EMI Health Advantage PPO (Low) - 53613AZ0020002 Health Insurance Plan

Educators Health Plans Life, Accident, and Health, Inc health insurance plan with the Plan ID 53613AZ0020002. The plan is called EMI Health Advantage PPO (Low).

Health Insurance Plan ID 53613AZ0020002
Health Insurance Plan Year 2023
State Arizona
Health Insurance Issuer Educators Health Plans Life, Accident, and Health, Inc
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 53613AZ0020002-01
Provider Network(s) ['AZN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT).

Providers Arizona 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 On Exchange Plan - 53613AZ0020002-01

Last Plan Update Date Thu, 11 Aug 2022 00:00 GMT
Last Import Date Tue, 23 Apr 2024 07:07 GMT

Benefits of EMI Health Advantage PPO (Low) Health Insurance Plan, 53613AZ0020002-01

Benefit Covered In Network Out Of Network
Accidental Dental
NO
Basic Dental Care - Adult

Exclusions: Fillings on the same surface 1 every 18 months. Basic benefits covered after 6 month waiting period.

Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

50.00% Coinsurance after deductible

 50.00% Coinsurance after deductible
Basic Dental Care - Child

Exclusions: Space Maintainers not covered after the end of the month the enrollee turns age 19.

Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

50.00% Coinsurance after deductible

 50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Year

Limit applies to Exams, Cleanings and Fluoride. Vertical Bitewing X-rays up to 8 every 6 months. Panoramic X-Ray is allowed 1 every 3 years. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

0.00% Coinsurance after deductible

 0.00% Coinsurance after deductible
Major Dental Care - Adult
NO
Major Dental Care - Child

Exclusions: Anesthesia is only covered when medically or dentally necessary. Implants not covered after the end of the month the enrollee turns age 19. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth.

Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

75.00% Coinsurance after deductible

 75.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Exclusions: Covered up to the end of the month the enrollee turns age 19.

Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

50.00%

 50.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

Limit applies to Exams, Cleanings and Fluoride. Vertical Bitewing X-rays up to 8 every 6 months. Panoramic X-Ray is allowed 1 every 3 years. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.

YES

0.00% Coinsurance after deductible

 0.00% Coinsurance after deductible

EMI Health Advantage PPO (Low) Health Insurance Plan Variant 53613AZ0020002-01 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 On Exchange Plan
Dental Only Plan Yes
EHB Apportionment for Pediatric Dental 1
First Tier Utilization 100%
HIOS Product ID 53613AZ002
Import Date 8/11/2022 1:01
Inpatient Copayment Maximum Days 0
Guaranteed Rate Guaranteed Rate
New/Existing Plan Existing
Issuer ID 53613
Issuer Marketplace Marketing Name EMI Health
Market Coverage Individual
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group $750 per group
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person $375 per person
Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out $375
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $225 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $75 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $75
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 per group not applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person per person not applicable
Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual Not Applicable
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 Yes
Network ID AZN002
Out of Country Coverage Yes
Out of Country Coverage Description Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States (a “Non U.S. Provider”) are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the following conditions: - Benefits may not be assigned to a Non U.S. Provider; - The Participant is responsible for making all payments to Non U.S. Providers, and submitting receipts to the Plan for reimbursement; - Benefit payments will be determined by the Plan based upon the exchange rate in effect on the incurred date; - The Non U.S. Provider shall be subject to, and in compliance with, all U.S. and other applicable licensing requirements; and - Claims for benefits must be submitted to the Plan in English and include a complete description of the services rendered.
Out of Service Area Coverage Yes
Out of Service Area Coverage Description PPO network or out-of-network coverage at PPO fee
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 53613AZ0020002-01
Plan Marketing Name EMI Health Advantage PPO (Low)
Plan Type PPO
Plan Variant Marketing Name EMI Health Advantage PPO (Low)
QHP/Non QHP On the Exchange
Service Area ID AZS001
Source Name HIOS
Plan ID 53613AZ0020002
State Code AZ
URL for Enrollment Payment URL

Copay & Coinsurance of EMI Health Advantage PPO (Low) Health Insurance Plan, 53613AZ0020002

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

Frequently Asked Questions(FAQ) about EMI Health Advantage PPO (Low), 53613AZ0020002 Health Insurance Plan, 53613AZ0020002

  • Does EMI Health Advantage PPO (Low) Health Insurance Plan, 53613AZ0020002 support Mail Ordering?

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

    • Does (53613AZ0020002) Health Insurance Plan, Variant (53613AZ0020002-01) have Out Of Country Coverage?

    Yes. Details: Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States (a “Non U.S. Provider”) are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the following conditions: - Benefits may not be assigned to a Non U.S. Provider; - The Participant is responsible for making all payments to Non U.S. Providers, and submitting receipts to the Plan for reimbursement; - Benefit payments will be determined by the Plan based upon the exchange rate in effect on the incurred date; - The Non U.S. Provider shall be subject to, and in compliance with, all U.S. and other applicable licensing requirements; and - Claims for benefits must be submitted to the Plan in English and include a complete description of the services rendered.

    Does (53613AZ0020002) Health Insurance Plan, Variant (53613AZ0020002-01) have Out of Service Area Coverage?

    Yes. Details: PPO network or out-of-network coverage at PPO fee

 

Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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