Family Basic Dental Plan (Low) - 48364TX0030001 Health Insurance Plan
SafeGuard Dental MetLife health insurance plan with the Plan ID 48364TX0030001. The plan is called Family 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 | 48364TX0030001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | SafeGuard Dental MetLife | ||||||||||||||||||
| Health Insurance Plan Variant | 48364TX0030001-00 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| 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 | Tue, 14 Jun 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Benefits of Family Basic Dental Plan (Low) Health Insurance Plan, 48364TX0030001-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Limit: 1.0 Treatment(s) per Procedure |
YES | $20.00 |
100.00% |
| Basic Dental Care - Child
Limit: 1.0 Treatment(s) per Procedure |
YES | $20.00 |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Visit(s) per 6 Months |
YES | $0.00 |
100.00% |
| Major Dental Care - Adult
Limit: 1.0 Treatment(s) per Procedure |
YES | $135.00 |
100.00% |
| Major Dental Care - Child
Limit: 1.0 Treatment(s) per Procedure |
YES | $135.00 |
100.00% |
| Orthodontia - Adult
Limit: 1.0 Treatment(s) per Procedure |
YES | $2,410.00 |
100.00% |
| Orthodontia - Child
|
YES | $2,410.00 |
100.00% |
| Routine Dental Services (Adult)
Limit: 1.0 Visit(s) per 6 Months |
YES | $0.00 |
100.00% |
Family Basic Dental Plan (Low) Health Insurance Plan Variant 48364TX0030001-00 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 | 2023 |
| Child-Only Offering | Allows Adult and 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 | 48364TX003 |
| Import Date | 6/14/2022 1:01 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer Actuarial Value | 70.00% |
| Issuer ID | 48364 |
| Issuer Marketplace Marketing Name | SafeGuard Dental MetLife |
| 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 | 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, 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 | No |
| Network ID | TXN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of country claims are only covered for emergency treatment only. 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 | Out of country claims are only covered for emergency treatment only with a reimbursement of $50 USD. |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 48364TX0030001-00 |
| 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 | Family Basic Dental Plan (Low) |
| Plan Type | HMO |
| Plan Variant Marketing Name | Family Basic Dental Plan (Low) |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 48364TX0030001 |
| State Code | TX |
Copay & Coinsurance of Family Basic Dental Plan (Low) Health Insurance Plan, 48364TX0030001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Family Basic Dental Plan (Low), 48364TX0030001 Health Insurance Plan, 48364TX0030001
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Does Family Basic Dental Plan (Low) Health Insurance Plan, 48364TX0030001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (48364TX0030001) Health Insurance Plan, Variant (48364TX0030001-00) have Out Of Country Coverage?
Yes. Details: Out of country claims are only covered for emergency treatment only. Covered services should be a recognized ADA procedure code to identify the service provided.
Does (48364TX0030001) Health Insurance Plan, Variant (48364TX0030001-00) have Out of Service Area Coverage?
Yes. Details: Out of country claims are only covered for emergency treatment only with a reimbursement of $50 USD.
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