Grand X Dental - 31256MI0020022 Health Insurance Plan
DENCAP Dental Plans, Inc. health insurance plan with the Plan ID 31256MI0020022. The plan is called Grand X Dental.
| Health Insurance Plan ID | 31256MI0020022 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | DENCAP Dental Plans, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 31256MI0020022-00 | ||||||||||||||||||
| Provider Network(s) | ['MIN003'] | ||||||||||||||||||
| 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 | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Grand X Dental Health Insurance Plan, 31256MI0020022-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Limit: 100.0 Dollars per Year When 50 or more miles away from your selected General Dentist, DENCAP will reimburse 50% up to $100 for emergency services that relieve severe pain and are covered benefits. |
YES | $5.00, 20.00% |
50.00% |
| Basic Dental Care - Adult
Limit: 3500.0 Dollars per Year $2500 Primary Care (General Dentist) Maximum, $1000 Specialty Care (Specialist) Maximum after 6 months of enrollment. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits. Click "Plan Brochure" above, then scroll to find the Schedule of Benefits for a complete listing of covered services with co-pays. |
YES | $5.00, 20.00% |
60.00% |
| Basic Dental Care - Child
Limit: 3500.0 Dollars per Year $2500 Primary Care (General Dentist) Maximum, $1000 Specialty Care (Specialist) Maximum after 6 months of enrollment. Maximums and waiting periods are waived for EHB pediatric dental benefits. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits. |
YES | $5.00, 20.00% |
60.00% |
| Dental Check-Up for Children
Limit: 3.0 Visit(s) per Year Percentages are approximate. Maximums and waiting periods are waived for EHB pediatric dental benefits. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits. |
YES | $5.00 |
60.00% |
| Major Dental Care - Adult
Limit: 3500.0 Dollars per Year $2500 Primary Care (General Dentist) Maximum, $1000 Specialty Care (Specialist) Maximum after 6 months of enrollment. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits. |
YES | $5.00, 30.00% |
60.00% |
| Major Dental Care - Child
Limit: 3500.0 Dollars per Year $2500 Primary Care (General Dentist) Maximum, $1000 Specialty Care (Specialist) Maximum after 6 months of enrollment. Maximums and waiting periods are waived for EHB pediatric dental benefits. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits. Click "Plan Brochure" above, then scroll to find the Schedule of Benefits for a complete listing of covered services with co-pays. |
YES | $5.00, 30.00% |
60.00% |
| Orthodontia - Adult
Limit: 1.0 Treatment(s) per Year In-Network Orthodontists give an $1200 discount with referral from your General Dentist. |
YES | 65.00% |
100.00% |
| Orthodontia - Child
Limit: 1.0 Treatment(s) per Year In-Network Orthodontists give an $1800 discount with referral from your General Dentist. |
YES | 65.00% |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits. |
YES | $5.00 |
60.00% |
Grand X Dental Health Insurance Plan Variant 31256MI0020022-00 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 | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 31256MI002 |
| Import Date | 2023-08-16 20:01:48 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 31256 |
| Issuer Marketplace Marketing Name | DENCAP Dental Plans, Inc |
| 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 | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | High |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MIN003 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | In-Network Dentists outside of Service Area |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 31256MI0020022-00 |
| Plan Marketing Name | Grand X Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Grand X Dental |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | MIS002 |
| Source Name | SERFF |
| Plan ID | 31256MI0020022 |
| State Code | MI |
| URL for Summary of Benefits & Coverage | URL |
Copay & Coinsurance of Grand X Dental Health Insurance Plan, 31256MI0020022
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Grand X Dental, 31256MI0020022 Health Insurance Plan, 31256MI0020022
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Does Grand X Dental Health Insurance Plan, 31256MI0020022 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (31256MI0020022) Health Insurance Plan, Variant (31256MI0020022-00) have Out Of Country Coverage?
Does (31256MI0020022) Health Insurance Plan, Variant (31256MI0020022-00) 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