Blue Dental PPO Plus 100/50/50 SG - 15560MI0420006 Health Insurance Plan
Blue Cross Blue Shield of Michigan Mutual Insurance Company health insurance plan with the Plan ID 15560MI0420006. The plan is called Blue Dental PPO Plus 100/50/50 SG.
| Health Insurance Plan ID | 15560MI0420006 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Michigan Mutual Insurance Company | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 15560MI0420006-00 | ||||||||||||||||||
| 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 | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Blue Dental PPO Plus 100/50/50 SG Health Insurance Plan Variant 15560MI0420006-00 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 | 2022 |
| 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 | 15560MI042 |
| Import Date | 8/18/2021 20:00 |
| 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 | $75 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $25 per person |
| Medical EHB Deductible, Out of Network, Individual | $25 |
| 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 | Yes |
| Out of Service Area Coverage Description | Any licensed dentist in the country can participate with us on a per-claim basis through our Blue Par Select arrangement. Like PPO network dentists, Blue Par Select dentists accept the Blues’ approved amount as full payment for covered services, less your plan’s deductible or any copay. |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 15560MI0420006-00 |
| Plan Level Exclusions | $1,000 annual benefit maximum for members age 19 or older when coverage begins. |
| Plan Marketing Name | Blue Dental PPO Plus 100/50/50 SG |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Dental PPO Plus 100/50/50 SG |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | MIS009 |
| Source Name | SERFF |
| Plan ID | 15560MI0420006 |
| State Code | MI |
Copay & Coinsurance of Blue Dental PPO Plus 100/50/50 SG Health Insurance Plan, 15560MI0420006
| 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 PPO Plus 100/50/50 SG, 15560MI0420006 Health Insurance Plan, 15560MI0420006
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Does Blue Dental PPO Plus 100/50/50 SG Health Insurance Plan, 15560MI0420006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15560MI0420006) Health Insurance Plan, Variant (15560MI0420006-00) have Out Of Country Coverage?
Yes. Details: Emergency
Does (15560MI0420006) Health Insurance Plan, Variant (15560MI0420006-00) have Out of Service Area Coverage?
Yes. Details: Any licensed dentist in the country can participate with us on a per-claim basis through our Blue Par Select arrangement. Like PPO network dentists, Blue Par Select dentists accept the Blues’ approved amount as full payment for covered services, less your plan’s deductible or any copay.
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