Delta Dental Pediatric Low Plan - 87701NH0100001 Health Insurance Plan

Delta Dental Plan of New Hampshire, Inc. health insurance plan with the Plan ID 87701NH0100001. The plan is called Delta Dental Pediatric Low Plan.

Health Insurance Plan ID

87701NH0100001

Health Insurance Plan Year

2025

State

New Hampshire

Health Insurance Issuer

Delta Dental Plan of New Hampshire, Inc.

Plan Marketing Materials URL

Marketing URL

Health Insurance Plan Variant

87701NH0100001-01

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).

Providers	New Hampshire	All US States
All	628	861
PCP	N/A	N/A
Allergy	N/A	N/A
OB/GYN	N/A	N/A
Dentists	425	572

Available Variants of the Health Plan

Standard On Exchange Plan - 87701NH0100001-01

Last Plan Update Date

Tue, 13 Aug 2024 00:00 GMT

Last Import Date

Thu, 21 Nov 2024 00:44 GMT

Benefits of Delta Dental Pediatric Low Plan Health Insurance Plan, 87701NH0100001-01

Benefit	Covered	In Network	Out Of Network
Accidental Dental	NO
Basic Dental Care - Adult	NO
Basic Dental Care - Child Exclusions: For more details, please refer to the Outline of Benefits and your plan documents Periodontal maintenance 4 times in 12 months; periodontal scaling and root planing once in 2 years; restorations once in 2 years per tooth; resin restorations on anterior teeth and the buccal surface of bicuspids only; anesthesia only in conjunction with covered services; stainless steel crowns once in 2 years per tooth.	YES	$30.00 Copay after deductible, 40.00% Coinsurance after deductible	$30.00 Copay after deductible, 40.00% Coinsurance after deductible
Dental Check-Up for Children Limit: 1.0 Visit(s) per 6 Months Exclusions: For more details, please refer to the Outline of Benefits and your plan documents Cleanings once in 6 months, evaluations once in 6 months, bitewing images once in 6 months; complete series or panoramic image once in 5 years; full mouth debridement once in a lifetime; fluoride treatments twice in 12 months; sealants once in 3 years on permanent, un-restored molars; space maintainers once in a lifetime.	YES	$30.00, 0.00%	$30.00, 0.00%
Major Dental Care - Adult	NO
Major Dental Care - Child Exclusions: For more details, please refer to the Outline of Benefits and your plan documents Root canal therapy once in 2 years; inlays, onlays and crowns over age 12 once in 5 years; dentures once in 5 years; periodontal surgery once in 3 years; implants over age 16 once in 5 years; occlusal guards over age 13 once in 12 months.	YES	$30.00 Copay after deductible, 50.00% Coinsurance after deductible	$30.00 Copay after deductible, 50.00% Coinsurance after deductible
Orthodontia - Adult	NO
Orthodontia - Child Exclusions: For more details, please refer to the Outline of Benefits and your plan documents Subject to medical necessity	YES	No Charge, 50.00%	No Charge, 50.00%
Routine Dental Services (Adult)	NO

Delta Dental Pediatric Low Plan Health Insurance Plan Variant 87701NH0100001-01 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 Low On Exchange Plan
Dental Only Plan	Yes
EHB Apportionment for Pediatric Dental	1.0
First Tier Utilization	100%
HIOS Product ID	87701NH010
Import Date	2024-08-13 20:01:38
Inpatient Copayment Maximum Days	0
Guaranteed Rate	Guaranteed Rate
New/Existing Plan	Existing
Issuer ID	87701
Issuer Marketplace Marketing Name	Northeast Delta 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	per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person	$150 per person
Medical EHB Deductible, Combined In/Out of Network, Individual	$150
Medical EHB Deductible, In Network (Tier 1), Family Per Group	per group not applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Person	$150 per person
Medical EHB Deductible, In Network (Tier 1), Individual	$150
Medical EHB Deductible, Out of Network, Family Per Group	per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person	$150 per person
Medical EHB Deductible, Out of Network, Individual	$150
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	Low
Multiple In Network Tiers	No
National Network	Yes
Network ID	NHN001
Out of Country Coverage	Yes
Out of Country Coverage Description	Same Coverage
Out of Service Area Coverage	Yes
Out of Service Area Coverage Description	Same Coverage
Plan Brochure	URL
Plan Effective Date	2025-01-01
Plan Expiration Date	2025-12-31
Plan ID (Standard Component ID with Variant)	87701NH0100001-01
Plan Level Exclusions	Many covered services, including but not limited to oral evaluations, x-rays, cleanings, fluoride treatments, sealants, restorations, periodontal treatment and surgery, tissue conditioning, crowns, inlays, onlays, dentures, implants, and root canal therapy, are subject to age, time, and frequency limitations. Covered services containing time and frequency limitations are available for more frequent treatment for pediatric enrollees with prior authorization. Medically necessary orthodontia is a covered benefit for pediatric enrollees only. Certain covered services apply to treatment for specified teeth. Certain procedures performed on the same date by the same dentist are not separately chargeable by the dentist. Certain covered services are considered part of the complete treatment and not separately chargeable by the dentist. Many dental repairs, replacements, and retreatments are time limited and not separately chargeable by the dentist. Other exclusions and limitations may apply. Please refer to your Policy for details.
Plan Marketing Name	Delta Dental Pediatric Low Plan
Plan Type	PPO
Plan Variant Marketing Name	Delta Dental Pediatric Low Plan
QHP/Non QHP	On the Exchange
Service Area ID	NHS001
Source Name	SERFF
Plan ID	87701NH0100001
State Code	NH
URL for Enrollment Payment	URL
URL for Summary of Benefits & Coverage	URL

Copay & Coinsurance of Delta Dental Pediatric Low Plan Health Insurance Plan, 87701NH0100001

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

Frequently Asked Questions(FAQ) about Delta Dental Pediatric Low Plan, 87701NH0100001 Health Insurance Plan, 87701NH0100001

Does Delta Dental Pediatric Low Plan Health Insurance Plan, 87701NH0100001 support Mail Ordering?

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

Does (87701NH0100001) Health Insurance Plan, Variant (87701NH0100001-01) have Out Of Country Coverage?

Yes. Details: Same Coverage

Does (87701NH0100001) Health Insurance Plan, Variant (87701NH0100001-01) have Out of Service Area Coverage?