Delta Dental Individual PPO, EHB Certified - 57874IN0040001 Health Insurance Plan
Renaissance Dental health insurance plan with the Plan ID 57874IN0040001. The plan is called Delta Dental Individual PPO, EHB Certified.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 85.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 14.10% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 57874IN0040001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Indiana | ||||||||||||||||||
| Health Insurance Issuer | Renaissance Dental | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57874IN0040001-00 | ||||||||||||||||||
| 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 | Wed, 16 Jun 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Delta Dental Individual PPO, EHB Certified Health Insurance Plan Variant 57874IN0040001-00 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 | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1 |
| First Tier Utilization | 25% |
| HIOS Product ID | 57874IN004 |
| Import Date | 6/16/2021 13:07 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Estimated Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 85.90% |
| Issuer ID | 57874 |
| Issuer Marketplace Marketing Name | Renaissance Dental |
| 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 | High |
| 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 | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 57874IN0040001-00 |
| Plan Marketing Name | Delta Dental Individual PPO, EHB Certified |
| Plan Type | PPO |
| Plan Variant Marketing Name | Delta Dental Individual PPO, EHB Certified |
| QHP/Non QHP | Off the Exchange |
| Second Tier Utilization | 75% |
| Service Area ID | INS001 |
| Source Name | HIOS |
| Plan ID | 57874IN0040001 |
| State Code | IN |
Copay & Coinsurance of Delta Dental Individual PPO, EHB Certified Health Insurance Plan, 57874IN0040001
| 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 PPO, EHB Certified, 57874IN0040001 Health Insurance Plan, 57874IN0040001
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Does Delta Dental Individual PPO, EHB Certified Health Insurance Plan, 57874IN0040001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57874IN0040001) Health Insurance Plan, Variant (57874IN0040001-00) have Out Of Country Coverage?
Yes. Details: Benefits paid at the Out of Network Level
Does (57874IN0040001) Health Insurance Plan, Variant (57874IN0040001-00) 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