54965 health insurance plan with the Plan ID 54965VA0070001. The plan is called Elite ePPO Basic.
Health Insurance Plan ID | 54965VA0070001 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
Health Insurance Issuer | 54965 | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 54965VA0070001-01 | ||||||||||||||||||
Provider Network(s) | ['VAN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Sep 2024 06:34 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Thu, 15 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Sep 2024 06:34 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Accidental Dental
|
YES | 38.00% |
100.00% |
Basic Dental Care - Adult
Subject to deductible of $25/individual and $75/three or more adults for In Network Services Only. Adult dental annual maximum of $1500 applies to Class 1, 2 and 3. Benefit limitations may apply to individual services. |
YES | 38.00% |
100.00% |
Basic Dental Care - Child
Benefit limitations may apply to individual services. Max Out of Pocket is $375 per child up to $750 per family |
YES | 65.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months 1 per 6 months Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208. |
YES | 0.00% |
20.00% |
Major Dental Care - Adult
Subject to deductible of $25/individual and $75/three or more adults for In Network Services Only. Adult dental annual maximum of $1500 applies to Class 1, 2 and 3. Benefit limitations may apply to individual services. |
YES | 50.00% |
100.00% |
Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 75.00% Coinsurance after deductible |
90.00% 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. Orthodontia services are only provided for severe, dysfunctional, handicapping maloclussion. |
YES | 50.00% |
100.00% |
Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Adult dental annual maximum of $1500 applies to Class 1, 2 and 3. Benefit limitations may apply to individual services. Benefit includes 2 visits per year. |
YES | 18.00% |
100.00% |
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 | 100% |
HIOS Product ID | 54965VA007 |
Import Date | 9/15/2022 20:01 |
Inpatient Copayment Maximum Days | 0 |
Guaranteed Rate | Guaranteed Rate |
New/Existing Plan | Existing |
Issuer ID | 54965 |
Issuer Marketplace Marketing Name | Dominion National |
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 | $200 per group |
Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $100 per person |
Medical EHB Deductible, Combined In/Out of Network, Individual | $100 |
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 | $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, 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 | VAN002 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency pain treatment only if 50 miles away from home zip code, up to $100 |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency pain treatment only if 50 miles away from home zip code, up to $100 |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 54965VA0070001-01 |
Plan Level Exclusions | Out of Pocket Maximum applies to children only. Adults have separate deductible and plan payment maximum, refer to plan document for details. Co-insurance equivalent percentages displayed except for orthodontic services; copay for orthodontic services will not equal more than out of pocket maximum. |
Plan Marketing Name | Elite ePPO Basic |
Plan Type | PPO |
Plan Variant Marketing Name | Elite ePPO Basic |
QHP/Non QHP | Both |
Service Area ID | VAS002 |
Source Name | SERFF |
Plan ID | 54965VA0070001 |
State Code | VA |
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, 10 Sep 2024 06:34 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