Delta Dental Individual PPO, EHB Certified - 57874IN0040002 Health Insurance Plan

Renaissance Dental health insurance plan with the Plan ID 57874IN0040002. The plan is called Delta Dental Individual PPO, EHB Certified.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.21% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.79% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 57874IN0040002
Health Insurance Plan Year 2024
State Indiana
Health Insurance Issuer Renaissance Dental
Health Insurance Plan Variant 57874IN0040002-00
Provider Network(s) ['INN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT).

Providers Indiana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 57874IN0040002-00

Last Plan Update Date Thu, 07 Mar 2024 00:00 GMT
Last Import Date Thu, 21 Nov 2024 00:44 GMT

Benefits of Delta Dental Individual PPO, EHB Certified Health Insurance Plan, 57874IN0040002-00

Benefit Covered In Network Out Of Network
Accidental Dental

Exclusions: See Plan Brochure.

YES

Tier 1: 50.00%

Tier 2: 50.00%

50.00%
Basic Dental Care - Adult

Exclusions: See Plan Brochure.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Basic Dental Care - Child

Exclusions: See Plan Brochure.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Benefit Period

Exclusions: See Plan Brochure. X-Rays may be subject to deductible.

YES

Tier 1: 0.00%

Tier 2: 20.00%

20.00%
Major Dental Care - Adult

Exclusions: See Plan Brochure.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Major Dental Care - Child

Exclusions: See Plan Brochure.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Exclusions: Limited to medically necessary. See Plan Brochure.

YES

Tier 1: 50.00%

Tier 2: 50.00%

50.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Benefit Period

Exclusions: See Plan Brochure. X-Rays may be subject to deductible.

YES

Tier 1: 50.00%

Tier 2: 50.00%

50.00%

Delta Dental Individual PPO, EHB Certified Health Insurance Plan Variant 57874IN0040002-00 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 2024
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 1.0
First Tier Utilization 25%
HIOS Product ID 57874IN004
Import Date 2024-03-07 01:01:23
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer Actuarial Value 71.21%
Issuer ID 57874
Issuer Marketplace Marketing Name Renaissance 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 $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, In Network (Tier 2), Family Per Group per group not applicable
Medical EHB Deductible, In Network (Tier 2), Family Per Person per person not applicable
Medical EHB Deductible, In Network (Tier 2), 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 $800 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $400 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $400
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Group $800 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person $400 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Individual $400
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 Yes
National Network Yes
Network ID INN001
Out of Country Coverage Yes
Out of Country Coverage Description Benefits paid at the Out of Network Level
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Same Benefit Level
Plan Effective Date 2024-01-01
Plan ID (Standard Component ID with Variant) 57874IN0040002-00
Plan Marketing Name Delta Dental Individual PPO, EHB Certified
Plan Type PPO
Plan Variant Marketing Name Delta Dental Individual PPO, EHB Certified
QHP/Non QHP Off the Exchange
Second Tier Utilization 75%
Service Area ID INS001
Source Name HIOS
Plan ID 57874IN0040002
State Code IN

Copay & Coinsurance of Delta Dental Individual PPO, EHB Certified Health Insurance Plan, 57874IN0040002

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Delta Dental Individual PPO, EHB Certified, 57874IN0040002 Health Insurance Plan, 57874IN0040002

  • Does Delta Dental Individual PPO, EHB Certified Health Insurance Plan, 57874IN0040002 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (57874IN0040002) Health Insurance Plan, Variant (57874IN0040002-00) have Out Of Country Coverage?

    Yes. Details: Benefits paid at the Out of Network Level

    Does (57874IN0040002) Health Insurance Plan, Variant (57874IN0040002-00) have Out of Service Area Coverage?

    Yes. Details: Same Benefit Level

 

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