Delta Dental Group PPO, EHB Certified - 28856IN0190004 Health Insurance Plan
Delta Dental Plan of Indiana, Inc. health insurance plan with the Plan ID 28856IN0190004. The plan is called Delta Dental Group PPO, EHB Certified.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.85% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.15% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 28856IN0190004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental Plan of Indiana, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 28856IN0190004-00 | ||||||||||||||||||
| Provider Network(s) | ['INN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Tue, 16 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of Delta Dental Group PPO, EHB Certified Health Insurance Plan, 28856IN0190004-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
YES | Tier 1: No Charge, 0.00% Tier 2: No Charge, 20.00% |
No Charge, 20.00% |
| Basic Dental Care - Adult
|
YES | Tier 1: No Charge, 50% Coinsurance after deductible Tier 2: No Charge, 50% Coinsurance after deductible |
No Charge, 50% Coinsurance after deductible |
| Basic Dental Care - Child
|
YES | Tier 1: No Charge, 50% Coinsurance after deductible Tier 2: No Charge, 50% Coinsurance after deductible |
No Charge, 50% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period |
YES | Tier 1: No Charge, 0.00% Tier 2: No Charge, 20.00% |
No Charge, 20.00% |
| Major Dental Care - Adult
|
YES | Tier 1: No Charge, 50% Coinsurance after deductible Tier 2: No Charge, 50% Coinsurance after deductible |
No Charge, 50% Coinsurance after deductible |
| Major Dental Care - Child
|
YES | Tier 1: No Charge, 50% Coinsurance after deductible Tier 2: No Charge, 50% Coinsurance after deductible |
No Charge, 50% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | Tier 1: No Charge, 50.00% Tier 2: No Charge, 50.00% |
No Charge, 50.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Benefit Period |
YES | Tier 1: No Charge, 0.00% Tier 2: No Charge, 20.00% |
No Charge, 20.00% |
Delta Dental Group PPO, EHB Certified Health Insurance Plan Variant 28856IN0190004-00 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 Low Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 25% |
| HIOS Product ID | 28856IN019 |
| Import Date | 8/16/2022 1:00 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Estimated Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 70.85% |
| Issuer ID | 28856 |
| Issuer Marketplace Marketing Name | Delta Dental of Indiana |
| 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 | $150 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $50 |
| 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, In Network (Tier 2), Family Per Group | per group not applicable |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | per person not applicable |
| Medical EHB Deductible, In Network (Tier 2), 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 | $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, In Network (Tier 2), Family Per Group | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), 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 | Low |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | INN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Benefits paid at the Out of Network Level |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Same Benefit Level |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 28856IN0190004-00 |
| Plan Marketing Name | Delta Dental Group PPO, EHB Certified |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental Group PPO, EHB Certified |
| QHP/Non QHP | Off the Exchange |
| Second Tier Utilization | 75% |
| Service Area ID | INS002 |
| Source Name | HIOS |
| Plan ID | 28856IN0190004 |
| State Code | IN |
Copay & Coinsurance of Delta Dental Group PPO, EHB Certified Health Insurance Plan, 28856IN0190004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Delta Dental Group PPO, EHB Certified, 28856IN0190004 Health Insurance Plan, 28856IN0190004
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Does Delta Dental Group PPO, EHB Certified Health Insurance Plan, 28856IN0190004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (28856IN0190004) Health Insurance Plan, Variant (28856IN0190004-00) have Out Of Country Coverage?
Does (28856IN0190004) Health Insurance Plan, Variant (28856IN0190004-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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