HIGH PLAINS SG GOLD WY - 38576WY0010001 Health Insurance Plan
Montana Health Cooperative health insurance plan with the Plan ID 38576WY0010001. The plan is called HIGH PLAINS SG GOLD WY.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.45% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.55% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 38576WY0010001 | ||||||||||||||||||
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| 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 | 38576WY0010001-00 | ||||||||||||||||||
| Provider Network(s) | ['WYN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
HIGH PLAINS SG GOLD WY Health Insurance Plan Variant 38576WY0010001-00 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | Yes |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Diabetes |
| First Tier Utilization | 100% |
| Formulary ID | WYF008 |
| Formulary URL | URL |
| HIOS Product ID | 38576WY001 |
| HSA/HRA Employer Contribution | No |
| Import Date | 8/18/2021 1:01 |
| 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 | 81.45% |
| Issuer ID | 38576 |
| Issuer Marketplace Marketing Name | Mountain Health CO-OP |
| Market Coverage | SHOP (Small Group) |
| 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 | Emergecy Only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergecy Only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 38576WY0010001-00 |
| Plan Marketing Name | HIGH PLAINS SG GOLD WY |
| Plan Type | PPO |
| Plan Variant Marketing Name | HIGH PLAINS SG GOLD WY |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,700 |
| 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 | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WYS002 |
| Source Name | HIOS |
| Plan ID | 38576WY0010001 |
| 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 | $5100 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of HIGH PLAINS SG GOLD WY Health Insurance Plan, 38576WY0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about HIGH PLAINS SG GOLD WY, 38576WY0010001 Health Insurance Plan, 38576WY0010001
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Does HIGH PLAINS SG GOLD WY Health Insurance Plan, 38576WY0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38576WY0010001) Health Insurance Plan, Variant (38576WY0010001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Diabetes
Does (38576WY0010001) Health Insurance Plan, Variant (38576WY0010001-00) have Out Of Country Coverage?
Yes. Details: Emergecy Only
Does (38576WY0010001) Health Insurance Plan, Variant (38576WY0010001-00) have Out of Service Area Coverage?
Yes. Details: Emergecy Only
Does (38576WY0010001) Health Insurance Plan, Variant (38576WY0010001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Diabetes
Does HIGH PLAINS SG GOLD WY Health Insurance Plan, Variant (38576WY0010001-00) offer Disease Management Programs for Asthma?
Yes, the HIGH PLAINS SG GOLD WY Health Insurance Plan Variant
38576WY0010001-00 offers Disease
Management Program for Asthma.
Does HIGH PLAINS SG GOLD WY Health Insurance Plan, Variant (38576WY0010001-00) offer Disease Management Programs for Diabetes?
Yes, the HIGH PLAINS SG GOLD WY Health Insurance Plan Variant
38576WY0010001-00 offers Disease
Management Program for Diabetes.
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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