EssentialSmile Utah - Total Care - 97462UT0090001 Health Insurance Plan
UnitedHealthcare Insurance Company health insurance plan with the Plan ID 97462UT0090001. The plan is called EssentialSmile Utah - Total Care.
| Health Insurance Plan ID | 97462UT0090001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | UnitedHealthcare Insurance Company | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 97462UT0090001-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| 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 | Tue, 13 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of EssentialSmile Utah - Total Care Health Insurance Plan, 97462UT0090001-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Includes Coverage for Fillings, Deep Cleanings, Extractions and Other Minor Restorative Procedures. Various member Copayments apply per specific procedure code of service. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | $60.00 |
100.00% |
| Basic Dental Care - Child
Includes Coverage for Fillings, Deep Cleanings, Extractions and Other Minor Restorative Procedures. Various member Copayments apply per specific procedure code of service. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | $56.00 Copay after deductible |
100.00% |
| 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. Additional covered services included for: space maintainers, diagnostic imaging such as cone beam CT and MRI image captures, lab tests to aid in the detection of cancer and other abnormalities. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | No Charge after deductible, No Charge |
100.00% |
| Major Dental Care - Adult
Includes Coverage for Crowns, Bridges, Dentures, Root Canals and Surgical Implants. Various member Copayments apply per specific procedure code of service. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | $350.00 |
100.00% |
| Major Dental Care - Child
Includes Coverage for Crowns, Bridges, Dentures, Root Canals and Surgical Implants. Various member Copayments apply per specific procedure code of service. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | $350.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
Includes Comprehensive Cosmetic Orthodontia Coverage for Adult Dentition - D8090 |
YES | $4,650.00 |
100.00% |
| Orthodontia - Child
Orthodontic treatment must be Medically Necessary. Various member Copayments apply per specific procedure code of service. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | $350.00 Copay after deductible |
100.00% |
| Routine Dental Services (Adult)
Includes Coverage For Routine Cleanings and Related Services. Various member Copayments apply per specific procedure code of service. For a complete listing of copayments by procedure service code, please refer to the Schedule of Benefits. |
YES | No Charge |
100.00% |
EssentialSmile Utah - Total Care Health Insurance Plan Variant 97462UT0090001-01 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 | 2025 |
| 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 | 0.93 |
| First Tier Utilization | 100% |
| HIOS Product ID | 97462UT009 |
| Import Date | 2024-08-13 20:01:38 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | New |
| Issuer ID | 97462 |
| Issuer Marketplace Marketing Name | UnitedHealthcare |
| 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 | $30 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $30 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $30 |
| 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 | $800 per group |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | $400 per person |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | $400 |
| 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 | No |
| National Network | No |
| Network ID | UTN011 |
| 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) | 97462UT0090001-01 |
| Plan Marketing Name | EssentialSmile Utah - Total Care |
| Plan Type | EPO |
| Plan Variant Marketing Name | EssentialSmile Utah - Total Care |
| QHP/Non QHP | On the Exchange |
| Service Area ID | UTS011 |
| Source Name | SERFF |
| Plan ID | 97462UT0090001 |
| State Code | UT |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of EssentialSmile Utah - Total Care Health Insurance Plan, 97462UT0090001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about EssentialSmile Utah - Total Care, 97462UT0090001 Health Insurance Plan, 97462UT0090001
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Does EssentialSmile Utah - Total Care Health Insurance Plan, 97462UT0090001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (97462UT0090001) Health Insurance Plan, Variant (97462UT0090001-01) have Out Of Country Coverage?
Does (97462UT0090001) Health Insurance Plan, Variant (97462UT0090001-01) 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