Delta Dental of North Carolina health insurance plan with the Plan ID 56891NC0120001. The plan is called Delta Dental Preferred Plan.
Health Insurance Plan ID | 56891NC0120001 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | North Carolina | ||||||||||||||||||
Health Insurance Issuer | Delta Dental of North Carolina | ||||||||||||||||||
Health Insurance Plan Variant | 56891NC0120001-01 | ||||||||||||||||||
Provider Network(s) | ['NCN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Fri, 12 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
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Accidental Dental
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NO | ||
Basic Dental Care - Adult
Exclusions: Subject to annual max 6 month wait |
YES | Tier 1: No Charge, 50.00% Coinsurance after deductible Tier 2: No Charge, 60.00% Coinsurance after deductible |
No Charge, 60.00% Coinsurance after deductible |
Basic Dental Care - Child
Exclusions: Age and frequency limits mirror benchmark |
YES | Tier 1: No Charge, 50.00% Coinsurance after deductible Tier 2: No Charge, 50.00% Coinsurance after deductible |
No Charge, 50.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period Exclusions: Age and frequency mirror benchmark |
YES | Tier 1: No Charge, 0.00% Coinsurance after deductible Tier 2: No Charge, 0.00% Coinsurance after deductible |
No Charge, 0.00% Coinsurance after deductible |
Major Dental Care - Adult
Exclusions: Subject to annual max 12 month wait |
YES | Tier 1: No Charge, 50.00% Coinsurance after deductible Tier 2: No Charge, 60.00% Coinsurance after deductible |
No Charge, 60.00% Coinsurance after deductible |
Major Dental Care - Child
Exclusions: Age and frequency limits mirror benchmark |
YES | Tier 1: No Charge, 50.00% Coinsurance after deductible Tier 2: No Charge, 50.00% Coinsurance after deductible |
No Charge, 50.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
YES | Tier 1: No Charge, 50.00% Coinsurance after deductible Tier 2: No Charge, 50.00% Coinsurance after deductible |
No Charge, 50.00% Coinsurance after deductible |
Routine Dental Services (Adult)
Exclusions: Subject to $1,000 annual maximum |
YES | Tier 1: No Charge, 0.00% Tier 2: No Charge, 20.00% |
No Charge, 20.00% |
Plan Attribute | Value |
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Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Low On Exchange Plan |
Dental Only Plan | Yes |
EHB Apportionment for Pediatric Dental | 1 |
First Tier Utilization | 25% |
HIOS Product ID | 56891NC012 |
Import Date | 8/12/2022 1:01 |
Inpatient Copayment Maximum Days | 0 |
Guaranteed Rate | Guaranteed Rate |
New/Existing Plan | New |
Issuer ID | 56891 |
Issuer Marketplace Marketing Name | Delta Dental of North Carolina |
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 | $225 per group |
Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $75 per person |
Medical EHB Deductible, Combined In/Out of Network, Individual | $75 |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $225 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $75 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $75 |
Medical EHB Deductible, In Network (Tier 2), Family Per Group | $225 per group |
Medical EHB Deductible, In Network (Tier 2), Family Per Person | $75 per person |
Medical EHB Deductible, In Network (Tier 2), Individual | $75 |
Medical EHB Deductible, Out of Network, Family Per Group | $225 per group |
Medical EHB Deductible, Out of Network, Family Per Person | $75 per person |
Medical EHB Deductible, Out of Network, Individual | $75 |
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | $750 per group |
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $375 per person |
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $375 |
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Group | $750 per group |
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | $375 per person |
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Individual | $375 |
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 | NCN001 |
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 Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 56891NC0120001-01 |
Plan Marketing Name | Delta Dental Preferred Plan |
Plan Type | PPO |
Plan Variant Marketing Name | Delta Dental Preferred Plan |
QHP/Non QHP | Both |
Second Tier Utilization | 75% |
Service Area ID | NCS001 |
Source Name | HIOS |
Plan ID | 56891NC0120001 |
State Code | NC |
URL for Enrollment Payment | URL |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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