Gold 1 with Adult Vision Services - 18167UT0040001 Health Insurance Plan
Molina Healthcare of Utah health insurance plan with the Plan ID 18167UT0040001. The plan is called Gold 1 with Adult Vision Services.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.36% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.64% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 18167UT0040001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Utah | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Utah | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 18167UT0040001-03 | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 18167UT0040001-00 Standard On Exchange Plan - 18167UT0040001-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold 1 with Adult Vision Services Health Insurance Plan, 18167UT0040001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
NO | ||
| Acupuncture
|
NO | ||
| Allergy Testing
Sublingual or colorimetric allergy testing are not covered. Charges for office visits in connection with repetitive injections are not covered. |
YES | $20.00 |
100.00% |
| Autism Spectrum Disorders
|
YES | $20.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Must be for the diagnosis of diabetes. |
YES | No Charge |
100.00% |
| Dialysis
|
YES | $50.00 |
100.00% |
| Durable Medical Equipment
DME over $750, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require Pre-authorization. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Molina covers frames, lenses, and contact lenses (in lieu of glasses) are covered for children. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | $20.00 |
100.00% |
| Generic Drugs
Limit: 30.0 Item(s) per Month |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Pre-authorization required only for home visits. Adopt the habilitation therapy definition as, Health care services that help a person keep, learn or improve skills and functioning for daily living which may include physical therapy, occupational therapy, and speech language pathology. Habilitative and Rehabilitative Services benefits have a combined limit of 20 visits per calendar year. Member Cost Sharing and visit limits shown apply in any place of service. |
YES | $20.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | No Charge |
100.00% |
| Hospice Services
Limit: 6.0 Months per 3 Years Requires Pre-authorization and Medical Case Management. |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorder - PKU
|
YES | $20.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $15.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Item(s) per Month Per Utah State Law, during calendar year 2022, the insulin prescription cap for a 30-day prescription supply of at least one insulin in each therapy category will $28.00 |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
This benefit includes Mental Health and Substance Use Disorder providers in an office setting. |
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Benefit Period Pre-authorization required only for home visits. Rehabilitation therapy will be defined as, The treatment of disease, injury, developmental delay or other cause, by physical agents and methods to assist in the rehabilitation of normal physical bodily function, that is goal oriented and where the Member has the potential for functional improvement and ability to progress. Habilitative and Rehabilitative Services benefits have a combined limit of 20 visits per calendar year. Member Cost Sharing and visit limits shown apply in any place of service. |
YES | $20.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Item(s) per Month Per Utah State Law, during calendar year 2022, the insulin prescription cap for a 30-day prescription supply of at least one insulin in each therapy category will $28.00 |
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Coverage limited to: Prostheses needed after a Medically Necessary mastectomy, including custom-made prostheses when Medically Necessary and up to three brassieres required to hold a prosthesis every 12 months. Prostheses to replace all or part of an external facial body part (including artificial eyes), that has been removed or impaired as a result of disease, injury, or congenital defect |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Benefit Period Pre-authorization required only for home visits. |
YES | $20.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Pre-authorization required only for home visits. |
YES | $20.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Visit(s) per Benefit Period Requires Pre-authorization and Medical Case Management. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 |
100.00% |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $20.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Benefit should mirror preventive care/screening/immunization. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Gold 1 LCS with Adult Vision Services Health Insurance Plan Variant 18167UT0040001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7836322822148821 |
| 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 | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9862101736909731 |
| First Tier Utilization | 100% |
| Formulary ID | UTF001 |
| Formulary URL | URL |
| HIOS Product ID | 18167UT004 |
| Import Date | 2023-08-16 20:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 18167 |
| Issuer Marketplace Marketing Name | Molina Healthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 18167UT0040001-03 |
| Plan Marketing Name | Gold 1 with Adult Vision Services |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 1 LCS with Adult Vision Services |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,550 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,550 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $40 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,550 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | UTS001 |
| Source Name | SERFF |
| Plan ID | 18167UT0040001 |
| State Code | UT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1550 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,550 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $16200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Gold 1 with Adult Vision Services Health Insurance Plan, 18167UT0040001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 1 with Adult Vision Services, 18167UT0040001 Health Insurance Plan, 18167UT0040001
-
Does Gold 1 with Adult Vision Services Health Insurance Plan, 18167UT0040001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (18167UT0040001) Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs?
Does (18167UT0040001) Health Insurance Plan, Variant (18167UT0040001-03) have Out Of Country Coverage?
Does (18167UT0040001) Health Insurance Plan, Variant (18167UT0040001-03) have Out of Service Area Coverage?
Does (18167UT0040001) Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs for Asthma?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs for Heart disease?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs for Depression?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs for Diabetes?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs for Pregnancy?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (18167UT0040001-03) offer Disease Management Programs for Weight loss programs?
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