EMI Health Choice PPO (High) - 40335UT0010001 Health Insurance Plan
Educators Health Plans Life, Accident, and Health, Inc health insurance plan with the Plan ID 40335UT0010001. The plan is called EMI Health Choice PPO (High).
| Health Insurance Plan ID | 40335UT0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Educators Health Plans Life, Accident, and Health, Inc | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40335UT0010001-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Benefits of EMI Health Choice PPO (High) Health Insurance Plan, 40335UT0010001-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Exclusions: Space Maintainers not covered after age 16. Fillings on the same surface 1 every 18 months. Basic benefits covered after 6 month waiting period. Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Basic Dental Care - Child
Exclusions: Space Maintainers not covered after age 16. Fillings on the same surface 1 every 18 months. Basic benefits covered after 6 month waiting period. Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Basic services for children apply to the deductible, but do not apply to the pediatric EHB out of pocket maximum. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 20.00% Coinsurance after deductible |
20.00% 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 per year. Periapical X-rays Up to 14 during any 3 year period. Panoramic X-Ray is allowed 1 every 3 years. Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Major Dental Care - Adult
Exclusions: Anesthesia only covered for the extraction of impacted teeth. Implants are not covered. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth. Benefits covered after 15 month waiting period. Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Major Dental Care - Child
Exclusions: Anesthesia for those age 8 and over is only covered for the extraction of impacted teeth. Anesthesia for those age 7 and under is covered once per year. Implants are not covered. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth. Benefits covered after 15 month waiting period. Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Major services for children apply to the deductible, but do not apply to the pediatric EHB out of pocket maximum. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: Covered for dependent children ages 7 through 18 after 24 month waiting period . Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Orthodontic services do not apply to the deductible or to the pediatric EHB out of pocket maximum. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. |
YES | Tier 1: 50.00% Tier 2: 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 per year. Periapical X-rays Up to 14 during any 3 year period. Panoramic X-Ray is allowed 1 every 3 years. Choice plans include two in-network tiers with different network options. The Advantage network is used for In Network Tier 1 and the Premier network is used for In Network Tier 2. Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. |
YES | Tier 1: 0.00% Coinsurance after deductible Tier 2: 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
EMI Health Choice PPO (High) Health Insurance Plan Variant 40335UT0010001-01 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 | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard High On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 0.409768576263836 |
| First Tier Utilization | 75% |
| HIOS Product ID | 40335UT001 |
| Import Date | 2023-08-16 20:01:48 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 40335 |
| 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 | 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 | $75 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $25 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $25 |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $150 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $50 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $50 |
| Medical EHB Deductible, Out of Network, Family Per Group | $150 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $50 per person |
| Medical EHB Deductible, Out of Network, Individual | $50 |
| 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, In Network (Tier 2), Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 2), 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 | High |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | UTN001 |
| 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 are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy. |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 40335UT0010001-01 |
| Plan Marketing Name | EMI Health Choice PPO (High) |
| Plan Type | PPO |
| Plan Variant Marketing Name | EMI Health Choice PPO (High) |
| QHP/Non QHP | On the Exchange |
| Second Tier Utilization | 25% |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 40335UT0010001 |
| State Code | UT |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of EMI Health Choice PPO (High) Health Insurance Plan, 40335UT0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about EMI Health Choice PPO (High), 40335UT0010001 Health Insurance Plan, 40335UT0010001
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Does EMI Health Choice PPO (High) Health Insurance Plan, 40335UT0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40335UT0010001) Health Insurance Plan, Variant (40335UT0010001-01) have Out Of Country Coverage?
Does (40335UT0010001) Health Insurance Plan, Variant (40335UT0010001-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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