Delta Dental of South Dakota health insurance plan with the Plan ID 25868SD0010003. The plan is called Delta Dental Individual & Family Standard Plan.
Health Insurance Plan ID | 25868SD0010003 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | South Dakota | ||||||||||||||||||
Health Insurance Issuer | Delta Dental of South Dakota | ||||||||||||||||||
Health Insurance Plan Variant | 25868SD0010003-00 | ||||||||||||||||||
Provider Network(s) | ['SDN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Wed, 15 Jun 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
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Accidental Dental
|
NO | ||
Basic Dental Care - Adult
Annual Adult maximum benefit of $1,000 |
YES | No Charge after deductible, 40.00% Coinsurance after deductible |
No Charge after deductible, 40.00% Coinsurance after deductible |
Basic Dental Care - Child
|
YES | No Charge after deductible, 40.00% Coinsurance after deductible |
No Charge after deductible, 40.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | No Charge after deductible, No Charge after deductible |
No Charge after deductible, No Charge after deductible |
Major Dental Care - Adult
Annual Adult maximum benefit of $1,000 |
YES | No Charge after deductible, 60.00% Coinsurance after deductible |
No Charge after deductible, 60.00% Coinsurance after deductible |
Major Dental Care - Child
|
YES | No Charge after deductible, 60.00% Coinsurance after deductible |
No Charge after deductible, 60.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Limited to Medically Necessary |
YES | No Charge after deductible, 60.00% Coinsurance after deductible |
No Charge after deductible, 60.00% Coinsurance after deductible |
Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Annual Adult maximum benefit of $1,000 |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
No Charge after deductible, 0.00% Coinsurance after deductible |
Plan Attribute | Value |
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Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
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 |
First Tier Utilization | 100% |
HIOS Product ID | 25868SD001 |
Import Date | 6/15/2022 20:00 |
Inpatient Copayment Maximum Days | 0 |
Guaranteed Rate | Guaranteed Rate |
New/Existing Plan | Existing |
Issuer ID | 25868 |
Issuer Marketplace Marketing Name | Delta Dental of South Dakota |
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 | $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 | $100 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $100 |
Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Medical EHB Deductible, Out of Network, Family Per Person | $100 per person |
Medical EHB Deductible, Out of Network, Individual | $100 |
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 | Low |
Multiple In Network Tiers | No |
National Network | Yes |
Network ID | SDN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Care obtained form any Delta Dental Plan Association member company Premier or PPO provider is considered covered. The Delta Dental Plan Associaton has a nationwide Premier presence. |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 25868SD0010003-00 |
Plan Level Exclusions | EHB Pediatric coverage not available for anyone over the age of 18 |
Plan Marketing Name | Delta Dental Individual & Family Standard Plan |
Plan Type | Indemnity |
Plan Variant Marketing Name | Delta Dental Individual & Family Standard Plan |
QHP/Non QHP | Off the Exchange |
Service Area ID | SDS001 |
Source Name | SERFF |
Plan ID | 25868SD0010003 |
State Code | SD |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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