DeltaCare USA Pediatric Basic Plan - 14948UT0010003 Health Insurance Plan
Alpha Dental of Utah, Inc. health insurance plan with the Plan ID 14948UT0010003. The plan is called DeltaCare USA Pediatric Basic Plan.
| Health Insurance Plan ID | 14948UT0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Alpha Dental of Utah, Inc. | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 14948UT0010003-00 | ||||||||||||||||||
| Provider Network(s) | ['UTN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of DeltaCare USA Pediatric Basic Plan Health Insurance Plan, 14948UT0010003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Dental Check-Up for Children
Limit: 2.0 Procedure(s) per Benefit Period Routine cleaning, exams, x-rays, and fluoride. Sealants once every five years. Refer to plan summary for specific copay/cost-share information. |
YES | $10.00 |
100.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Routine Dental Services (Adult)
|
NO |
DeltaCare USA Pediatric Basic Plan Health Insurance Plan Variant 14948UT0010003-00 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 | 2025 |
| Child-Only Offering | Allows Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Low Off Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 1.0 |
| First Tier Utilization | 100% |
| HIOS Product ID | 14948UT001 |
| Import Date | 2024-08-12 20:01:40 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | Existing |
| Issuer ID | 14948 |
| Issuer Marketplace Marketing Name | DeltaCare USA |
| Market Coverage | Individual |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | Not Applicable |
| 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 | 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 | $850 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $425 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $425 |
| 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 | No |
| Network ID | UTN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 14948UT0010003-00 |
| Plan Marketing Name | DeltaCare USA Pediatric Basic Plan |
| Plan Type | HMO |
| Plan Variant Marketing Name | DeltaCare USA Pediatric Basic Plan |
| QHP/Non QHP | Off the Exchange |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 14948UT0010003 |
| State Code | UT |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of DeltaCare USA Pediatric Basic Plan Health Insurance Plan, 14948UT0010003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about DeltaCare USA Pediatric Basic Plan, 14948UT0010003 Health Insurance Plan, 14948UT0010003
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Does DeltaCare USA Pediatric Basic Plan Health Insurance Plan, 14948UT0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (14948UT0010003) Health Insurance Plan, Variant (14948UT0010003-00) have Out Of Country Coverage?
Does (14948UT0010003) Health Insurance Plan, Variant (14948UT0010003-00) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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