Plus SG Silver MT HD - 32225MT0070011 Health Insurance Plan

Montana Health Cooperative health insurance plan with the Plan ID 32225MT0070011. The plan is called Plus SG Silver MT HD.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.33% (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 28.67% 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 32225MT0070011
Health Insurance Plan Year 2023
State Montana
Health Insurance Issuer Montana Health Cooperative
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 32225MT0070011-01
Provider Network(s) ['MTN006']
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 Montana 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 - 32225MT0070011-00

Standard On Exchange Plan - 32225MT0070011-01

Last Plan Update Date Thu, 15 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Plus SG Silver MT HD Health Insurance Plan, 32225MT0070011-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Acupuncture

Limit: 12.0 Visit(s) per Year

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Allergy Testing
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Chiropractic Care

Limit: 20.0 Visit(s) per Benefit Period

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Cosmetic Surgery

Only medically necessary cosmetic surgery is covered to treat accidents and genetic defects.

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Dialysis
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Durable Medical Equipment
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Emergency Room Services
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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

0.00% Coinsurance after deductible
Gender Affirming Care
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Generic Drugs
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Infertility Treatment

We pay for the diagnosis of infertility & Artificial Insemination (but not listed in the contract).

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Nutritional Counseling

Also covered under preventive health care.

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Preferred Brand Drugs
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

Tier 1: No Charge

Tier 2: No Charge

0.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Radiation
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Also an Outpatient Therapies benefit.

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Also an Outpatient Therapies benefit.

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% 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

0.00% Coinsurance after deductible
Routine Foot Care

Foot care provided to a Member with diabetes.

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

Also referred to as 'convalescent home.'

YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Specialist Visit
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Specialty Drugs
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Transplant
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

Tier 1: No Charge

Tier 2: No Charge

0.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

Tier 1: 0.00% Coinsurance after deductible

Tier 2: 0.00% Coinsurance after deductible

0.00% Coinsurance after deductible

Plus SG Silver MT HD Health Insurance Plan Variant 32225MT0070011-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.713269606
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 Silver On Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Diabetes
First Tier Utilization 5%
Formulary ID MTF001
Formulary URL URL
HIOS Product ID 32225MT007
HSA/HRA Employer Contribution No
Import Date 9/15/2022 20:01
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
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 SHOP (Small Group)
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers Yes
National Network Yes
Network ID MTN006
Out of Country Coverage Yes
Out of Country Coverage Description Emergent Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description All Services
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 32225MT0070011-01
Plan Marketing Name Plus SG Silver MT HD
Plan Type PPO
Plan Variant Marketing Name Plus SG Silver MT HD
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,000
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 $2,400
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 95%
Service Area ID MTS002
Source Name SERFF
Plan ID 32225MT0070011
State Code MT
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $40000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $20000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $20,000
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $40000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $20000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $20,000
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $5,000
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $30000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $15000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $15,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $10000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $10000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $5000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $5,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $30000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $15000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $15,000
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Plus SG Silver MT HD Health Insurance Plan, 32225MT0070011

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

Frequently Asked Questions(FAQ) about Plus SG Silver MT HD, 32225MT0070011 Health Insurance Plan, 32225MT0070011

  • Does Plus SG Silver MT HD Health Insurance Plan, 32225MT0070011 support Mail Ordering?

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

  • Does (32225MT0070011) Health Insurance Plan, Variant (32225MT0070011-01) offer Disease Management Programs?

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

    Does (32225MT0070011) Health Insurance Plan, Variant (32225MT0070011-01) have Out Of Country Coverage?

    Yes. Details: Emergent Only

    Does (32225MT0070011) Health Insurance Plan, Variant (32225MT0070011-01) have Out of Service Area Coverage?

    Yes. Details: All Services

    Does (32225MT0070011) Health Insurance Plan, Variant (32225MT0070011-01) offer Disease Management Programs?

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

    Does Plus SG Silver MT HD Health Insurance Plan, Variant (32225MT0070011-01) offer Disease Management Programs for Asthma?

    Yes, the Plus SG Silver MT HD Health Insurance Plan Variant 32225MT0070011-01 offers Disease Management Program for Asthma.

    Does Plus SG Silver MT HD Health Insurance Plan, Variant (32225MT0070011-01) offer Disease Management Programs for Diabetes?

    Yes, the Plus SG Silver MT HD Health Insurance Plan Variant 32225MT0070011-01 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