12 months; periodontal scaling and root planing once in 2 years; restorations once in 2 years per tooth; resin restorations on anterior teeth and the buccal surface of bicuspids only; anesthesia only in conjunction with covered services; stainless steel crowns once in 2 years per tooth. |
YES | $30.00 Copay after deductible, 40.00% Coinsurance after deductible |
$30.00 Copay after deductible, 40.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months Exclusions: For more detail, please refer to the Outline of Benefits and your plan documents Cleanings once in 6 months, evaluations once in 6 months, bitewing images once in 6 months; complete series or panoramic image once in 5 years; full mouth debridement once in a lifetime. |
YES | $30.00, 0.00% |
$30.00, 0.00% |
| Major Dental Care - Adult
Exclusions: For more detail, please refer to the Outline of Coverage and your plan documents Root canal therapy once in 2 years; inlays, onlays and crowns over age 12 once in 5 years; dentures once in 5 years; periodontal surgery once in 3 years; implants over age 16 once in 5 years; occlusal guards over age 13 once in 12 months. |
YES | $30.00 Copay after deductible, 50.00% Coinsurance after deductible |
$30.00 Copay after deductible, 50.00% Coinsurance after deductible |
| Major Dental Care - Child
Exclusions: For more detail, please refer to the Outline of Coverage and your plan documents Root canal therapy once in 2 years; inlays, onlays and crowns over age 12 once in 5 years; dentures once in 5 years; periodontal surgery once in 3 years; implants over age 16 once in 5 years; occlusal guards over age 13 once in 12 months. |
YES | $30.00 Copay after deductible, 50.00% Coinsurance after deductible |
$30.00 Copay after deductible, 50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: For more detail, please refer to the Outline of Coverage and your plan documents Subject to medical necessity |
YES | No Charge, 50.00% |
No Charge, 50.00% |
| Routine Dental Services (Adult)
Limit: 1.0 Visit(s) per 6 Months Exclusions: For more detail, please refer to the Outline of Benefits and your plan documents Cleanings once in 6 months, evaluations once in 6 months, bitewing images once in 6 months; complete series or panoramic image once in 5 years; full mouth debridement once in a lifetime. |
YES | $30.00, 0.00% |
$30.00, 0.00% |
Delta Dental Family Low Plan Health Insurance Plan Variant 87701NH0080001-00 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 Low Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 0.9823 |
| First Tier Utilization | 100% |
| HIOS Product ID | 87701NH008 |
| Import Date | 2024-08-13 20:01:38 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 87701 |
| Issuer Marketplace Marketing Name | Northeast Delta Dental |
| 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 | $150 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $150 |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $150 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $150 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| 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 | $850 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $425 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $425 |
| 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 | NHN001 |
| 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 Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 87701NH0080001-00 |
| 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 | NHS001 |
| Source Name | SERFF |
| Plan ID | 87701NH0080001 |
| State Code | NH |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
Copay & Coinsurance of Delta Dental Family Low Plan Health Insurance Plan, 87701NH0080001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Delta Dental Family Low Plan, 87701NH0080001 Health Insurance Plan, 87701NH0080001
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Does Delta Dental Family Low Plan Health Insurance Plan, 87701NH0080001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87701NH0080001) Health Insurance Plan, Variant (87701NH0080001-00) have Out Of Country Coverage?
Does (87701NH0080001) Health Insurance Plan, Variant (87701NH0080001-00) 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