Elite PPO Premium Kids - 67775DE0020003 Health Insurance Plan
Dominion Dental Services, Inc. health insurance plan with the Plan ID 67775DE0020003. The plan is called Elite PPO Premium Kids.
| Health Insurance Plan ID | 67775DE0020003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Delaware | ||||||||||||||||||
| Health Insurance Issuer | Dominion Dental Services, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 67775DE0020003-00 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| 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 Premium Kids Health Insurance Plan, 67775DE0020003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 1.0 Visit(s) per 6 Months Should cover 1 visit every six months. |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | 0.00% |
20.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
YES | 50.00% Coinsurance after deductible |
70.00% 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)
|
NO |
Elite PPO Premium Kids Health Insurance Plan Variant 67775DE0020003-00 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 High 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 | $100 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 | $100 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $50 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $50 |
| Medical EHB Deductible, Out of Network, Family Per Group | $100 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Out of Network, Individual | $50 |
| 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 | High |
| 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) | 67775DE0020003-00 |
| Plan Marketing Name | Elite PPO Premium Kids |
| Plan Type | PPO |
| Plan Variant Marketing Name | Elite PPO Premium Kids |
| QHP/Non QHP | Both |
| Service Area ID | DES002 |
| Source Name | SERFF |
| Plan ID | 67775DE0020003 |
| State Code | DE |
Copay & Coinsurance of Elite PPO Premium Kids Health Insurance Plan, 67775DE0020003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Elite PPO Premium Kids, 67775DE0020003 Health Insurance Plan, 67775DE0020003
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Does Elite PPO Premium Kids Health Insurance Plan, 67775DE0020003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (67775DE0020003) Health Insurance Plan, Variant (67775DE0020003-00) have Out Of Country Coverage?
Does (67775DE0020003) Health Insurance Plan, Variant (67775DE0020003-00) 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