Fidelis Care | Dental Plan Comparison Tool

Plan

Plan Name:

Ambetter from Fidelis Care Gold Enhanced, Gold, NS, INN, Fidelis Care HBX Network, Dep25, Family Vision, Free Telemedicine Program, Family Dental

Issuer Name:

Fidelis Care

HIOS ID:

25303NY0550001

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:

$600

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:

Gold

Coverage Level:

Couple

Benefits Excluded from In Network MOOP:

None

QHP In Network Cost Sharing Adult Benefits

QHP Deductible 2+ Adult Members:

$1,200

QHP MOOP Adult Individual:

$7,900

QHP MOOP 2+ Adult Members:

$15,800

QHP Office Visit With No Additional Services - Adult:

CP: $25

QHP Oral Evaluation - Adult:

CP: $25

QHP Complete Set of X-Rays - Adult:

CP: $25

QHP Topical Fluoride - Adult:

CP: $25

QHP Polishing - Adult:

CP: $25

QHP Sealant (per tooth) - Adult:

CP: $25

QHP Simple Extraction - Adult:

CP: $25

QHP Fillings - Adult:

CP: $25

QHP Single Restoration Crowns - Adult:

CP: $25

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: $25

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:

$600

QHP Deductible Pediatric 2+ Children:

$1,200

QHP MOOP Pediatric Individual:

$7,900

QHP MOOP Pediatric 2+ Children:

$15,800

QHP Dental Check-Up - Child:

CP: $25

QHP Basic Dental Care - Child:

CP: $25

QHP Cosmetic Orthodontia - Child:

CI: Not covered

QHP Orthodontia - Child:

CP: $25 Copay AD

QHP Major Dental Care - Child:

CP: $25 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:

$1,751.10

Allegany:

$1,484.10

Bronx:

$2,333.34

Broome:

$1,706.70

Cattaraugus:

$1,484.10

Cayuga:

$1,706.70

Chautauqua:

$1,484.10

Chemung:

$1,706.70

Chenango:

$1,734.50

Columbia:

$1,751.10

Cortland:

$1,706.70

Delaware:

$2,014.14

Dutchess:

$2,014.14

Erie:

$1,484.10

Essex:

$1,734.50

Franklin:

$1,734.50

Fulton:

$1,751.10

Genesee:

$1,484.10

Greene:

$1,751.10

Hamilton:

$1,734.50

Jefferson:

$1,734.50

Kings:

$2,333.34

Lewis:

$1,734.50

Livingston:

$1,829.76

Madison:

$1,734.50

Monroe:

$1,829.76

Nassau:

$2,063.60

New York:

$2,333.34

Niagara:

$1,484.10

Oneida:

$1,734.50

Onondaga:

$1,706.70

Ontario:

$1,829.76

Orange:

$2,014.14

Orleans:

$1,484.10

Oswego:

$1,734.50

Putnam:

$2,014.14

Queens:

$2,333.34

Rensselaer:

$1,751.10

Richmond:

$2,333.34

Rockland:

$2,333.34

Saratoga:

$1,751.10

Schenectady:

$1,751.10

Schuyler:

$1,706.70

Seneca:

$1,829.76

St Lawrence:

$1,734.50

Steuben:

$1,706.70

Suffolk:

$2,063.60

Sullivan:

$2,014.14

Tioga:

$1,706.70

Ulster:

$2,014.14

Warren:

$1,751.10

Washington:

$1,751.10

Wayne:

$1,829.76

Westchester:

$2,333.34

Wyoming:

$1,484.10

Yates:

$1,829.76