Delta Dental Pediatric Gold Plan - 28348AR0090002 Health Insurance Plan
Delta Dental Plan of Arkansas, Inc. health insurance plan with the Plan ID 28348AR0090002. The plan is called Delta Dental Pediatric Gold Plan.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 85.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 15.00% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 28348AR0090002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Arkansas | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental Plan of Arkansas, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 28348AR0090002-01 | ||||||||||||||||||
| 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 | Mon, 10 Jun 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Delta Dental Pediatric Gold Plan Health Insurance Plan, 28348AR0090002-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Exclusions: See Statement of Benefits See Statement of Benefits |
YES | Tier 1: No Charge, 10.00% Tier 2: No Charge, 10.00% |
No Charge, 19.00% |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period Exclusions: See Statement of Benefits See Statement of Benefits |
YES | Tier 1: No Charge Tier 2: No Charge |
No Charge, 10.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Exclusions: See Statement of Benefits See Statement of Benefits |
YES | Tier 1: No Charge, 50.00% Tier 2: No Charge, 50.00% |
No Charge, 55.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Routine Dental Services (Adult)
|
NO |
Delta Dental Pediatric Gold Plan Health Insurance Plan Variant 28348AR0090002-01 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 On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 30% |
| HIOS Product ID | 28348AR009 |
| Import Date | 2024-06-10 20:01:24 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 85.00% |
| Issuer ID | 28348 |
| Issuer Marketplace Marketing Name | Delta Dental of Arkansas |
| 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 | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| 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 | $700 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $350 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $350 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Group | $700 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | $350 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Individual | $350 |
| 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 | ARN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Claims will be paid as a out of network in US dollars using an approved fee level based on the policy holders home address |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Claims will be paid based on In Network fee level and out of network benefit levels. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 28348AR0090002-01 |
| Plan Marketing Name | Delta Dental Pediatric Gold Plan |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental Pediatric Gold Plan |
| QHP/Non QHP | On the Exchange |
| Second Tier Utilization | 70% |
| Service Area ID | ARS001 |
| Source Name | SERFF |
| Plan ID | 28348AR0090002 |
| State Code | AR |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of Delta Dental Pediatric Gold Plan Health Insurance Plan, 28348AR0090002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Delta Dental Pediatric Gold Plan, 28348AR0090002 Health Insurance Plan, 28348AR0090002
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Does Delta Dental Pediatric Gold Plan Health Insurance Plan, 28348AR0090002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (28348AR0090002) Health Insurance Plan, Variant (28348AR0090002-01) have Out Of Country Coverage?
Does (28348AR0090002) Health Insurance Plan, Variant (28348AR0090002-01) 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