Blue Cross Dental Elite - 15287RI0910001 Health Insurance Plan
Blue Cross & Blue Shield of Rhode Island health insurance plan with the Plan ID 15287RI0910001. The plan is called Blue Cross Dental Elite.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 84.84% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 15.16% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 15287RI0910001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Rhode Island | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross & Blue Shield of Rhode Island | ||||||||||||||||||
| Health Insurance Plan Variant | 15287RI0910001-01 | ||||||||||||||||||
| Provider Network(s) | ['RIN003'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Blue Cross Dental Elite Health Insurance Plan Variant 15287RI0910001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High On Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 15287RI091 |
| Import Date | 1/23/2023 |
| Guaranteed Rate | Estimated Rate |
| IsItANewPlan | Existing |
| Issuer Actuarial Value | 84.84% |
| Issuer ID | 15287 |
| Market Coverage | SHOP (Small Group) |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group 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 person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Family | $25 per person | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | $25 |
| Medical EHB Deductible, Out of Network, Family | $25 per person | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | $25 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $350 per person | $700 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $350 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | per person not applicable | per group 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 | RIN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Please refer to your subscriber agreements or contact Customer Service for details about your coverage. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Please refer to your subscriber agreements or contact Customer Service for details about your coverage. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 15287RI0910001-01 |
| Plan Level Exclusions | This plan does not include coverage that is not dentally necessary. This plan does not cover services rendered by excluded providers, providers or facilities who are not legally qualified or licensed, services not performed within the indicated time limits, anesthesia, services provided by Christian Scientist Practitioners, clerical errors, cosmetic services, telephone consults, employment related injuries, experimental/investigational services, new dental services, research studies, specialty oral examinations, services related to the treatment of Temporomandibular Joint Syndrome (TMJ) or travel expenses. |
| Plan Marketing Name | Blue Cross Dental Elite |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Cross Dental Elite |
| QHP/Non QHP | Both |
| Service Area ID | RIS001 |
| Source Name | SERFF |
| Plan ID | 15287RI0910001 |
| State Code | RI |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Cross Dental Elite Health Insurance Plan, 15287RI0910001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Cross Dental Elite, 15287RI0910001 Health Insurance Plan, 15287RI0910001
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Does Blue Cross Dental Elite Health Insurance Plan, 15287RI0910001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15287RI0910001) Health Insurance Plan, Variant (15287RI0910001-01) have Out Of Country Coverage?
Yes. Details: Please refer to your subscriber agreements or contact Customer Service for details about your coverage.
Does (15287RI0910001) Health Insurance Plan, Variant (15287RI0910001-01) have Out of Service Area Coverage?
Yes. Details: Please refer to your subscriber agreements or contact Customer Service for details about your coverage.
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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