HIGH PLAINS GOLD - 38576WY0010001 Health Insurance Plan

Montana Health Cooperative health insurance plan with the Plan ID 38576WY0010001. The plan is called HIGH PLAINS GOLD.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.48% (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 19.52% 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 2025
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) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 27 May 2025 18:07 GMT).

Providers Wyoming All US States
All 1290 4291
PCP 154 610
Allergy N/A 1
OB/GYN 3 33
Dentists N/A 4
Available Variants of the Health Plan

Standard Off Exchange Plan - 38576WY0010001-00

Standard On Exchange Plan - 38576WY0010001-01

Last Plan Update Date Sat, 11 Jan 2025 00:00 GMT
Last Import Date Tue, 27 May 2025 18:07 GMT

HIGH PLAINS GOLD Health Insurance Plan Variant 38576WY0010001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.8047871863941128
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
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 WYF007
Formulary URL URL
HIOS Product ID 38576WY001
HSA/HRA Employer Contribution No
Import Date 2025-01-11 00:01:52
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 Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Only
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 38576WY0010001-00
Plan Marketing Name HIGH PLAINS GOLD
Plan Type PPO
Plan Variant Marketing Name HIGH PLAINS GOLD
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,600
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 $500
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
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 $39000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $19500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $19,500
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $6000 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 $4000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $2,000
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 $26000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $13000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $13,000
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 GOLD 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 GOLD, 38576WY0010001 Health Insurance Plan, 38576WY0010001

  • Does HIGH PLAINS GOLD 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: Emergency Only

    Does (38576WY0010001) Health Insurance Plan, Variant (38576WY0010001-00) have Out of Service Area Coverage?

    Yes. Details: Emergency 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 GOLD Health Insurance Plan, Variant (38576WY0010001-00) offer Disease Management Programs for Asthma?

    Yes, the HIGH PLAINS GOLD Health Insurance Plan Variant 38576WY0010001-00 offers Disease Management Program for Asthma.

    Does HIGH PLAINS GOLD Health Insurance Plan, Variant (38576WY0010001-00) offer Disease Management Programs for Diabetes?

    Yes, the HIGH PLAINS GOLD Health Insurance Plan Variant 38576WY0010001-00 offers Disease Management Program for Diabetes.

 

Disclaimer: This is based on the import(Date: Tue, 27 May 2025 18:07 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