Delta Dental Individual PPO Gold Plan, EHB Certified - 28856IN0160001 Health Insurance Plan
Delta Dental Plan of Indiana, Inc. health insurance plan with the Plan ID 28856IN0160001. The plan is called Delta Dental Individual PPO Gold Plan, EHB Certified.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 86.26% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 13.74% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 28856IN0160001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental Plan of Indiana, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 28856IN0160001-00 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 12 Sep 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Delta Dental Individual PPO Gold Plan, EHB Certified Health Insurance Plan, 28856IN0160001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Exclusions: See Plan Brochure. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
0.00% |
| Basic Dental Care - Adult
Exclusions: These services may be subject to a waiting period. See Plan Brochure for additional information. |
YES | Tier 1: 20% Coinsurance after deductible Tier 2: 40% Coinsurance after deductible |
40% Coinsurance after deductible |
| Basic Dental Care - Child
Exclusions: See Plan Brochure. |
YES | Tier 1: 20% Coinsurance after deductible Tier 2: 40% Coinsurance after deductible |
40% 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: 0.00% |
0.00% |
| Major Dental Care - Adult
Exclusions: These services may be subject to a waiting period. See Plan Brochure for additional information. |
YES | Tier 1: 50% Coinsurance after deductible Tier 2: 50% Coinsurance after deductible |
50% Coinsurance after deductible |
| Major Dental Care - Child
Exclusions: See Plan Brochure. |
YES | Tier 1: 50% Coinsurance after deductible Tier 2: 50% Coinsurance after deductible |
50% 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: 0.00% Tier 2: 0.00% |
0.00% |
Delta Dental Individual PPO Gold Plan, EHB Certified Health Insurance Plan Variant 28856IN0160001-00 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 High Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 25% |
| HIOS Product ID | 28856IN016 |
| Import Date | 2024-09-12 01:01:41 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 86.26% |
| Issuer ID | 28856 |
| Issuer Marketplace Marketing Name | Delta Dental of Indiana |
| 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 | $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, In Network (Tier 2), Family Per Group | $850 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | $425 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), 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 | 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 | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 28856IN0160001-00 |
| Plan Marketing Name | Delta Dental Individual PPO Gold Plan, EHB Certified |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental Individual PPO Gold Plan, EHB Certified |
| QHP/Non QHP | Off the Exchange |
| Second Tier Utilization | 75% |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 28856IN0160001 |
| State Code | IN |
Copay & Coinsurance of Delta Dental Individual PPO Gold Plan, EHB Certified Health Insurance Plan, 28856IN0160001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Delta Dental Individual PPO Gold Plan, EHB Certified, 28856IN0160001 Health Insurance Plan, 28856IN0160001
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Does Delta Dental Individual PPO Gold Plan, EHB Certified Health Insurance Plan, 28856IN0160001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (28856IN0160001) Health Insurance Plan, Variant (28856IN0160001-00) have Out Of Country Coverage?
Does (28856IN0160001) Health Insurance Plan, Variant (28856IN0160001-00) 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