Dental Choice Plus 0-20-50 25-1500 - 23603MT0330007 Health Insurance Plan
PacificSource Health Plans health insurance plan with the Plan ID 23603MT0330007. The plan is called Dental Choice Plus 0-20-50 25-1500.
| Health Insurance Plan ID | 23603MT0330007 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Montana | ||||||||||||||||||
| Health Insurance Issuer | PacificSource Health Plans | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 23603MT0330007-00 | ||||||||||||||||||
| Provider Network(s) | ['MTN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Dental Choice Plus 0-20-50 25-1500 Health Insurance Plan Variant 23603MT0330007-00 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 | Yes |
| CSR Variation Type | Standard High Off Exchange Plan |
| Dental Only Plan | Yes |
| First Tier Utilization | 100% |
| HIOS Product ID | 23603MT033 |
| Import Date | 8/18/2021 20:00 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Estimated Rate |
| New/Existing Plan | Existing |
| Issuer ID | 23603 |
| Issuer Marketplace Marketing Name | PacificSource Health Plans |
| Market Coverage | SHOP (Small Group) |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | $375 |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $75 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $25 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $25 |
| 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, 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 | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | Not Applicable |
| 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 | No |
| National Network | Yes |
| Network ID | MTN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | This plan covers eligible services when performed by an eligible provider. |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 23603MT0330007-00 |
| Plan Marketing Name | Dental Choice Plus 0-20-50 25-1500 |
| Plan Type | Indemnity |
| Plan Variant Marketing Name | Dental Choice Plus 0-20-50 25-1500 |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | MTS004 |
| Source Name | SERFF |
| Plan ID | 23603MT0330007 |
| State Code | MT |
| URL for Summary of Benefits & Coverage | URL |
Copay & Coinsurance of Dental Choice Plus 0-20-50 25-1500 Health Insurance Plan, 23603MT0330007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Dental Choice Plus 0-20-50 25-1500, 23603MT0330007 Health Insurance Plan, 23603MT0330007
-
Does Dental Choice Plus 0-20-50 25-1500 Health Insurance Plan, 23603MT0330007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (23603MT0330007) Health Insurance Plan, Variant (23603MT0330007-00) have Out Of Country Coverage?
Yes. Details: Emergency care only
Does (23603MT0330007) Health Insurance Plan, Variant (23603MT0330007-00) have Out of Service Area Coverage?
Yes. Details: This plan covers eligible services when performed by an eligible provider.
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