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 AV Calculator by CMS.gov, the plan has an actuarial value of 81.54% (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 18.46% 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 38576WY0010001
Health Insurance Plan Year 2023
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) ['WYN002']
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 - 38576WY0010001-00

Standard On Exchange Plan - 38576WY0010001-01

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of High Plains SG Gold WY Health Insurance Plan, 38576WY0010001-00

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

Includes professional services.

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

$50.00

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

$20.00

50.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

$30.00

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

$100.00

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 SG Gold WY Health Insurance Plan Variant 38576WY0010001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.815383224
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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 WYF010
Formulary URL URL
HIOS Product ID 38576WY001
HSA/HRA Employer Contribution No
Import Date 2/24/2023 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 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 WYN002
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 1/1/2023
Plan Expiration Date 12/31/2023
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 $1,300
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $1,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $200
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $100
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 $7350 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $3,000
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 No
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

Frequently Asked Questions(FAQ) about High Plains SG Gold WY, 38576WY0010001 Health Insurance Plan, 38576WY0010001

  • 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: 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