Fidelis Care | Dental Plan Comparison Tool

Plan

Plan Name:

Ambetter from Fidelis Care Silver Enhanced, Silver, NS, INN, Fidelis Care HBX Network, Dep 25, Family Vision, Free Telemedicine Program, Family Dental

Issuer Name:

Fidelis Care

HIOS ID:

25303NY0460001

Annual Benefit Maximum:

N/A

Plan Brochure Link:

View

Out of Network Coverage:

N

Dental Plan Type

Dental Plan Type:

QHP that includes family dental benefits

Plan Information

Dep Age:

Age 25

Plan Type:

HMO

Standard or Non-Standard Plan:

Non-Standard

Waiting Periods:

No

Deductible Adult Individual:

$2,100

Limit Description:

1 exam and cleaning per 6 months. Full mouth x-rays or panoramic x-rays at 36-month intervals and bitewing x-rays at 6 month intervals

Limits on Services:

Y

Lifetime Benefit Maximum:

N/A

Metal Level:

Silver

Coverage Level:

Family

Benefits Excluded from In Network MOOP:

None

QHP In Network Cost Sharing Adult Benefits

QHP Deductible 2+ Adult Members:

$4,200

QHP MOOP Adult Individual:

$9,200

QHP MOOP 2+ Adult Members:

$18,400

QHP Office Visit With No Additional Services - Adult:

CP: $30

QHP Oral Evaluation - Adult:

CP: $30

QHP Complete Set of X-Rays - Adult:

CP: $30

QHP Topical Fluoride - Adult:

CP: $30

QHP Polishing - Adult:

CP: $30

QHP Sealant (per tooth) - Adult:

CP: $30

QHP Simple Extraction - Adult:

CP: $30

QHP Fillings - Adult:

CP: $30

QHP Single Restoration Crowns - Adult:

CP: $30

QHP Pulp Cap - Adult:

CI: Not covered

QHP Root Canal - Adult:

CI: Not covered

QHP Scaling - Adult:

CI: Not covered

QHP Gingivectomy or Gingivoplasty - Adult:

CI: Not covered

QHP Gum Surgery - Adult:

CI: Not covered

QHP Tissue Grafting - Adult:

CI: Not covered

QHP Routine Braces - Adult:

CI: Not covered

QHP Partial Dentures - Adult:

CI: Not covered

QHP Complete Dentures - Adult:

CI: Not covered

QHP Dental Implants - Adults:

CI: Not covered

QHP Bridges - Adults:

CI: Not covered

QHP Veneers - Adult:

CI: Not covered

QHP TMJ - Adult:

CI: Not covered

QHP Prophylaxis - Adult:

CP: $30

QHP Spacers - Adult:

CI: Not covered

QHP Bonding - Adult:

CI: Not covered

QHP Additional Out of Network Cost Sharing Adult Benefits

QHP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):

N/A

QHP Deductible 2+ Adult Members (Out of Network Cost Sharing Adult Benefits):

N/A

QHP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):

N/A

QHP MOOP 2+ Adult Members (Out of Network Cost Sharing Adult Benefits):

N/A

QHP In Network Cost Sharing Pediatric Benefits

QHP Deductible Pediatric Individual:

$2,100

QHP Deductible Pediatric 2+ Children:

$4,200

QHP MOOP Pediatric Individual:

$9,200

QHP MOOP Pediatric 2+ Children:

$18,400

QHP Dental Check-Up - Child:

CP: $30

QHP Basic Dental Care - Child:

CP: $30

QHP Cosmetic Orthodontia - Child:

CI: Not covered

QHP Orthodontia - Child:

CP: $30 Copay AD

QHP Major Dental Care - Child:

CP: $30 Copay AD

QHP Out of Network Cost Sharing Pediatric Benefits

QHP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):

N/A

QHP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):

N/A

QHP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):

N/A

QHP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):

N/A

Network Information (QHP)

QHP Out of Country Coverage:

N

QHP Out of Service Area Coverage:

N

QHP National Network:

N

QHP Network Name:

Fidelis Care HBX Network

QHP Network URL

https://www.fideliscare.org/Find-A-Doctor

Counties

Albany:

$1,933.16

Allegany:

$1,638.38

Bronx:

$2,575.92

Broome:

$1,884.14

Cattaraugus:

$1,638.38

Cayuga:

$1,884.14

Chautauqua:

$1,638.38

Chemung:

$1,884.14

Chenango:

$1,914.83

Columbia:

$1,933.16

Cortland:

$1,884.14

Delaware:

$2,223.54

Dutchess:

$2,223.54

Erie:

$1,638.38

Essex:

$1,914.83

Franklin:

$1,914.83

Fulton:

$1,933.16

Genesee:

$1,638.38

Greene:

$1,933.16

Hamilton:

$1,914.83

Jefferson:

$1,914.83

Kings:

$2,575.92

Lewis:

$1,914.83

Livingston:

$2,019.99

Madison:

$1,914.83

Monroe:

$2,019.99

Nassau:

$2,278.15

New York:

$2,575.92

Niagara:

$1,638.38

Oneida:

$1,914.83

Onondaga:

$1,884.14

Ontario:

$2,019.99

Orange:

$2,223.54

Orleans:

$1,638.38

Oswego:

$1,914.83

Putnam:

$2,223.54

Queens:

$2,575.92

Rensselaer:

$1,933.16

Richmond:

$2,575.92

Rockland:

$2,575.92

Saratoga:

$1,933.16

Schenectady:

$1,933.16

Schuyler:

$1,884.14

Seneca:

$2,019.99

St Lawrence:

$1,914.83

Steuben:

$1,884.14

Suffolk:

$2,278.15

Sullivan:

$2,223.54

Tioga:

$1,884.14

Ulster:

$2,223.54

Warren:

$1,933.16

Washington:

$1,933.16

Wayne:

$2,019.99

Westchester:

$2,575.92

Wyoming:

$1,638.38

Yates:

$2,019.99