High Plains Gold - 38576WY0020001 Health Insurance Plan
Montana Health Cooperative health insurance plan with the Plan ID 38576WY0020001. The plan is called High Plains Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.96% (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 19.04% 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 | 38576WY0020001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Wyoming | ||||||||||||||||||
| Health Insurance Issuer | Montana Health Cooperative | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 38576WY0020001-03 | ||||||||||||||||||
| Provider Network(s) | ['WYN001'] | ||||||||||||||||||
| 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 - 38576WY0020001-00 Standard On Exchange Plan - 38576WY0020001-01 |
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| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of High Plains Gold Health Insurance Plan, 38576WY0020001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Pediatric only - Restorations of the mouth, tooth, or jaw which are necessary due to an accidental injury are limited to those services, supplies, and appliances appropriate for dental needs. These are not pediatric only benefits. The section refers to some excluded services that are covered under Pediatric Dental but this section applies to all enrollees under the product. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Limited to 20 visits per calendar year. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Limit: 1.0 Item(s) per Lifetime Covered Outpatient self-management training and education are limited to a one-time evaluation and training program when Medically Necessary, within one (1) year of diagnosis. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Some items require Pre-Certification. The rental or the purchase of durable medical equipment, whichever is less expensive, is a Covered Service. When a purchase is authorized, Benefits will also be provided for repair, maintenance, replacement, and adjustment of the equipment. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Covers one pair of eyeglasses or 12 month supply of contacts per calendar year. |
YES | No Charge |
25.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
|
YES | $5.00 |
50.00% Coinsurance after deductible |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant's hospitalization was required. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Hospice Services
Pre-Certification is required. The Participant must be diagnosed with a terminal illness for which the attending Physician's prognosis for life expectancy is estimated to be six (6) months or less. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
NO | ||
| Inpatient Hospital Services (e.g., Hospital Stay)
Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | $100.00 |
50.00% Coinsurance after deductible |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Outpatient Rehabilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $40.00 |
50.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Inpatient Private Duty Nursing Services are Covered Services only in certain circumstances such as: The Participant's Condition would ordinarily require that the Participant be placed in an intensive or coronary care unit, but the Hospital does not have such facilities. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prosthetic Devices
Some items require Pre-Certification. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Pre-Certification Required. Reconstructive procedures which correct deformities of the jaw. Reconstructive Surgery is a Covered Service only where Participant's Surgery is required as the result of a birth defect, accidental injury, or a malignant disease process or its treatment. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Covers one exam per calendar year subject to deductible and coinsurance. |
YES | No Charge |
25.00% Coinsurance after deductible |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Pre-Certification Required and subject to approval by Case Benefit Management. Care must begin within 14 days after discharge from the hospital or skilled nursing facility. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
No referral needed for a specialist. |
YES | $50.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Must be pre-approved. |
YES | $150.00 |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
50.00% Coinsurance after deductible |
| Transplant
Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $75.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
High Plains Gold Health Insurance Plan Variant 38576WY0020001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8095807676585209 |
| 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, Diabetes |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | WYF001 |
| Formulary URL | URL |
| HIOS Product ID | 38576WY002 |
| Import Date | 2023-12-19 01:01:03 |
| 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 | 38576 |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WYN001 |
| 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) | 38576WY0020001-03 |
| Plan Marketing Name | High Plains Gold |
| Plan Type | PPO |
| Plan Variant Marketing Name | High Plains Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,500 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $500 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WYS001 |
| Source Name | HIOS |
| Plan ID | 38576WY0020001 |
| State Code | WY |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $49000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $24500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $24,500 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $6500 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $3250 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $3,250 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $2000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $4500 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $2250 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $2,250 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $36000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $18000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $18,000 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of High Plains Gold Health Insurance Plan, 38576WY0020001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about High Plains Gold, 38576WY0020001 Health Insurance Plan, 38576WY0020001
-
Does High Plains Gold Health Insurance Plan, 38576WY0020001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38576WY0020001) Health Insurance Plan, Variant (38576WY0020001-03) offer Disease Management Programs?
Does (38576WY0020001) Health Insurance Plan, Variant (38576WY0020001-03) have Out Of Country Coverage?
Does (38576WY0020001) Health Insurance Plan, Variant (38576WY0020001-03) have Out of Service Area Coverage?
Does (38576WY0020001) Health Insurance Plan, Variant (38576WY0020001-03) offer Disease Management Programs?
Does High Plains Gold Health Insurance Plan, Variant (38576WY0020001-03) offer Disease Management Programs for Asthma?
Does High Plains Gold Health Insurance Plan, Variant (38576WY0020001-03) 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