HIGH PLAINS IND BRONZE WY - 38576WY0020003 Health Insurance Plan

Montana Health Cooperative health insurance plan with the Plan ID 38576WY0020003. The plan is called HIGH PLAINS IND BRONZE WY .

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.32% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.68% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.72% (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 36.28% 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 38576WY0020003
Health Insurance Plan Year 2022
State Wyoming
Health Insurance Issuer Montana Health Cooperative
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 38576WY0020003-00
Provider Network(s) ['WYN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Wyoming 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 - 38576WY0020003-00

Standard On Exchange Plan - 38576WY0020003-01

Open to Indians below 300% FPL - 38576WY0020003-02

Open to Indians above 300% FPL - 38576WY0020003-03

Last Plan Update Date Wed, 18 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

HIGH PLAINS IND BRONZE WY Health Insurance Plan Variant 38576WY0020003-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.637210985
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Diabetes
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WYF003
Formulary URL URL
HIOS Product ID 38576WY002
Import Date 8/18/2021 1:01
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 Actuarial Value 64.32%
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 Expanded Bronze
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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 38576WY0020003-00
Plan Marketing Name HIGH PLAINS IND BRONZE WY
Plan Type PPO
Plan Variant Marketing Name HIGH PLAINS IND BRONZE WY
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $700
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $1,600
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WYS001
Source Name HIOS
Plan ID 38576WY0020003
State Code WY
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $63700 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $31850 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $31,850
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $58200 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $29100 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $29,100
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 60.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $43200 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $21600 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $21,600
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8150 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,150
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $47400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $23700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $23,700
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of HIGH PLAINS IND BRONZE WY Health Insurance Plan, 38576WY0020003

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

Frequently Asked Questions(FAQ) about HIGH PLAINS IND BRONZE WY , 38576WY0020003 Health Insurance Plan, 38576WY0020003

  • Does HIGH PLAINS IND BRONZE WY Health Insurance Plan, 38576WY0020003 support Mail Ordering?

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

  • Does (38576WY0020003) Health Insurance Plan, Variant (38576WY0020003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes

    Does (38576WY0020003) Health Insurance Plan, Variant (38576WY0020003-00) have Out Of Country Coverage?

    Yes. Details: Emergent Only

    Does (38576WY0020003) Health Insurance Plan, Variant (38576WY0020003-00) have Out of Service Area Coverage?

    Yes. Details: Emergent Only

    Does (38576WY0020003) Health Insurance Plan, Variant (38576WY0020003-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Diabetes

    Does HIGH PLAINS IND BRONZE WY Health Insurance Plan, Variant (38576WY0020003-00) offer Disease Management Programs for Asthma?

    Yes, the HIGH PLAINS IND BRONZE WY Health Insurance Plan Variant 38576WY0020003-00 offers Disease Management Program for Asthma.

    Does HIGH PLAINS IND BRONZE WY Health Insurance Plan, Variant (38576WY0020003-00) offer Disease Management Programs for Diabetes?

    Yes, the HIGH PLAINS IND BRONZE WY Health Insurance Plan Variant 38576WY0020003-00 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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