Connect Ind Gold Standard MT

32225MT0090010
Gold
PPO

Connect Ind Gold Standard MT is a Gold PPO plan by Mountain Health CO-OP.

IMPORTANT: You are viewing the 2023 version of Connect Ind Gold Standard MT 32225MT0090010. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Connect Ind Gold Standard MT is offered in the following counties.

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Plan Overview

This is a plan overview for 2023 version of Connect Ind Gold Standard MT 32225MT0090010.
Insurer: Mountain Health CO-OP
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 32225MT0090010

Cost-Sharing Overview

Connect Ind Gold Standard MT offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Connect Ind Gold Standard MT?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Connect Ind Gold Standard MT offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Diabetes
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Connect Ind Gold Standard MT covers when you are out of the service area or out of the country.

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
National Network: No

Additional Benefits and Cost-Sharing

Connect Ind Gold Standard MT includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 45.00% Coinsurance after deductible
Specialist Visit
Covered
$60.00 45.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 45.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Hospice Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible 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.
Routine Dental Services (Adult)
Infertility Treatment
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible We pay for the diagnosis of infertility & Artificial Insemination.
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$45.00 45.00% Coinsurance after deductible
Home Health Care Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible180 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.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Bariatric Surgery
Cosmetic Surgery
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Only medically necessary cosmetic surgery is covered to treat accidents and genetic defects.
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible60 Days per Benefit Period Also referred to as ‘convalescent home.’
Prenatal and Postnatal Care
Covered
$30.00 45.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$30.00 45.00% Coinsurance after deductible 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.
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$30.00 45.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Generic Drugs
Covered
$15.00 45.00% Coinsurance after deductible
Preferred Brand Drugs
Covered
$30.00 45.00% Coinsurance after deductible
Non-Preferred Brand Drugs
Covered
$60.00 45.00% Coinsurance after deductible
Specialty Drugs
Covered
$250.00 45.00% Coinsurance after deductible
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible 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.
Habilitation Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible 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.
Chiropractic Care
Covered
$60.00 45.00% Coinsurance after deductible20 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
0.00% 45.00% Coinsurance after deductible
Routine Foot Care
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Foot care provided to a Member with diabetes.
Acupuncture
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible12 Visit(s) per Year
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 25.00% Coinsurance after deductible1 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.
Eye Glasses for Children
Covered
No Charge 25.00% Coinsurance after deductible1 Item(s) per Benefit Period One pair of glasses (frames and lenses) or one pair of contacts per Benefit Period.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 45.00% Coinsurance after deductible Also an Outpatient Therapies benefit.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 45.00% Coinsurance after deductible Also an Outpatient Therapies benefit.
Well Baby Visits and Care
Covered
No Charge 45.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Orthodontia for children is only covered when medically necessary.
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Transplant
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Accidental Dental
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Dialysis
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Allergy Testing
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Chemotherapy
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Radiation
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Diabetes Education
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible
Infusion Therapy
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible The preparation, administration, or furnishing of parenteral medications, or parenteral or enteral nutritional services to a Member by a Home Infusion Therapy Agency.
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Also covered under preventive health care.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible Reconstructive breast surgery only. Also covered in case of an accident/ injury or due to treat congenital anomaly.
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 45.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Connect Ind Gold Standard MT preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Connect Ind Gold Standard MT including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Connect Ind Gold Standard MT?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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