Delta Dental Plan of Indiana, Inc. health insurance plan with the Plan ID 28856IN0170002. The plan is called Delta Dental Individual Pediatric-Only PPO, EHB Certified.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.86% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.14% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 28856IN0170002 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Indiana | ||||||||||||||||||
Health Insurance Issuer | Delta Dental Plan of Indiana, Inc. | ||||||||||||||||||
Health Insurance Plan Variant | 28856IN0170002-00 | ||||||||||||||||||
Provider Network(s) | ['INN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 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, 14 May 2024 06:16 GMT |
Benefit | Covered | In Network | Out Of Network |
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Accidental Dental
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Exclusions: See Plan Brochure. |
YES | Tier 1: 50% Coinsurance after deductible Tier 2: 50% Coinsurance after deductible |
50% Coinsurance after deductible |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Benefit Period Exclusions: See Plan Brochure. X-Rays may be subject to deductible. |
YES | Tier 1: 0.00% Tier 2: 20.00% |
20.00% |
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
Exclusions: See Plan Brochure. |
YES | Tier 1: 50% Coinsurance after deductible Tier 2: 50% Coinsurance after deductible |
50% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Exclusions: Limited to medically necessary. See Plan Brochure. |
YES | Tier 1: 50.00% Tier 2: 50.00% |
50.00% |
Routine Dental Services (Adult)
|
NO |
Plan Attribute | Value |
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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 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 | 25% |
HIOS Product ID | 28856IN017 |
Import Date | 8/16/2022 1:00 |
Inpatient Copayment Maximum Days | 0 |
Guaranteed Rate | Estimated Rate |
New/Existing Plan | Existing |
Issuer Actuarial Value | 71.86% |
Issuer ID | 28856 |
Issuer Marketplace Marketing Name | Delta Dental of Indiana |
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 | $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 | INN001 |
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) | 28856IN0170002-00 |
Plan Marketing Name | Delta Dental Individual Pediatric-Only PPO, EHB Certified |
Plan Type | PPO |
Plan Variant Marketing Name | Delta Dental Individual Pediatric-Only PPO, EHB Certified |
QHP/Non QHP | Off the Exchange |
Second Tier Utilization | 75% |
Service Area ID | INS001 |
Source Name | HIOS |
Plan ID | 28856IN0170002 |
State Code | IN |
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, 14 May 2024 06:16 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