Connect Silver Option 2 - 32225MT0090005 Health Insurance Plan
Montana Health Cooperative health insurance plan with the Plan ID 32225MT0090005. The plan is called Connect Silver Option 2.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.63% (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 5.37% 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 | 32225MT0090005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Montana | ||||||||||||||||||
| Health Insurance Issuer | Montana Health Cooperative | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 32225MT0090005-06 | ||||||||||||||||||
| Provider Network(s) | ['MTN002'] | ||||||||||||||||||
| 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 - 32225MT0090005-00 Standard On Exchange Plan - 32225MT0090005-01 Open to Indians below 300% FPL - 32225MT0090005-02 Open to Indians above 300% FPL - 32225MT0090005-03 73% AV Silver Plan - 32225MT0090005-04 |
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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 Connect Silver Option 2 Health Insurance Plan, 32225MT0090005-06
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 20.00% |
40.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year |
YES | 20.00% |
40.00% |
| Allergy Testing
|
YES | 20.00% |
40.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% |
40.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Benefit Period |
YES | $25.00 |
40.00% |
| Cosmetic Surgery
Only medically necessary cosmetic surgery is covered to treat accidents and genetic defects. |
YES | 20.00% |
40.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% |
40.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 20.00% |
40.00% |
| Dialysis
|
YES | 20.00% |
40.00% |
| Durable Medical Equipment
|
YES | 20.00% |
40.00% |
| Emergency Room Services
|
YES | 30.00% |
30.00% |
| Emergency Transportation/Ambulance
|
YES | 30.00% |
30.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period One pair of glasses (frames and lenses) or one pair of contacts per Benefit Period. |
YES | No Charge |
25.00% |
| Gender Affirming Care
|
YES | 20.00% |
40.00% |
| Generic Drugs
See formulary at mountainhealth.coop for a list of $0 medications. |
YES | $0.00 |
40.00% |
| Habilitation Services
Coverage will be provided for Habilitative Care services when the Member requires help to keep, learn or improve skills and functioning for daily living. These services include, but are not limited to: physical and occupational therapy; speech-language pathology; and other services for people with disabilities. These services may be provided in a variety of Inpatient and/or Outpatient settings as prescribed by a Physician. |
YES | 20.00% |
40.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 180.0 Visit(s) per Benefit Period Includes Nursing services, Home Health Aide services, Hospice services, Physical Therapy, Occupational Therapy, Speech Therapy, Medical social worker, Medical supplies and equipment suitable for use in the home, Medically Necessary personal hygiene, grooming and dietary assistance. |
YES | 20.00% |
40.00% |
| Hospice Services
A coordinated program of home care and Inpatient Care that provides or coordinates palliative and supportive care to meet the needs of a terminally ill Member and the Member's Immediate Family. |
YES | 20.00% |
40.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% |
40.00% |
| Infertility Treatment
We pay for the diagnosis of infertility & Artificial Insemination (but not listed in the contract). |
YES | 20.00% |
40.00% |
| Infusion Therapy
The preparation, administration, or furnishing of parenteral medications, or parenteral or enteral nutritional services to a Member by a Home Infusion Therapy Agency. |
YES | 20.00% |
40.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% |
40.00% |
| Inpatient Physician and Surgical Services
|
YES | 20.00% |
40.00% |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% |
40.00% |
| 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% |
40.00% |
| Mental/Behavioral Health Outpatient Services
The care and treatment of mental illness provided by a hospital; a physician or prescribed by a physician; a mental health treatment center; a chemical dependency treatment center; a psychologist, a licensed social worker; a licensed professional addiction counselor, a licensed clinical professional counselor or a licensed psychiatrist. Outpatient benefits must be provided to diagnose and treat recognized mental illness and treatment must be reasonably expected to improve and restore the level of functioning that has been affected by the mental illness. |
YES | $20.00 |
40.00% |
| Non-Preferred Brand Drugs
|
YES | $100.00 |
40.00% |
| Nutritional Counseling
Also covered under preventive health care. |
YES | 20.00% |
40.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Orthodontia for children is only covered when medically necessary. |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
40.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% |
40.00% |
| Outpatient Rehabilitation Services
Rehabilitation Therapy: A specialized, intense and comprehensive program of therapies and treatment services (including but not limited to Physical Therapy, Occupational Therapy and Speech Therapy) provided by a Multidisciplinary Team for treatment of an Injury or physical deficit. Also an Outpatient Therapies benefit. |
YES | 20.00% |
40.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% |
40.00% |
| Preferred Brand Drugs
See formulary at mountainhealth.coop for a list of $0 medications. |
YES | $20.00 |
40.00% |
| Prenatal and Postnatal Care
|
YES | 20.00% |
40.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
40.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
40.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% |
40.00% |
| Radiation
|
YES | 20.00% |
40.00% |
| Reconstructive Surgery
Reconstructive breast surgery only. Also covered in case of an accident/ injury or due to treat congenital anomaly. |
YES | 20.00% |
40.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Also an Outpatient Therapies benefit. |
YES | $25.00 |
40.00% |
| Rehabilitative Speech Therapy
Also an Outpatient Therapies benefit. |
YES | $25.00 |
40.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Benefit Period The following services only may be provided by a licensed ophthalmologist or optometrist operating within the scope of his or her license, or a dispensing optician to Members under 19 years of age: One Routine vision exam per Benefit Period. |
YES | No Charge |
25.00% |
| Routine Foot Care
Foot care provided to a Member with diabetes. |
YES | 20.00% |
40.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Also referred to as 'convalescent home.' |
YES | 20.00% |
40.00% |
| Specialist Visit
|
YES | $25.00 |
40.00% |
| Specialty Drugs
|
YES | $120.00 |
40.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% |
40.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 |
40.00% |
| Transplant
|
YES | 20.00% |
40.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $35.00 |
40.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
40.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% |
40.00% |
Connect Silver Option 2 Health Insurance Plan Variant 32225MT0090005-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.9462576847542241 |
| 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 | 94% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Diabetes |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MTF008 |
| Formulary URL | URL |
| HIOS Product ID | 32225MT009 |
| 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 | 32225 |
| Issuer Marketplace Marketing Name | Mountain Health CO-OP |
| 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 | MTN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergent Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergent Only |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 32225MT0090005-06 |
| Plan Marketing Name | Connect Silver Option 2 |
| Plan Type | PPO |
| Plan Variant Marketing Name | Connect Silver Option 2 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,000 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MTS001 |
| Source Name | SERFF |
| Plan ID | 32225MT0090005 |
| State Code | MT |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $8000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $4000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $4,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $2000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $1000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $1,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $3,000 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Connect Silver Option 2 Health Insurance Plan, 32225MT0090005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Silver Option 2, 32225MT0090005 Health Insurance Plan, 32225MT0090005
-
Does Connect Silver Option 2 Health Insurance Plan, 32225MT0090005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (32225MT0090005) Health Insurance Plan, Variant (32225MT0090005-06) offer Disease Management Programs?
Does (32225MT0090005) Health Insurance Plan, Variant (32225MT0090005-06) have Out Of Country Coverage?
Does (32225MT0090005) Health Insurance Plan, Variant (32225MT0090005-06) have Out of Service Area Coverage?
Does (32225MT0090005) Health Insurance Plan, Variant (32225MT0090005-06) offer Disease Management Programs?
Does Connect Silver Option 2 Health Insurance Plan, Variant (32225MT0090005-06) offer Disease Management Programs for Asthma?
Does Connect Silver Option 2 Health Insurance Plan, Variant (32225MT0090005-06) offer Disease Management Programs for Diabetes?
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