Delta Dental of Colorado Summit Plan - 28052CO0020004 Health Insurance Plan
28052 health insurance plan with the Plan ID 28052CO0020004. The plan is called Delta Dental of Colorado Summit Plan.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 13.00% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 28052CO0020004 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Colorado | ||||||||||||||||||
| Health Insurance Issuer | 28052 | ||||||||||||||||||
| Health Insurance Plan Variant | 28052CO0020004-01 | ||||||||||||||||||
| Provider Network(s) | ['CON001'] | ||||||||||||||||||
| 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 | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Delta Dental of Colorado Summit Plan Health Insurance Plan Variant 28052CO0020004-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 85% |
| First Tier Utilization | 100% |
| HIOS Product ID | 28052CO002 |
| Import Date | 1/23/2023 |
| Guaranteed Rate | Guaranteed Rate |
| IsItANewPlan | Existing |
| Issuer Actuarial Value | 87.00% |
| Issuer ID | 28052 |
| Market Coverage | Individual |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family | per person not applicable | per group 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 person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Family | $50 per person | $150 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $50 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family | $350 per person | $700 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $350 |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | High |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | CON001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Delta Dental National PPO Network |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 28052CO0020004-01 |
| Plan Marketing Name | Delta Dental of Colorado Summit Plan |
| Plan Type | EPO |
| Plan Variant Marketing Name | Delta Dental of Colorado Summit Plan |
| QHP/Non QHP | Both |
| Service Area ID | COS001 |
| Source Name | SERFF |
| Plan ID | 28052CO0020004 |
| State Code | CO |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Delta Dental of Colorado Summit Plan Health Insurance Plan, 28052CO0020004
| 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 of Colorado Summit Plan, 28052CO0020004 Health Insurance Plan, 28052CO0020004
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Does Delta Dental of Colorado Summit Plan Health Insurance Plan, 28052CO0020004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (28052CO0020004) Health Insurance Plan, Variant (28052CO0020004-01) have Out Of Country Coverage?
Does (28052CO0020004) Health Insurance Plan, Variant (28052CO0020004-01) have Out of Service Area Coverage?
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