Blue Dental EPO 100/80/50 Voluntary SG - 15560MI0680001 Health Insurance Plan
Blue Cross Blue Shield of Michigan Mutual Insurance Company health insurance plan with the Plan ID 15560MI0680001. The plan is called Blue Dental EPO 100/80/50 Voluntary SG .
| Health Insurance Plan ID | 15560MI0680001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Michigan Mutual Insurance Company | ||||||||||||||||||
| Health Insurance Plan Variant | 15560MI0680001-00 | ||||||||||||||||||
| Provider Network(s) | ['MIN003'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Tue, 30 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Blue Dental EPO 100/80/50 Voluntary SG Health Insurance Plan, 15560MI0680001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Exclusions: 6-month waiting period waived for emergency palliative treatment. Benefit only applies to MOOP for pediatric members. Pediatric members are defined as members age 18 or younger when their coverage begins. Emergency palliative treatment for temporary pain relief |
YES | 20% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Limit: 2.0 Procedure(s) per Year Periodontal maintenance - 2x per calendar year in combination with routine prohylaxis (cleaning). Fillings - 1x per 24 months for primary teeth, 1x per 48 months for permanent teeth. Members age 19 or older when their coverage begins are considered non-pediatric |
YES | 20% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Child
Limit: 3.0 Procedure(s) per Year Periodontal maintenance - 3x per calendar year in combination with routine prohylaxis (cleaning). Fillings - 1x per 24 months for primary teeth, 1x per 48 months for permanent teeth. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 20% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 3.0 Procedure(s) per Year Prophylaxis (Cleaning)- 3x per calendar year. Exams - 2x per calendar year. Bitewing X-rays - One set (up to 4) per calendar year. Fluoride - 2x per calendar year. Sealants - 1x per permanent molars, every 3 years. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | No Charge |
100.00% |
| Major Dental Care - Adult
Limit: 1.0 Procedure(s) per 3 Years Exclusions: 12 month waiting period on Class III services, except root canals and extractions of non-impacted teeth. Members age 19 or older when their coverage begins are considered non-pediatric. Scaling and root planing - 1x per quadrant, per 36 months. Simple and surgical extractions - 1x per lifetime. Root canals - 1x per lifetime per tooth. Onlays, crowns, veneers - 1x every 60 months. Bridges and dentures - 1x every 84 months. Implants - 1x per tooth, per lifetime, excluding 3rd molars. Covered Periodontal surgery services - 1x every 36 months per quadrant. Members age 19 or older when their coverage begins are considered non-pediatric. |
YES | 50% Coinsurance after deductible |
100.00% |
| Major Dental Care - Child
Limit: 1.0 Procedure(s) per 2 Years Exclusions: Implants are not covered. Scaling and root planing - 1x per quadrant, per 24 months. Simple and surgical extractions - 1x per lifetime. Root canals - 1x per lifetime per tooth. Onlays, crowns, veneers - 1x every 60 months. Bridges and dentures - 1x every 84 months. Implants - not covered. Covered Periodontal surgery services - 1x every 36 months per quadrant. Pediatric members are defined as members age 18 or younger when their coverage begins. |
YES | 50% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
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NO | ||
| Orthodontia - Child
|
NO | ||
| Routine Dental Services (Adult)
Limit: 2.0 Procedure(s) per Year Prophylaxis (Cleaning)- 2x per calendar year. Exams - 2x per calendar year. Bitewing X-rays - One set (up to 4) per calendar year. Fluoride - not covered. Sealants - not covered. Members age 19 or older when their coverage begins are considered non-pediatric |
YES | No Charge |
100.00% |
Blue Dental EPO 100/80/50 Voluntary SG Health Insurance Plan Variant 15560MI0680001-00 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 | 2023 |
| 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 | 15560MI068 |
| Import Date | 8/30/2022 20:01 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 15560 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Michigan Mutual Insurance Company |
| 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 | $75 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $25 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $25 |
| 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 | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $375 |
| 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 | MIN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 15560MI0680001-00 |
| Plan Level Exclusions | $1,250 annual benefit maximum for members age 19 or older when coverage begins. Plan excludes coverage for services performed by non-PPO (out-of-network) dentists. |
| Plan Marketing Name | Blue Dental EPO 100/80/50 Voluntary SG |
| Plan Type | EPO |
| Plan Variant Marketing Name | Blue Dental EPO 100/80/50 Voluntary SG |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | MIS008 |
| Source Name | SERFF |
| Plan ID | 15560MI0680001 |
| State Code | MI |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of Blue Dental EPO 100/80/50 Voluntary SG Health Insurance Plan, 15560MI0680001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Dental EPO 100/80/50 Voluntary SG , 15560MI0680001 Health Insurance Plan, 15560MI0680001
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Does Blue Dental EPO 100/80/50 Voluntary SG Health Insurance Plan, 15560MI0680001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15560MI0680001) Health Insurance Plan, Variant (15560MI0680001-00) have Out Of Country Coverage?
Does (15560MI0680001) Health Insurance Plan, Variant (15560MI0680001-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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