EHB Basic Dental Plan (Low) - 69051IN0110001 Health Insurance Plan

Metropolitan Life Insurance Company health insurance plan with the Plan ID 69051IN0110001. The plan is called EHB Basic Dental Plan (Low).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 30.00% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 69051IN0110001
Health Insurance Plan Year 2025
State Indiana
Health Insurance Issuer Metropolitan Life Insurance Company
Health Insurance Plan Variant 69051IN0110001-00
Provider Network(s) ['INN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Indiana All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 69051IN0110001-00

Last Plan Update Date Sat, 08 Jun 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of EHB Basic Dental Plan (Low) Health Insurance Plan, 69051IN0110001-00

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Limit: 1.0 Treatment(s) per Procedure

YES

50% Coinsurance after deductible

60% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Visit(s) per 6 Months

YES

10% Coinsurance after deductible

20% Coinsurance after deductible
Major Dental Care - Adult
NO
Major Dental Care - Child

Limit: 1.0 Treatment(s) per Procedure

YES

50.00% Coinsurance after deductible

60% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00%

50.00%
Routine Dental Services (Adult)
NO

EHB Basic Dental Plan (Low) Health Insurance Plan Variant 69051IN0110001-00 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 2025
Child-Only Offering Allows Child-Only
Composite Rating Offered No
CSR Variation Type Standard Low Off Exchange Plan
Dental Only Plan Yes
First Tier Utilization 100%
HIOS Product ID 69051IN011
Import Date 2024-06-08 01:01:06
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer Actuarial Value 70.00%
Issuer ID 69051
Issuer Marketplace Marketing Name Metropolitan Life Insurance Company
Market Coverage SHOP (Small Group)
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 per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
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 $100
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 $100
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group $850 per group
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person $425 per person
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual $425
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 No
National Network Yes
Network ID INN001
Out of Country Coverage Yes
Out of Country Coverage Description Payment is made to the employee in U.S. dollars and is based upon the rate of exchange for the date in which the expense was incurred. Covered services should be a recognized ADA procedure code to identify the service provided.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description The PPO plan has an indemnity schedule of benefits for out of service area coverage.
Plan Effective Date 2025-01-01
Plan ID (Standard Component ID with Variant) 69051IN0110001-00
Plan Level Exclusions When sold off the exchange, MetLife's Dental EHB plans and benefits will meet the stated actuarial value, but the exact plan and benefit design may vary according to the terms of the insurance certificate.
Plan Marketing Name EHB Basic Dental Plan (Low)
Plan Type PPO
Plan Variant Marketing Name EHB Basic Dental Plan (Low)
QHP/Non QHP Off the Exchange
Service Area ID INS001
Source Name HIOS
Plan ID 69051IN0110001
State Code IN

Copay & Coinsurance of EHB Basic Dental Plan (Low) Health Insurance Plan, 69051IN0110001

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about EHB Basic Dental Plan (Low), 69051IN0110001 Health Insurance Plan, 69051IN0110001

  • Does EHB Basic Dental Plan (Low) Health Insurance Plan, 69051IN0110001 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (69051IN0110001) Health Insurance Plan, Variant (69051IN0110001-00) have Out Of Country Coverage?

    Yes. Details: Payment is made to the employee in U.S. dollars and is based upon the rate of exchange for the date in which the expense was incurred. Covered services should be a recognized ADA procedure code to identify the service provided.

    Does (69051IN0110001) Health Insurance Plan, Variant (69051IN0110001-00) have Out of Service Area Coverage?

    Yes. Details: The PPO plan has an indemnity schedule of benefits for out of service area coverage.

 

Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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