Delta Dental Individual Plan - 22384TN0030002 Health Insurance Plan
Delta Dental of Tennessee health insurance plan with the Plan ID 22384TN0030002. The plan is called Delta Dental Individual Plan.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 86.18% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 13.82% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 22384TN0030002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Tennessee | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental of Tennessee | ||||||||||||||||||
| Health Insurance Plan Variant | 22384TN0030002-00 | ||||||||||||||||||
| Provider Network(s) | ['TNN002'] | ||||||||||||||||||
| 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, 17 Jun 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Delta Dental Individual Plan Health Insurance Plan, 22384TN0030002-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Exclusions: See Summary of Benefits |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months Exclusions: See Summary of Benefits |
YES | No Charge, 0.00% |
0.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Exclusions: See Summary of Benefits |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: See Summary of Benefits |
YES | 50.00% |
50.00% |
| Routine Dental Services (Adult)
|
NO |
Delta Dental Individual Plan Health Insurance Plan Variant 22384TN0030002-00 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 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 | 22384TN003 |
| Import Date | 2024-06-17 20:36:40 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 86.18% |
| Issuer ID | 22384 |
| Issuer Marketplace Marketing Name | Delta Dental of Tennessee |
| 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 | $150 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $50 |
| 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 | $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 | High |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | TNN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Benefits allowed as 'Non-Participating' |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Benefits allowed as Delta Dental PPO or Non-Participating |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 22384TN0030002-00 |
| Plan Marketing Name | Delta Dental Individual Plan |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental Individual Plan |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | TNS002 |
| Source Name | HIOS |
| Plan ID | 22384TN0030002 |
| State Code | TN |
Copay & Coinsurance of Delta Dental Individual Plan Health Insurance Plan, 22384TN0030002
| 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 Individual Plan, 22384TN0030002 Health Insurance Plan, 22384TN0030002
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Does Delta Dental Individual Plan Health Insurance Plan, 22384TN0030002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (22384TN0030002) Health Insurance Plan, Variant (22384TN0030002-00) have Out Of Country Coverage?
Does (22384TN0030002) Health Insurance Plan, Variant (22384TN0030002-00) 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