EssentialSmile Ohio - Total Care - 57086OH0010001 Health Insurance Plan
Solstice Healthplans of Ohio, Inc. health insurance plan with the Plan ID 57086OH0010001. The plan is called EssentialSmile Ohio - Total Care.
| Health Insurance Plan ID | 57086OH0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Ohio | ||||||||||||||||||
| Health Insurance Issuer | Solstice Healthplans of Ohio, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57086OH0010001-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 | Mon, 05 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of EssentialSmile Ohio - Total Care Health Insurance Plan, 57086OH0010001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Includes Coverage for White Fillings, Deep Cleaning, Extractions and Other Minor Restorative Procedures |
YES | $56.00 |
100.00% |
| Basic Dental Care - Child
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
YES | $56.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
YES | No Charge after deductible |
100.00% |
| Major Dental Care - Adult
Includes Coverage for Crowns, Bridges, Dentures, Root Canals and Surgical Implants. |
YES | $260.00 |
100.00% |
| Major Dental Care - Child
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
YES | $350.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
|
YES | $3,700.00 |
100.00% |
| Orthodontia - Child
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental - High Option Plan. |
YES | $350.00 Copay after deductible |
100.00% |
| Routine Dental Services (Adult)
Includes Coverage For Routine Cleaning, Exams, Fluoride, Sealants and X-Rays |
YES | $10.00 |
100.00% |
EssentialSmile Ohio - Total Care Health Insurance Plan Variant 57086OH0010001-00 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 | 57086OH001 |
| Import Date | 2024-08-05 20:01:34 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 57086 |
| Issuer Marketplace Marketing Name | Solstice Healthplans of Ohio, 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 | 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 | $30 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $30 |
| 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 | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $400 |
| 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 | OHN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Only for palliative care where a network provider is not available. |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 57086OH0010001-00 |
| Plan Marketing Name | EssentialSmile Ohio - Total Care |
| Plan Type | HMO |
| Plan Variant Marketing Name | EssentialSmile Ohio - Total Care |
| QHP/Non QHP | Both |
| Service Area ID | OHS001 |
| Source Name | SERFF |
| Plan ID | 57086OH0010001 |
| State Code | OH |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of EssentialSmile Ohio - Total Care Health Insurance Plan, 57086OH0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about EssentialSmile Ohio - Total Care, 57086OH0010001 Health Insurance Plan, 57086OH0010001
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Does EssentialSmile Ohio - Total Care Health Insurance Plan, 57086OH0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57086OH0010001) Health Insurance Plan, Variant (57086OH0010001-00) have Out Of Country Coverage?
Does (57086OH0010001) Health Insurance Plan, Variant (57086OH0010001-00) 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