HIGH PLAINS IND SILVER WY BASE
38576WY0020006
Silver
PPO
HIGH PLAINS IND SILVER WY BASE is a Silver PPO plan by Mountain Health CO-OP.
Locations
HIGH PLAINS IND SILVER WY BASE is offered in the following counties.
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Plan Overview
This is a plan overview for 2022 version of HIGH PLAINS IND SILVER WY BASE 38576WY0020006.
| Insurer: | Mountain Health CO-OP |
| Network Type: | PPO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 38576WY0020006 |
Cost-Sharing Overview
HIGH PLAINS IND SILVER WY BASE offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for HIGH PLAINS IND SILVER WY BASE includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 8700 | 17400 |
| Deductible: | 8000 | 16000 |
| Coinsurance: | 16000 | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for HIGH PLAINS IND SILVER WY BASE will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | 26100 | 52200 |
| Out-of-Network Deductible: | 24000 | 48000 |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 8000 |
| Copayment: | 0 |
| Coinsurance: | 700 |
| Limit: | 60 |
| Deductible: | 900 |
| Copayment: | 800 |
| Coinsurance: | 100 |
| Limit: | 20 |
| Deductible: | 2100 |
| Copayment: | 700 |
| Coinsurance: | 0 |
| Limit: | 0 |
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 HIGH PLAINS IND SILVER WY BASE?
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
HIGH PLAINS IND SILVER WY BASE 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 HIGH PLAINS IND SILVER WY BASE 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
HIGH PLAINS IND SILVER WY BASE 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 | $80.00 / N/A | / | |
| Specialist Visit Covered | $160.00 / N/A | / | No referral needed for a specialist. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $80.00 / N/A | / | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Outpatient Surgery Physician/Surgical Services Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Hospice Services Covered | N/A / 45.00% Coinsurance after deductible | / | 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. |
| Routine Dental Services (Adult) | / | / | |
| Infertility Treatment | / | / | |
| Long-Term/Custodial Nursing Home Care | / | / | |
| Private-Duty Nursing Covered | N/A / 45.00% Coinsurance after deductible | / | 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. |
| Routine Eye Exam (Adult) | / | / | |
| Urgent Care Centers or Facilities Covered | $240.00 / N/A | / | |
| Home Health Care Services Covered | N/A / 45.00% Coinsurance after deductible | / | Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant?s hospitalization was required. |
| Emergency Room Services Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Emergency Transportation/Ambulance Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | N/A / 45.00% Coinsurance after deductible | / | Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions. |
| Inpatient Physician and Surgical Services Covered | N/A / 45.00% Coinsurance after deductible | / | Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions. |
| Bariatric Surgery Covered | N/A / 45.00% Coinsurance after deductible | / | 1 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. |
| Cosmetic Surgery | / | / | |
| Skilled Nursing Facility Covered | N/A / 45.00% Coinsurance after deductible | / | 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. |
| Prenatal and Postnatal Care Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Delivery and All Inpatient Services for Maternity Care Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Mental/Behavioral Health Outpatient Services Covered | $80.00 / N/A | / | |
| Mental/Behavioral Health Inpatient Services Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Substance Abuse Disorder Outpatient Services Covered | $80.00 / N/A | / | |
| Substance Abuse Disorder Inpatient Services Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Generic Drugs Covered | N/A / 40.00% | / | |
| Preferred Brand Drugs Covered | N/A / 50.00% | / | |
| Non-Preferred Brand Drugs Covered | N/A / 60.00% | / | |
| Specialty Drugs Covered | N/A / 70.00% | / | Must be pre-approved. |
| Outpatient Rehabilitation Services Covered | N/A / 45.00% Coinsurance after deductible | / | 20 Visit(s) per Year Outpatient Rehabilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant. |
| Habilitation Services Covered | N/A / 45.00% Coinsurance after deductible | / | 20 Visit(s) per Year Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant. |
| Chiropractic Care Covered | $160.00 / N/A | / | 20 Visit(s) per Year Limited to 20 visits per calendar year. |
| Durable Medical Equipment Covered | N/A / 45.00% Coinsurance after deductible | / | 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. |
| Hearing Aids | / | / | |
| Imaging (CT/PET Scans, MRIs) Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Preventive Care/Screening/Immunization Covered | No Charge / N/A | / | |
| Routine Foot Care | / | / | |
| Acupuncture | / | / | |
| Weight Loss Programs | / | / | |
| Routine Eye Exam for Children Covered | No Charge / N/A | / | 1 Exam(s) per Year Covers one exam per calendar year subject to deductible and coinsurance. |
| Eye Glasses for Children Covered | No Charge / N/A | / | 1 Item(s) per Year Covers one pair of eyeglasses or 12 month supply of contacts per calendar year. |
| Dental Check-Up for Children Not Covered | / | / | |
| Rehabilitative Speech Therapy Covered | $160.00 / N/A | / | 20 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. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $160.00 / N/A | / | 60 Visit(s) per Year Outpatient is limited to 40 visits per calendar year each. |
| Well Baby Visits and Care Covered | No Charge / N/A | / | |
| Laboratory Outpatient and Professional Services Covered | N/A / 45.00% Coinsurance after deductible | / | |
| X-rays and Diagnostic Imaging Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Basic Dental Care – Child Not Covered | / | / | |
| Orthodontia – Child Not Covered | / | / | |
| Major Dental Care – Child Not Covered | / | / | |
| Basic Dental Care – Adult | / | / | |
| Orthodontia – Adult | / | / | |
| Major Dental Care – Adult | / | / | |
| Abortion for Which Public Funding is Prohibited | / | / | |
| Transplant Covered | N/A / 45.00% Coinsurance after deductible | / | Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services. |
| Accidental Dental Covered | N/A / 45.00% Coinsurance after deductible | / | 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. |
| Dialysis Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Allergy Testing | / | / | |
| Chemotherapy Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Radiation Covered | N/A / 45.00% Coinsurance after deductible | / | |
| Diabetes Education Covered | N/A / 45.00% Coinsurance after deductible | / | 1 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. |
| Prosthetic Devices Covered | N/A / 45.00% Coinsurance after deductible | / | Some items require Pre-Certification. |
| Infusion Therapy | / | / | |
| Treatment for Temporomandibular Joint Disorders | / | / | |
| Nutritional Counseling | / | / | |
| Reconstructive Surgery Covered | N/A / 45.00% Coinsurance after deductible | / | 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. |
Free Preventive Services
There is no copayment or coinsurance for any of the following HIGH PLAINS IND SILVER WY BASE 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for HIGH PLAINS IND SILVER WY BASE 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 HIGH PLAINS IND SILVER WY BASE?
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