Dominion Dental Services, Inc. health insurance plan with the Plan ID 66759NC0010001. The plan is called Choice PPO Basic.
Health Insurance Plan ID | 66759NC0010001 | ||||||||||||||||||
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Health Insurance Plan Year | 2024 | ||||||||||||||||||
State | North Carolina | ||||||||||||||||||
Health Insurance Issuer | Dominion Dental Services, Inc. | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 66759NC0010001-01 | ||||||||||||||||||
Provider Network(s) | CHOICE | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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Available Variants of the Health Plan | |||||||||||||||||||
Last Plan Update Date | Thu, 02 Nov 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefit | Covered | In Network | Out Of Network |
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Accidental Dental
|
YES | 85.00% Coinsurance after deductible |
90.00% Coinsurance after deductible |
Basic Dental Care - Adult
Subject to deductible of $50/individual and $150/three or more adults. Annual maximum of $1,000 (Choice PPO Basic) and $1,500 (Choice PPO Premium). Benefit limitations may apply to individual services. Waiting Periods Apply to Basic Services of 6 months and Major services of 12 months (Choice PPO Premium) |
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
Basic Dental Care - Child
|
YES | 65.00% Coinsurance after deductible |
80.00% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period |
YES | 0.00% |
20.00% |
Major Dental Care - Adult
Subject to deductible of $50/individual and $150/three or more adults. Annual maximum of $1,000 (Choice PPO Basic) and $1,500 (Choice PPO Premium). Benefit limitations may apply to individual services. Waiting Periods Apply to Basic Services of 6 months and Major services of 12 months (Choice PPO Premium) |
YES | 85.00% Coinsurance after deductible |
90.00% Coinsurance after deductible |
Major Dental Care - Child
|
YES | 75.00% Coinsurance after deductible |
90.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
Routine Dental Services (Adult)
Subject to deductible of $50/individual and $150/three or more adults. Annual maximum of $1,000 (Choice PPO Basic) and $1,500 (Choice PPO Premium). Benefit limitations may apply to individual services. Waiting Periods Apply to Basic Services of 6 months and Major services of 12 months (Choice PPO Premium) |
YES | 0.00% Coinsurance after deductible |
10.00% Coinsurance after deductible |
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 Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Low On Exchange Plan |
Dental Only Plan | Yes |
EHB Apportionment for Pediatric Dental | 1.0 |
First Tier Utilization | 100% |
HIOS Product ID | 66759NC001 |
Import Date | 2023-11-02 01:01:23 |
Inpatient Copayment Maximum Days | 0 |
Guaranteed Rate | Guaranteed Rate |
New/Existing Plan | Existing |
Issuer ID | 66759 |
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 | $200 per group |
Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $100 per person |
Medical EHB Deductible, Combined In/Out of Network, Individual | $100 |
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 | Yes |
Network ID | NCN001 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Standard Out of Network PPO Benefits |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Standard Out of Network PPO Benefits |
Plan Brochure | URL |
Plan Effective Date | 2024-01-01 |
Plan Expiration Date | 2024-12-31 |
Plan ID (Standard Component ID with Variant) | 66759NC0010001-01 |
Plan Level Exclusions | Out of Pocket Maximum applies to children only. Adults have separate deductible and plan payment maximum, refer to plan document for details. |
Plan Marketing Name | Choice PPO Basic |
Plan Type | PPO |
Plan Variant Marketing Name | Choice PPO Basic |
QHP/Non QHP | Both |
Service Area ID | NCS001 |
Source Name | HIOS |
Plan ID | 66759NC0010001 |
State Code | NC |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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