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Benefits Cost Sharing PUF - 2018
|
Businessyear
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Statecode
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Issuerid
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Sourcename
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Importdate
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Standardcomponentid
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Planid
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Benefitname
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Copayinntier1
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Copayinntier2
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Copayoutofnet
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Coinsinntier1
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Coinsinntier2
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Coinsoutofnet
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Isehb
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Iscovered
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Quantlimitonsvc
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Limitqty
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Limitunit
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Exclusions
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Explanation
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Ehbvarreason
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Isexclfrominnmoop
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Isexclfromoonmoop
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Basic Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Dental Check-Up for Children
|
Not Applicable
|
Not Applicable
|
30.00%
|
0.3
|
t
|
Covered
|
t
|
1
|
Visit(s) per 6 Months
|
Substantially Equal
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Major Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.5
|
Covered
|
t
|
1000
|
Dollars per Year
|
12-exclusion period period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Major Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Orthodontia - Adult
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Orthodontia - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
Only medically necessary orthodontia is covered
|
Substantially Equal
|
f
|
f
|
||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-00
|
Routine Dental Services (Adult)
|
Not Applicable
|
Not Applicable
|
20.00%
|
0.2
|
Covered
|
t
|
1000
|
Dollars per Year
|
Combined annual benefit maximum
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Basic Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Dental Check-Up for Children
|
Not Applicable
|
Not Applicable
|
30.00%
|
0.3
|
t
|
Covered
|
t
|
1
|
Visit(s) per 6 Months
|
Substantially Equal
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Major Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.5
|
Covered
|
t
|
1000
|
Dollars per Year
|
12-exclusion period period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Major Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Orthodontia - Adult
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Orthodontia - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
Only medically necessary orthodontia is covered
|
Substantially Equal
|
f
|
f
|
||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0030001
|
21989AK0030001-01
|
Routine Dental Services (Adult)
|
Not Applicable
|
Not Applicable
|
20.00%
|
0.2
|
Covered
|
t
|
1000
|
Dollars per Year
|
Combined annual benefit maximum
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Basic Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
20.00%
|
0.5
|
Covered
|
t
|
1000
|
Visit(s) per Year
|
6-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Basic Dental Care - Child
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Major Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.5
|
Covered
|
t
|
1000
|
Visit(s) per Year
|
12-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Major Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Orthodontia - Adult
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Orthodontia - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
Only medically necessary orthodontia is covered
|
Substantially Equal
|
f
|
f
|
||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-00
|
Routine Dental Services (Adult)
|
Not Applicable
|
Not Applicable
|
No Charge
|
0.5
|
Covered
|
t
|
1000
|
Dollars per Year
|
Combined annual benefit maximum
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Basic Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
20.00%
|
0.5
|
Covered
|
t
|
1000
|
Visit(s) per Year
|
6-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Basic Dental Care - Child
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Major Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.5
|
Covered
|
t
|
1000
|
Visit(s) per Year
|
12-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Major Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Orthodontia - Adult
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Orthodontia - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
Only medically necessary orthodontia is covered
|
Substantially Equal
|
f
|
f
|
||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050001
|
21989AK0050001-01
|
Routine Dental Services (Adult)
|
Not Applicable
|
Not Applicable
|
No Charge
|
0.5
|
Covered
|
t
|
1000
|
Dollars per Year
|
Combined annual benefit maximum
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Basic Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
20.00%
|
0.5
|
Covered
|
t
|
1500
|
Visit(s) per Year
|
6-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Basic Dental Care - Child
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Major Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.5
|
Covered
|
t
|
1500
|
Visit(s) per Year
|
12-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Major Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Orthodontia - Adult
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Orthodontia - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
Only medically necessary orthodontia is covered
|
Substantially Equal
|
f
|
f
|
||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-00
|
Routine Dental Services (Adult)
|
Not Applicable
|
Not Applicable
|
No Charge
|
0.5
|
Covered
|
t
|
1500
|
Dollars per Year
|
Combined annual benefit maximum
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Basic Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
20.00%
|
0.5
|
Covered
|
t
|
1500
|
Visit(s) per Year
|
6-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Basic Dental Care - Child
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Major Dental Care - Adult
|
Not Applicable
|
Not Applicable
|
50.00%
|
0.5
|
Covered
|
t
|
1500
|
Visit(s) per Year
|
12-month exclusion period for age 19 and over if member does not have 12 continuous months of prior dental coverage with no more than a 90-day break in coverage from the end of the old policy to the effective date of the new policy.
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Major Dental Care - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
f
|
f
|
||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Orthodontia - Adult
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Orthodontia - Child
|
Not Applicable
|
Not Applicable
|
70.00%
|
0.7
|
t
|
Covered
|
Only medically necessary orthodontia is covered
|
Substantially Equal
|
f
|
f
|
||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0050002
|
21989AK0050002-01
|
Routine Dental Services (Adult)
|
Not Applicable
|
Not Applicable
|
No Charge
|
0.5
|
Covered
|
t
|
1500
|
Dollars per Year
|
Combined annual benefit maximum
|
Not EHB
|
f
|
f
|
||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0070001
|
21989AK0070001-00
|
Accidental Dental
|
||||||||||||||||
|
2018
|
AK
|
21989
|
HIOS
|
2017-09-26 02:21:16
|
21989AK0070001
|
21989AK0070001-00
|
Basic Dental Care - Adult
|
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