Silver 12 with First 4 Primary Care Visits Free - 18167UT0010010 Health Insurance Plan

Molina Healthcare of Utah health insurance plan with the Plan ID 18167UT0010010. The plan is called Silver 12 with First 4 Primary Care Visits Free.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.21% (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 29.79% 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 18167UT0010010
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 18167UT0010010-01
Provider Network(s) ['UTN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT).

Providers Utah 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 Off Exchange Plan - 18167UT0010010-00

Standard On Exchange Plan - 18167UT0010010-01

Open to Indians below 300% FPL - 18167UT0010010-02

Open to Indians above 300% FPL - 18167UT0010010-03

73% AV Silver Plan - 18167UT0010010-04

87% AV Silver Plan - 18167UT0010010-05

94% AV Silver Plan - 18167UT0010010-06

Last Plan Update Date Wed, 16 Aug 2023 00:00 GMT
Last Import Date Tue, 24 Dec 2024 06:21 GMT

Benefits of Silver 12 with First 4 Primary Care Visits Free Health Insurance Plan, 18167UT0010010-01

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

$40.00

100.00%
Autism Spectrum Disorders
YES

$40.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care
NO
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% 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

$75.00

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

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% 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

$40.00

100.00%
Generic Drugs

Limit: 30.0 Item(s) per Month

YES

$10.00

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% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance after deductible

100.00%
Inherited Metabolic Disorder - PKU
YES

$40.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$40.00

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

20.00% 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

$40.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% 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% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% 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

$100.00

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

$40.00

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

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Covers mastectomy in the treatment of cancer and reconstructive surgery after a mastectomy.

YES

20.00% 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% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Pre-authorization required only for home visits.

YES

20.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
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

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$75.00

100.00%
Specialty Drugs

Limit: 30.0 Item(s) per Month

YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$40.00

100.00%
Transplant
YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$60.00

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

20.00% Coinsurance after deductible

100.00%

Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7021390278069211
Begin Primary Care Cost-Sharing After Number Of Visits 4
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 Silver On Exchange Plan
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 0.996689533753085
First Tier Utilization 100%
Formulary ID UTF005
Formulary URL URL
HIOS Product ID 18167UT001
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 New
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 Silver
Multiple In Network Tiers No
National Network No
Network ID UTN001
Out of Country Coverage No
Out of Service Area Coverage No
Out of Service Area Coverage Description Molina covers emergencies only.
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 18167UT0010010-01
Plan Marketing Name Silver 12 with First 4 Primary Care Visits Free
Plan Type HMO
Plan Variant Marketing Name Silver 12 250 with First 4 Primary Care Visits Free
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,100
SBC Scenario, Having a Baby, Copayment $60
SBC Scenario, Having a Baby, Deductible $7,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,800
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID UTS001
Source Name SERFF
Plan ID 18167UT0010010
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $14000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,000
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 $18900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9450 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,450
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 Silver 12 with First 4 Primary Care Visits Free Health Insurance Plan, 18167UT0010010

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

Frequently Asked Questions(FAQ) about Silver 12 with First 4 Primary Care Visits Free, 18167UT0010010 Health Insurance Plan, 18167UT0010010

  • Does Silver 12 with First 4 Primary Care Visits Free Health Insurance Plan, 18167UT0010010 support Mail Ordering?

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

  • Does (18167UT0010010) Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs

    Does (18167UT0010010) Health Insurance Plan, Variant (18167UT0010010-01) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (18167UT0010010) Health Insurance Plan, Variant (18167UT0010010-01) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Molina covers emergencies only.

    Does (18167UT0010010) Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs

    Does Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs for Asthma?

    Yes, the Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 offers Disease Management Program for Asthma.

    Does Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs for Heart disease?

    Yes, the Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 offers Disease Management Program for Heart disease.

    Does Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs for Depression?

    Yes, the Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 offers Disease Management Program for Depression.

    Does Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs for Diabetes?

    Yes, the Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 offers Disease Management Program for Diabetes.

    Does Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs for Pregnancy?

    Yes, the Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 offers Disease Management Program for Pregnancy.

    Does Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan, Variant (18167UT0010010-01) offer Disease Management Programs for Weight loss programs?

    Yes, the Silver 12 250 with First 4 Primary Care Visits Free Health Insurance Plan Variant 18167UT0010010-01 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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