Delta Dental Individual Pediatric-Only PPO, EHB Certified - 34930MI0120001 Health Insurance Plan
Delta Dental Plan of Michigan, Inc. health insurance plan with the Plan ID 34930MI0120001. The plan is called Delta Dental Individual Pediatric-Only PPO, EHB Certified.
| Health Insurance Plan ID | 34930MI0120001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Delta Dental Plan of Michigan, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 34930MI0120001-00 | ||||||||||||||||||
| Provider Network(s) | ['MIN001'] | ||||||||||||||||||
| 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 | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefits of Delta Dental Individual Pediatric-Only PPO, EHB Certified Health Insurance Plan, 34930MI0120001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
Exclusions: See Plan Brochure. |
YES | Tier 1: 0.00% Tier 2: 0.00% |
0.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Exclusions: See Plan Brochure. |
YES | Tier 1: 20.00% Tier 2: 40.00% |
40.00% |
| 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: 0.00% |
0.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Exclusions: See Plan Brochure. |
YES | Tier 1: 50.00% Tier 2: 50.00% |
50.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Routine Dental Services (Adult)
|
NO |
Delta Dental Individual Pediatric-Only PPO, EHB Certified Health Insurance Plan Variant 34930MI0120001-00 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 | 2024 |
| Child-Only Offering | Allows Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 25% |
| HIOS Product ID | 34930MI012 |
| Import Date | 2023-08-16 20:01:48 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 34930 |
| Issuer Marketplace Marketing Name | Delta Dental of Michigan |
| 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 | $0 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $0 |
| 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 | $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, In Network (Tier 2), Family Per Group | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), 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 | High |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | MIN001 |
| 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 | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 34930MI0120001-00 |
| 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 | MIS001 |
| Source Name | SERFF |
| Plan ID | 34930MI0120001 |
| State Code | MI |
Copay & Coinsurance of Delta Dental Individual Pediatric-Only PPO, EHB Certified Health Insurance Plan, 34930MI0120001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Delta Dental Individual Pediatric-Only PPO, EHB Certified, 34930MI0120001 Health Insurance Plan, 34930MI0120001
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Does Delta Dental Individual Pediatric-Only PPO, EHB Certified Health Insurance Plan, 34930MI0120001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (34930MI0120001) Health Insurance Plan, Variant (34930MI0120001-00) have Out Of Country Coverage?
Yes. Details: Benefits paid at the Out of Network Level
Does (34930MI0120001) Health Insurance Plan, Variant (34930MI0120001-00) have Out of Service Area Coverage?
Yes. Details: Same Benefit Level
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