Elite PPO Basic - 67775DE0020004 Health Insurance Plan

Dominion Dental Services, Inc. health insurance plan with the Plan ID 67775DE0020004. The plan is called Elite PPO Basic.

Health Insurance Plan ID

67775DE0020004

Health Insurance Plan Year

2025

State

Delaware

Health Insurance Issuer

Dominion Dental Services, Inc.

Plan Marketing Materials URL

Marketing URL

Health Insurance Plan Variant

67775DE0020004-00

Provider Network(s)

ELITE

In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT).

Providers	Delaware	All US States
All	71	86
PCP	N/A	N/A
Allergy	N/A	N/A
OB/GYN	N/A	N/A
Dentists	51	62

Available Variants of the Health Plan

Standard Off Exchange Plan - 67775DE0020004-00

Standard On Exchange Plan - 67775DE0020004-01

Last Plan Update Date

Fri, 07 Jun 2024 00:00 GMT

Last Import Date

Thu, 21 Nov 2024 00:44 GMT

Benefits of Elite PPO Basic Health Insurance Plan, 67775DE0020004-00

Benefit	Covered	In Network	Out Of Network
Accidental Dental	NO
Basic Dental Care - Adult Limit: 1.0 Procedure(s) per 2 Years	YES	50.00% Coinsurance after deductible	70.00% Coinsurance after deductible
Basic Dental Care - Child Limit: 1.0 Visit(s) per 6 Months Should cover 1 visit every six months.	YES	65.00% Coinsurance after deductible	80.00% Coinsurance after deductible
Dental Check-Up for Children Limit: 1.0 Visit(s) per 6 Months	YES	10.00%	20.00%
Major Dental Care - Adult Limit: 84.0 Months per Procedure	YES	85.00% Coinsurance after deductible	90.00% Coinsurance after deductible
Major Dental Care - Child	YES	75.00% Coinsurance after deductible	90.00% Coinsurance after deductible
Orthodontia - Adult	NO
Orthodontia - Child Covered Services, which are intended to treat a severe dental abnormality and are the only method capable of preventing irreversible damage to the Member's teeth or their supporting structures, and restoring the Member's oral structure to health and function.	YES	50.00%	100.00%
Routine Dental Services (Adult) Limit: 2.0 Visit(s) per Year	YES	0.00% Coinsurance after deductible	10.00% Coinsurance after deductible

Elite PPO Basic Health Insurance Plan Variant 67775DE0020004-00 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 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	1.0
First Tier Utilization	100%
HIOS Product ID	67775DE002
Import Date	2024-06-07 20:01:19
Inpatient Copayment Maximum Days	0
Guaranteed Rate	Guaranteed Rate
New/Existing Plan	Existing
Issuer ID	67775
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	$200 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person	$100 per person
Medical EHB Deductible, In Network (Tier 1), Individual	$100
Medical EHB Deductible, Out of Network, Family Per Group	$200 per group
Medical EHB Deductible, Out of Network, Family Per Person	$100 per person
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	DEN002
Out of Country Coverage	Yes
Out of Country Coverage Description	Standard Out of Network PPO Benefits
Out of Service Area Coverage	Yes
Out of Service Area Coverage Description	Standard Out of Network PPO Benefits
Plan Brochure	URL
Plan Effective Date	2025-01-01
Plan Expiration Date	2025-12-31
Plan ID (Standard Component ID with Variant)	67775DE0020004-00
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.
Plan Marketing Name	Elite PPO Basic
Plan Type	PPO
Plan Variant Marketing Name	Elite PPO Basic
QHP/Non QHP	Both
Service Area ID	DES002
Source Name	SERFF
Plan ID	67775DE0020004
State Code	DE

Copay & Coinsurance of Elite PPO Basic Health Insurance Plan, 67775DE0020004

Drug Tier	Pharmacy Type	Copay amount	Copay option	Coinsurance rate	Coinsurance option	Mail Order

Frequently Asked Questions(FAQ) about Elite PPO Basic, 67775DE0020004 Health Insurance Plan, 67775DE0020004

Does Elite PPO Basic Health Insurance Plan, 67775DE0020004 support Mail Ordering?

Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

Does (67775DE0020004) Health Insurance Plan, Variant (67775DE0020004-00) have Out Of Country Coverage?

Yes. Details: Standard Out of Network PPO Benefits

Does (67775DE0020004) Health Insurance Plan, Variant (67775DE0020004-00) have Out of Service Area Coverage?