Select Plan Basic Kids - 67775DE0010003 Health Insurance Plan

Dominion Dental Services, Inc. health insurance plan with the Plan ID 67775DE0010003. The plan is called Select Plan Basic Kids.

Health Insurance Plan ID

67775DE0010003

Health Insurance Plan Year

2024

State

Delaware

Health Insurance Issuer

Dominion Dental Services, Inc.

Plan Marketing Materials URL

Marketing URL

Health Insurance Plan Variant

67775DE0010003-00

Provider Network(s)

SELECT

In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT).

Providers	Delaware	All US States
All	N/A	N/A
PCP	N/A	N/A
Allergy	N/A	N/A
OB/GYN	N/A	N/A
Dentists	N/A	N/A

Available Variants of the Health Plan

Standard Off Exchange Plan - 67775DE0010003-00

Standard On Exchange Plan - 67775DE0010003-01

Last Plan Update Date

Wed, 16 Aug 2023 00:00 GMT

Last Import Date

Tue, 22 Oct 2024 06:47 GMT

Benefits of Select Plan Basic Kids Health Insurance Plan, 67775DE0010003-00

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	28.00%	100.00%
Dental Check-Up for Children Limit: 1.0 Visit(s) per 6 Months	YES	$20.00	100.00%
Major Dental Care - Adult	NO
Major Dental Care - Child	YES	39.00%	100.00%
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	$400.00	100.00%
Routine Dental Services (Adult)	NO

Select Plan Basic Kids Health Insurance Plan Variant 67775DE0010003-00 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 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	67775DE001
Import Date	2023-08-16 20:01:48
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	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	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	$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	DEN001
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	2024-01-01
Plan Expiration Date	2024-12-31
Plan ID (Standard Component ID with Variant)	67775DE0010003-00
Plan Level Exclusions	Co-insurance equivalent percentages displayed. Discount provided for non-medically necessary orthodontia. Must choose participating Select Plan dentist.
Plan Marketing Name	Select Plan Basic Kids
Plan Type	HMO
Plan Variant Marketing Name	Select Plan Basic Kids
QHP/Non QHP	Both
Service Area ID	DES001
Source Name	SERFF
Plan ID	67775DE0010003
State Code	DE

Copay & Coinsurance of Select Plan Basic Kids Health Insurance Plan, 67775DE0010003

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

Frequently Asked Questions(FAQ) about Select Plan Basic Kids, 67775DE0010003 Health Insurance Plan, 67775DE0010003

Does Select Plan Basic Kids Health Insurance Plan, 67775DE0010003 support Mail Ordering?

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

Does (67775DE0010003) Health Insurance Plan, Variant (67775DE0010003-00) have Out Of Country Coverage?

Yes. Details: Emergency pain treatment only if 50 miles away from home ZIP code, up to $100

Does (67775DE0010003) Health Insurance Plan, Variant (67775DE0010003-00) have Out of Service Area Coverage?