High Plains Silver Standard - 38576WY0020009 Health Insurance Plan
Montana Health Cooperative health insurance plan with the Plan ID 38576WY0020009. The plan is called High Plains Silver Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.09% (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 26.91% 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 | 38576WY0020009 | ||||||||||||||||||
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| 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 | 38576WY0020009-04 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Mon, 23 Jun 2025 12:50 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 38576WY0020009-00 Standard On Exchange Plan - 38576WY0020009-01 Open to Indians below 300% FPL - 38576WY0020009-02 Open to Indians above 300% FPL - 38576WY0020009-03 73% AV Silver Plan - 38576WY0020009-04 |
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| Last Plan Update Date | Sat, 11 Jan 2025 00:00 GMT | ||||||||||||||||||
| Last Import Date | Mon, 23 Jun 2025 12:50 GMT |
High Plains Silver Standard Health Insurance Plan Variant 38576WY0020009-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7309378231069821 |
| 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 | No |
| CSR Variation Type | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Diabetes |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | WYF005 |
| Formulary URL | URL |
| HIOS Product ID | 38576WY002 |
| Import Date | 2025-01-11 00:01:52 |
| 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 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 | Silver |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 38576WY0020009-04 |
| Plan Marketing Name | High Plains Silver Standard |
| Plan Type | PPO |
| Plan Variant Marketing Name | High Plains Silver Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $5,700 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WYS001 |
| Source Name | HIOS |
| Plan ID | 38576WY0020009 |
| State Code | WY |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $38400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $19200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $19,200 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $18000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $9000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $9,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $6000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $12000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $6000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $6,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $12800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $25600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $12800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $12,800 |
| 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 Silver Standard Health Insurance Plan, 38576WY0020009
| 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 Silver Standard, 38576WY0020009 Health Insurance Plan, 38576WY0020009
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Does High Plains Silver Standard Health Insurance Plan, 38576WY0020009 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38576WY0020009) Health Insurance Plan, Variant (38576WY0020009-04) offer Disease Management Programs?
Does (38576WY0020009) Health Insurance Plan, Variant (38576WY0020009-04) have Out Of Country Coverage?
Does (38576WY0020009) Health Insurance Plan, Variant (38576WY0020009-04) have Out of Service Area Coverage?
Does (38576WY0020009) Health Insurance Plan, Variant (38576WY0020009-04) offer Disease Management Programs?
Does High Plains Silver Standard Health Insurance Plan, Variant (38576WY0020009-04) offer Disease Management Programs for Asthma?
Does High Plains Silver Standard Health Insurance Plan, Variant (38576WY0020009-04) offer Disease Management Programs for Diabetes?
Disclaimer: This is based on the import(Date: Mon, 23 Jun 2025 12:50 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