Blue Select Children's Dental, ST, OON, Pediatric Dental - 78124NY1160003 Health Insurance Plan
Excellus Health Plan, Inc health insurance plan with the Plan ID 78124NY1160003. The plan is called Blue Select Children's Dental, ST, OON, Pediatric Dental.
| Health Insurance Plan ID | 78124NY1160003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | New York | ||||||||||||||||||
| Health Insurance Issuer | Excellus Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 78124NY1160003-01 | ||||||||||||||||||
| Provider Network(s) | ['NYN014'] | ||||||||||||||||||
| 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 Select Children's Dental, ST, OON, Pediatric Dental Health Insurance Plan Variant 78124NY1160003-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Child-Only |
| Composite Rating Offered | No |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 100% |
| First Tier Utilization | 100% |
| HIOS Product ID | 78124NY116 |
| Import Date | 1/23/2023 |
| Guaranteed Rate | Guaranteed Rate |
| IsItANewPlan | Existing |
| Issuer ID | 78124 |
| Market Coverage | Individual |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | $350 per person | $700 per group |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | $350 |
| Medical EHB Deductible, Combined In/Out of Network, Family | $50 per person | $150 per group |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $50 |
| Medical EHB Deductible, In Network (Tier 1), Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group 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 person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | Not Applicable |
| 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 | Low |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NYN014 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Local: lesser of fee schedule or charge |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 78124NY1160003-01 |
| Plan Marketing Name | Blue Select Children's Dental, ST, OON, Pediatric Dental |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Select Children's Dental, ST, OON, Pediatric Dental |
| QHP/Non QHP | Both |
| Service Area ID | NYS009 |
| Source Name | SERFF |
| Plan ID | 78124NY1160003 |
| State Code | NY |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Select Children's Dental, ST, OON, Pediatric Dental Health Insurance Plan, 78124NY1160003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Blue Select Children's Dental, ST, OON, Pediatric Dental, 78124NY1160003 Health Insurance Plan, 78124NY1160003
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Does Blue Select Children's Dental, ST, OON, Pediatric Dental Health Insurance Plan, 78124NY1160003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (78124NY1160003) Health Insurance Plan, Variant (78124NY1160003-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (78124NY1160003) Health Insurance Plan, Variant (78124NY1160003-01) have Out of Service Area Coverage?
Yes. Details: Local: lesser of fee schedule or charge
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