Plus Gold - 32225MT0060004 Health Insurance Plan
Montana Health Cooperative health insurance plan with the Plan ID 32225MT0060004. The plan is called Plus Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.31% (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 20.69% 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 | 32225MT0060004 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 32225MT0060004-00 | ||||||||||||||||||
| Provider Network(s) | ['MTN003'] | ||||||||||||||||||
| 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 - 32225MT0060004-00 Standard On Exchange Plan - 32225MT0060004-01 |
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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 Plus Gold Health Insurance Plan, 32225MT0060004-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
Limit: 12.0 Visit(s) per Year |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Allergy Testing
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 20.0 Visit(s) per Benefit Period |
YES | Tier 1: $50.00 Tier 2: $50.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Only medically necessary cosmetic surgery is covered to treat accidents and genetic defects. |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dialysis
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| 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 | Tier 1: No Charge Tier 2: No Charge |
25.00% Coinsurance after deductible |
| Gender Affirming Care
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
See formulary at mountainhealth.coop for a list of $0 medications. |
YES | Tier 1: $5.00 Tier 2: $5.00 |
50.00% Coinsurance after deductible |
| 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 | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
We pay for the diagnosis of infertility & Artificial Insemination (but not listed in the contract). |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 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 | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: $5.00 Tier 2: $25.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | Tier 1: $100.00 Tier 2: $100.00 |
50.00% Coinsurance after deductible |
| Nutritional Counseling
Also covered under preventive health care. |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Orthodontia for children is only covered when medically necessary. |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: $5.00 Tier 2: $25.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
See formulary at mountainhealth.coop for a list of $0 medications. |
YES | Tier 1: $40.00 Tier 2: $40.00 |
50.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: $5.00 Tier 2: $25.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Reconstructive breast surgery only. Also covered in case of an accident/ injury or due to treat congenital anomaly. |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Also an Outpatient Therapies benefit. |
YES | Tier 1: $50.00 Tier 2: $50.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Also an Outpatient Therapies benefit. |
YES | Tier 1: $50.00 Tier 2: $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 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 | Tier 1: No Charge Tier 2: No Charge |
25.00% Coinsurance after deductible |
| Routine Foot Care
Foot care provided to a Member with diabetes. |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period Also referred to as 'convalescent home.' |
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | Tier 1: $50.00 Tier 2: $50.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | Tier 1: $150.00 Tier 2: $150.00 |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: $5.00 Tier 2: $25.00 |
50.00% Coinsurance after deductible |
| Transplant
|
YES | Tier 1: 30.00% Coinsurance after deductible Tier 2: 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | Tier 1: $75.00 Tier 2: $75.00 |
50.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: 40.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Plus Gold Health Insurance Plan Variant 32225MT0060004-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7931346212087991 |
| 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 | Standard Gold Off Exchange 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 | 5% |
| Formulary ID | MTF001 |
| Formulary URL | URL |
| HIOS Product ID | 32225MT006 |
| 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 | Gold |
| Multiple In Network Tiers | Yes |
| National Network | Yes |
| Network ID | MTN003 |
| 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) | 32225MT0060004-00 |
| Plan Marketing Name | Plus Gold |
| Plan Type | PPO |
| Plan Variant Marketing Name | Plus Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $1,300 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 95% |
| Service Area ID | MTS001 |
| Source Name | SERFF |
| Plan ID | 32225MT0060004 |
| State Code | MT |
| 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 | $8500 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $4250 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $4,250 |
| 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 | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $2000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $2,000 |
| 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), In Network (Tier 2), Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), 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 Plus Gold Health Insurance Plan, 32225MT0060004
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Plus Gold, 32225MT0060004 Health Insurance Plan, 32225MT0060004
-
Does Plus Gold Health Insurance Plan, 32225MT0060004 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (32225MT0060004) Health Insurance Plan, Variant (32225MT0060004-00) offer Disease Management Programs?
Does (32225MT0060004) Health Insurance Plan, Variant (32225MT0060004-00) have Out Of Country Coverage?
Does (32225MT0060004) Health Insurance Plan, Variant (32225MT0060004-00) have Out of Service Area Coverage?
Does (32225MT0060004) Health Insurance Plan, Variant (32225MT0060004-00) offer Disease Management Programs?
Does Plus Gold Health Insurance Plan, Variant (32225MT0060004-00) offer Disease Management Programs for Asthma?
Does Plus Gold Health Insurance Plan, Variant (32225MT0060004-00) 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