Delta Dental Individual & Family Standard Plan - 25868SD0010003 Health Insurance Plan
Delta Dental of South Dakota health insurance plan with the Plan ID 25868SD0010003. The plan is called Delta Dental Individual & Family Standard Plan.
| Health Insurance Plan ID | 25868SD0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | South Dakota | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental of South Dakota | ||||||||||||||||||
| Health Insurance Plan Variant | 25868SD0010003-00 | ||||||||||||||||||
| Provider Network(s) | ['SDN001'] | ||||||||||||||||||
| 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 | Wed, 15 Jun 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Benefits of Delta Dental Individual & Family Standard Plan Health Insurance Plan, 25868SD0010003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Annual Adult maximum benefit of $1,000 |
YES | No Charge after deductible, 40.00% Coinsurance after deductible |
No Charge after deductible, 40.00% Coinsurance after deductible |
| Basic Dental Care - Child
|
YES | No Charge after deductible, 40.00% Coinsurance after deductible |
No Charge after deductible, 40.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | No Charge after deductible, No Charge after deductible |
No Charge after deductible, No Charge after deductible |
| Major Dental Care - Adult
Annual Adult maximum benefit of $1,000 |
YES | No Charge after deductible, 60.00% Coinsurance after deductible |
No Charge after deductible, 60.00% Coinsurance after deductible |
| Major Dental Care - Child
|
YES | No Charge after deductible, 60.00% Coinsurance after deductible |
No Charge after deductible, 60.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limited to Medically Necessary |
YES | No Charge after deductible, 60.00% Coinsurance after deductible |
No Charge after deductible, 60.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Annual Adult maximum benefit of $1,000 |
YES | No Charge after deductible, 0.00% Coinsurance after deductible |
No Charge after deductible, 0.00% Coinsurance after deductible |
Delta Dental Individual & Family Standard Plan Health Insurance Plan Variant 25868SD0010003-00 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 |
| EHB Apportionment for Pediatric Dental | 1 |
| First Tier Utilization | 100% |
| HIOS Product ID | 25868SD001 |
| Import Date | 6/15/2022 20:00 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 25868 |
| Issuer Marketplace Marketing Name | Delta Dental of South Dakota |
| 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 | per group not applicable |
| 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 | $100 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $100 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | $100 per person |
| Medical EHB Deductible, Out of Network, Individual | $100 |
| 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 | Low |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | SDN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Care obtained form any Delta Dental Plan Association member company Premier or PPO provider is considered covered. The Delta Dental Plan Associaton has a nationwide Premier presence. |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 25868SD0010003-00 |
| Plan Level Exclusions | EHB Pediatric coverage not available for anyone over the age of 18 |
| Plan Marketing Name | Delta Dental Individual & Family Standard Plan |
| Plan Type | Indemnity |
| Plan Variant Marketing Name | Delta Dental Individual & Family Standard Plan |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | SDS001 |
| Source Name | SERFF |
| Plan ID | 25868SD0010003 |
| State Code | SD |
Copay & Coinsurance of Delta Dental Individual & Family Standard Plan Health Insurance Plan, 25868SD0010003
| 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 Individual & Family Standard Plan, 25868SD0010003 Health Insurance Plan, 25868SD0010003
-
Does Delta Dental Individual & Family Standard Plan Health Insurance Plan, 25868SD0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (25868SD0010003) Health Insurance Plan, Variant (25868SD0010003-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (25868SD0010003) Health Insurance Plan, Variant (25868SD0010003-00) have Out of Service Area Coverage?
Yes. Details: Care obtained form any Delta Dental Plan Association member company Premier or PPO provider is considered covered. The Delta Dental Plan Associaton has a nationwide Premier presence.
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