Ultra Dental - 31256MI0020017 Health Insurance Plan

DENCAP Dental Plans, Inc. health insurance plan with the Plan ID 31256MI0020017. The plan is called Ultra Dental.

Health Insurance Plan ID 31256MI0020017
Health Insurance Plan Year 2023
State Michigan
Health Insurance Issuer DENCAP Dental Plans, Inc.
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 31256MI0020017-00
Provider Network(s) ['MIN003']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 GMT).

Providers Michigan 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 - 31256MI0020017-00

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Tue, 14 May 2024 06:16 GMT

Benefits of Ultra Dental Health Insurance Plan, 31256MI0020017-00

Benefit Covered In Network Out Of Network
Accidental Dental

Limit: 100.0 Dollars per Year

When 50 or more miles away from your selected General Dentist, DENCAP will reimburse 50% up to $100 for emergency services that relieve severe pain and are covered benefits.

YES

No Charge, 20.00%

50.00%
Basic Dental Care - Adult

Limit: 3000.0 Dollars per Year

$2500 Primary Care (General Dentist) Maximum, $500 Specialty Care (Specialist) Maximum after 6 months of enrollment. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits.

YES

No Charge, 15.00%

100.00%
Basic Dental Care - Child

Limit: 3000.0 Dollars per Year

$2500 Primary Care (General Dentist) Maximum, $500 Specialty Care (Specialist) Maximum after 6 months of enrollment. Maximums and waiting periods are waived for EHB benefits. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits.

YES

No Charge, 15.00%

100.00%
Dental Check-Up for Children

Limit: 3.0 Visit(s) per Year

Percentages are approximate. Maximums and waiting periods are waived for EHB benefits. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits.

YES

No Charge

100.00%
Major Dental Care - Adult

Limit: 3000.0 Dollars per Year

$2500 Primary Care (General Dentist) Maximum, $500 Specialty Care (Specialist) Maximum after 6 months of enrollment. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits.

YES

No Charge, 20.00%

100.00%
Major Dental Care - Child

Limit: 3000.0 Dollars per Year

$2500 Primary Care (General Dentist) Maximum, $500 Specialty Care (Specialist) Maximum after 6 months of enrollment. Maximums and waiting periods are waived for EHB benefits. Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits.

YES

No Charge, 20.00%

100.00%
Orthodontia - Adult

Limit: 1.0 Treatment(s) per Year

In-Network Orthodontists give an $1200 discount with referral from your General Dentist.

YES

65.00%

100.00%
Orthodontia - Child

Limit: 1.0 Treatment(s) per Year

In-Network Orthodontists give an $1800 discount with referral from your General Dentist.

YES

65.00%

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Percentages are approximate. Your out of pocket (co-pay) payment to your Dentist is shown on the Schedule of Benefits.

YES

No Charge

100.00%

Ultra Dental Health Insurance Plan Variant 31256MI0020017-00 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 High Off Exchange Plan
Dental Only Plan Yes
First Tier Utilization 100%
HIOS Product ID 31256MI002
Import Date 8/17/2022 20:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 31256
Issuer Marketplace Marketing Name DENCAP Dental Plans, Inc
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 $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
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 High
Multiple In Network Tiers No
National Network No
Network ID MIN003
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description In-Network Dentists outside of Service Area
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 31256MI0020017-00
Plan Marketing Name Ultra Dental
Plan Type HMO
Plan Variant Marketing Name Ultra Dental
QHP/Non QHP Off the Exchange
Service Area ID MIS002
Source Name SERFF
Plan ID 31256MI0020017
State Code MI

Copay & Coinsurance of Ultra Dental Health Insurance Plan, 31256MI0020017

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

Frequently Asked Questions(FAQ) about Ultra Dental, 31256MI0020017 Health Insurance Plan, 31256MI0020017

  • Does Ultra Dental Health Insurance Plan, 31256MI0020017 support Mail Ordering?

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

  • Does (31256MI0020017) Health Insurance Plan, Variant (31256MI0020017-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (31256MI0020017) Health Insurance Plan, Variant (31256MI0020017-00) have Out of Service Area Coverage?

    Yes. Details: In-Network Dentists outside of Service Area

 

Disclaimer: This is based on the import(Date: Tue, 14 May 2024 06:16 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