EHB Basic Dental Plan (Low) - 69051IN0110001 Health Insurance Plan
Metropolitan Life Insurance Company health insurance plan with the Plan ID 69051IN0110001. The plan is called EHB Basic Dental Plan (Low).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 30.00% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 69051IN0110001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Metropolitan Life Insurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 69051IN0110001-00 | ||||||||||||||||||
| Provider Network(s) | ['INN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Sat, 08 Jun 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of EHB Basic Dental Plan (Low) Health Insurance Plan, 69051IN0110001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 1.0 Treatment(s) per Procedure |
YES | 50% Coinsurance after deductible |
60% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | 10% Coinsurance after deductible |
20% Coinsurance after deductible |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Limit: 1.0 Treatment(s) per Procedure |
YES | 50.00% Coinsurance after deductible |
60% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% |
50.00% |
| Routine Dental Services (Adult)
|
NO |
EHB Basic Dental Plan (Low) Health Insurance Plan Variant 69051IN0110001-00 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 | 2025 |
| Child-Only Offering | Allows Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Low Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 69051IN011 |
| Import Date | 2024-06-08 01:01:06 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 70.00% |
| Issuer ID | 69051 |
| Issuer Marketplace Marketing Name | Metropolitan Life Insurance Company |
| Market Coverage | SHOP (Small Group) |
| 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 | $100 |
| 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 | $100 |
| 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 | INN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Payment is made to the employee in U.S. dollars and is based upon the rate of exchange for the date in which the expense was incurred. Covered services should be a recognized ADA procedure code to identify the service provided. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | The PPO plan has an indemnity schedule of benefits for out of service area coverage. |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 69051IN0110001-00 |
| Plan Level Exclusions | When sold off the exchange, MetLife's Dental EHB plans and benefits will meet the stated actuarial value, but the exact plan and benefit design may vary according to the terms of the insurance certificate. |
| Plan Marketing Name | EHB Basic Dental Plan (Low) |
| Plan Type | PPO |
| Plan Variant Marketing Name | EHB Basic Dental Plan (Low) |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 69051IN0110001 |
| State Code | IN |
Copay & Coinsurance of EHB Basic Dental Plan (Low) Health Insurance Plan, 69051IN0110001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about EHB Basic Dental Plan (Low), 69051IN0110001 Health Insurance Plan, 69051IN0110001
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Does EHB Basic Dental Plan (Low) Health Insurance Plan, 69051IN0110001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69051IN0110001) Health Insurance Plan, Variant (69051IN0110001-00) have Out Of Country Coverage?
Does (69051IN0110001) Health Insurance Plan, Variant (69051IN0110001-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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