Dental Choice 0-20-50 1500 - 23603MT0330004 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 23603MT0330004. The plan is called Dental Choice 0-20-50 1500.
| Health Insurance Plan ID | 23603MT0330004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Montana | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 23603MT0330004-00 | ||||||||||||||||||
| Provider Network(s) | ['MTN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Dental Choice 0-20-50 1500 Health Insurance Plan, 23603MT0330004-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 36 month only if no prophylaxis in the prior 36 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. Charge for root canal therapy 1 per tooth per 36 months. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Basic Dental Care - Child
Composite, resin, or similar restoration per tooth surface per 24 months. Periodontal scaling and root planing or curettage 1 per quadrant (8 or fewer teeth in one arch) per 24 months. Full mouth debridement 1 every 24 month only if no prophylaxis in the prior 24 months and an exam cannot be performed due to obstruction. Complicated oral and periodontal surgery are covered. Pulp capping only payable when pulp is exposed. Pulpotomy only for deciduous teeth. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Periodic exams 2 per year. Comprehensive exams covered. Full mouth, cone beams, or panorex x-rays 1 per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 2 per year. Fluoride applications 4 per year. Sealants 1 per permanent molar and bicuspid in a 36 month period. Athletic mouth guards 1 per lifetime. Brush biopsies to aid in diagnosis of oral cancer are covered. Space maintainers are covered. |
YES | No Charge |
No Charge |
| Major Dental Care - Adult
Exclusions: Separate charges for denture adjustments and relines performed within 6 months of initial placement. Crowns and other restorations 1 per tooth per 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Initial placement only covered if natural tooth lost or extracted while coverage is in effect or after at least 36 consecutive months. Surgical placement and removal of implants 1 per tooth space per lifetime. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Major Dental Care - Child
Crowns and other restorations 1 per tooth every 60 months. Replacement of existing prosthetic only when unserviceable and in place at least 60 months. Cast partial, full, and immediate dentures, or overdenture limited to cost of standard full or cast partial denture. Benefits for relines provided once per 12 months. Surgical placement and removal of implants 1 per tooth space per 60 months. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: Coverage for orthodontia services are excluded unless medically necessary. Medically necessary orthodontia requires a predetermination and a treatment plan. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Exclusions: Space maintainers, athletic mouth guards, and sealants are not covered for members age 19 and older. Periodic exams 2 per year. Comprehensive exams 2 per year. Full mouth, cone beams, or panorex x-rays 1 set per 36 months. Bitewing x-rays 1 set per 6 months. Prophylaxis or periodontal maintenance 3 per year. Fluoride applications 4 per year. Brush biopsies to aid in diagnosis of oral cancer are covered. Members age 19 and older may be subject to a wait period and an annual maximum benefit amount. See brochure for more information. |
YES | No Charge |
No Charge |
Dental Choice 0-20-50 1500 Health Insurance Plan Variant 23603MT0330004-00 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 | Yes |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 23603MT033 |
| Import Date | 2023-08-16 20:01:48 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 23603 |
| Issuer Marketplace Marketing Name | PacificSource Health Plans |
| Market Coverage | SHOP (Small Group) |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | $400 |
| 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, 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 | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | Not Applicable |
| 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 | No |
| National Network | Yes |
| Network ID | MTN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | This plan covers eligible services when performed by an eligible provider. |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 23603MT0330004-00 |
| Plan Marketing Name | Dental Choice 0-20-50 1500 |
| Plan Type | Indemnity |
| Plan Variant Marketing Name | Dental Choice 0-20-50 1500 |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | MTS004 |
| Source Name | SERFF |
| Plan ID | 23603MT0330004 |
| State Code | MT |
Copay & Coinsurance of Dental Choice 0-20-50 1500 Health Insurance Plan, 23603MT0330004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Dental Choice 0-20-50 1500, 23603MT0330004 Health Insurance Plan, 23603MT0330004
-
Does Dental Choice 0-20-50 1500 Health Insurance Plan, 23603MT0330004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (23603MT0330004) Health Insurance Plan, Variant (23603MT0330004-00) have Out Of Country Coverage?
Does (23603MT0330004) Health Insurance Plan, Variant (23603MT0330004-00) 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