DentaTrust PPO Family Basic Option - 69103VA0040005 Health Insurance Plan
Dental Care Plus, Inc health insurance plan with the Plan ID 69103VA0040005. The plan is called DentaTrust PPO Family Basic Option.
| Health Insurance Plan ID | 69103VA0040005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Virginia | ||||||||||||||||||
| Health Insurance Issuer | Dental Care Plus, Inc | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69103VA0040005-00 | ||||||||||||||||||
| Provider Network(s) | ['VAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 15 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of DentaTrust PPO Family Basic Option Health Insurance Plan, 69103VA0040005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
See plan brochure for plan details and limitations and exclusions. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
Subject to 6 month waiting period See plan brochure for plan details and limitations and exclusions. Total benefits payable in the benefit period are limited to a maximum of $1,000 for each covered individual over age 19. Subject to $50 deductible per covered individual or $150 per family.Benefit limitations may apply to individual services. The deductible is combined for pediatric and adult services. DEDUCTIBLES: Restorative and other Basic Services, and Complex Dental Services described above are subject to a deductible for each covered individual in each policy. For policies with three or more covered individuals, no one covered individual can contribute more than $50 to the ?per Policy? deductible amount of $150. The deductible for In Network and Out of Network Services is combined. OUT OF POCKET MAXIMUM: The out of pocket maximum related to in-network covered services is limited to $350 per policies with one member under age 19 with a maximum of $700 per certificate with two or more members under age 19. The out of pocket maximum does not apply to services received from non-participating dentists. No one covered individual under age 19 can contribute more than $350 to the $700 out of pocket maximum for certificates that cover two or more covered individuals under age 19. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Child
Benefit limitations may apply to individual services. Subject to $50 deductible per covered individual or $150 per family. The deductible is combined for pediatric and adult services.Benefit limitations may apply to individual services. The deductible is combined for pediatric and adult services. DEDUCTIBLES: Restorative and other Basic Services, and Complex Dental Services described above are subject to a deductible for each covered individual in each policy. For policies with three or more covered individuals, no one covered individual can contribute more than $50 to the ?per Policy? deductible amount of $150. The deductible for In Network and Out of Network Services is combined. OUT OF POCKET MAXIMUM: The out of pocket maximum related to in-network covered services is limited to $350 per policies with one member under age 19 with a maximum of $700 per certificate with two or more members under age 19. The out of pocket maximum does not apply to services received from non-participating dentists. No one covered individual under age 19 can contribute more than $350 to the $700 out of pocket maximum for certificates that cover two or more covered individuals under age 19. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Treatment(s) per 6 Months Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208. |
YES | $10.00, No Charge |
$10.00, No Charge |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Benefit limitations may apply to individual services. Subject to $50 deductible per covered individual or $150 per family. The deductible is combined for pediatric and adult services.Benefit limitations may apply to individual services. The deductible is combined for pediatric and adult services. DEDUCTIBLES: Restorative and other Basic Services, and Complex Dental Services described above are subject to a deductible for each covered individual in each policy. For policies with three or more covered individuals, no one covered individual can contribute more than $50 to the ?per Policy? deductible amount of $150. The deductible for In Network and Out of Network Services is combined. OUT OF POCKET MAXIMUM: The out of pocket maximum related to in-network covered services is limited to $350 per policies with one member under age 19 with a maximum of $700 per certificate with two or more members under age 19. The out of pocket maximum does not apply to services received from non-participating dentists. No one covered individual under age 19 can contribute more than $350 to the $700 out of pocket maximum for certificates that cover two or more covered individuals under age 19. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limit: 1.0 Treatment(s) per Lifetime Limit applies to one comprehensive orthodontic treatment of the adolescent dentition. |
YES | 50.00% |
50.00% |
| Routine Dental Services (Adult)
Limit: 1.0 Treatment(s) per 6 Months See plan brochure for plan details and limitations and exclusions. Total benefits payable in the benefit period are limited to a maximum of $1,000 for each covered individual over age 19. |
YES | $10.00, No Charge |
$10.00, No Charge |
DentaTrust PPO Family Basic Option Health Insurance Plan Variant 69103VA0040005-00 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 | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Low Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1 |
| First Tier Utilization | 100% |
| HIOS Product ID | 69103VA004 |
| Import Date | 8/15/2022 20:01 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 69103 |
| Issuer Marketplace Marketing Name | Dental Care Plus, Inc |
| 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, 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, 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 | No |
| Network ID | VAN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out-of-Network coverage is available for covered services obtained from non-participating dentists. See the schedule of benefits for out-of-network coverage levels. Non-contracting dentists are permitted to charge for the difference between the fee schedule and non-contracting dentist’s billed charges. You may be required to pay more for services obtained from a non-contracting dentist than the same services provided by a contracting dentist. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 69103VA0040005-00 |
| Plan Level Exclusions | Please refer to the exclusions listed in the Plan Brochure for specific plan level exclusions. |
| Plan Marketing Name | DentaTrust PPO Family Basic Option |
| Plan Type | PPO |
| Plan Variant Marketing Name | DentaTrust PPO Family Basic Option |
| QHP/Non QHP | Both |
| Service Area ID | VAS001 |
| Source Name | SERFF |
| Plan ID | 69103VA0040005 |
| State Code | VA |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of DentaTrust PPO Family Basic Option Health Insurance Plan, 69103VA0040005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about DentaTrust PPO Family Basic Option, 69103VA0040005 Health Insurance Plan, 69103VA0040005
-
Does DentaTrust PPO Family Basic Option Health Insurance Plan, 69103VA0040005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69103VA0040005) Health Insurance Plan, Variant (69103VA0040005-00) have Out Of Country Coverage?
Does (69103VA0040005) Health Insurance Plan, Variant (69103VA0040005-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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