Moda Health Affinity Bronze 7750 - 39424OR1680005 Health Insurance Plan
Moda Health Plan, Inc. health insurance plan with the Plan ID 39424OR1680005. The plan is called Moda Health Affinity Bronze 7750.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.71% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.29% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 39424OR1680005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Moda Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 39424OR1680005-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 39424OR1680005-00 Standard On Exchange Plan - 39424OR1680005-01 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Moda Health Affinity Bronze 7750 Health Insurance Plan, 39424OR1680005-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | 0.00% |
100.00% |
| Accidental Dental
For treatment within 12 months of the date of injury to restore teeth to a functional state. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Year Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided. |
YES | $85.00 |
100.00% |
| Allergy Testing
Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Year Plan uses the term "spinal manipulation." Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided. |
YES | $85.00 |
100.00% |
| Cosmetic Surgery
Benefit is limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Limit: 3.0 Hours per Year Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 45.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 45.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Eye Glasses for Children
1 pair of glasses for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses. |
YES | 0.00% |
100.00% |
| Gender Affirming Care
Gender affirming care is covered when determined by a provider as medically necessary and follows accepted standards of care. Please check with the insurance carrier for coverage information, including any limitations and exclusions. |
YES | ||
| Generic Drugs
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. |
YES | 40.00% |
40.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to mental health and substance use disorder services. |
YES | $140.00 |
100.00% |
| Hearing Aids
1 hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 3 years as medically necessary for the treatment of a member's hearing loss. |
YES | 45.00% |
100.00% |
| Home Health Care Services
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Hormone Therapy
|
YES | ||
| Hospice Services
Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Some medications may be limited to certain providers or settings. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Medical Service Drugs
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met. |
YES | $85.00 |
100.00% |
| Non-Preferred Brand
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Non-preferred tier in the plan, and these medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Generic
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. |
YES | 40.00% |
40.00% |
| Nutritional Counseling
Authorization required after first 5 visits. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met. |
YES | $85.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Additional 30 visits for neurological conditions. Visit limits do not apply to mental health and substance use disorder services. |
YES | $140.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Preferred Brand
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it Includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications . |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Preferred Brand Drugs
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Preferred tier in the plan, and it includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Preferred Generic
Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $35 for a 30-day supply. Known as the Value tier in the plan, and it includes commonly prescribed medications used to treat chronic medical conditions. |
YES | $2.00 |
$2.00 |
| Prenatal and Postnatal Care
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
7 exams ages 1 to 4 and one per year age 5 and over. See policy for other visit limits. |
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met. |
YES | $85.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Additional 30 visits for neurological conditions. Visit limits do not apply to mental health and substance use disorder services. |
YES | $140.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Additional 30 visits for neurological conditions. Visit limits do not apply to mental health and substance use disorder services. |
YES | $140.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
1 exam per year for members through the end of the month in which they reach age 19. |
YES | $0.00 |
100.00% |
| Routine Foot Care
Benefit is limited to persons with a medical condition that requires it. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Includes office visits by naturopaths. |
YES | $140.00 |
100.00% |
| Specialty Drugs
Up to 30-day supply per prescription at designated specialty pharmacies only. Non-Preferred Specialty tier may have higher cost sharing. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met. |
YES | $85.00 |
100.00% |
| Telehealth - Primary Care
|
YES | $10.00 |
100.00% |
| Telehealth - Specialisst
|
YES | $10.00 |
100.00% |
| Transplant
Authorized transplant facility only. $7,500 maximum for travel and housing per transplant. |
YES | 45.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $140.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
1 in-hospital newborn visit and 6 additional visits for the first year of life. |
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 45.00% Coinsurance after deductible |
100.00% |
| Zero Cost Share Preventive Drugs
Include prescribed preventive medications under the Affordable Care Act |
YES | $0.00 |
$0.00 |
Moda Health Affinity Bronze 7750 Health Insurance Plan Variant 39424OR1680005-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| 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 | Standard Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9984 |
| First Tier Utilization | 100% |
| Formulary ID | ORF029 |
| Formulary URL | URL |
| HIOS Product ID | 39424OR168 |
| Import Date | 2024-08-14 20:01:41 |
| 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 Actuarial Value | 64.71% |
| Issuer ID | 39424 |
| Issuer Marketplace Marketing Name | Moda Health Plan, Inc. |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ORN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency care and out-of-area dependent coverage for students or children under a QMCSO |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 39424OR1680005-00 |
| Plan Marketing Name | Moda Health Affinity Bronze 7750 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Moda Health Affinity Bronze 7750 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $750 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,750 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $4,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS003 |
| Source Name | SERFF |
| Plan ID | 39424OR1680005 |
| State Code | OR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 45.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,750 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Moda Health Affinity Bronze 7750 Health Insurance Plan, 39424OR1680005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Moda Health Affinity Bronze 7750, 39424OR1680005 Health Insurance Plan, 39424OR1680005
-
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, 39424OR1680005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (39424OR1680005) Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs?
Does (39424OR1680005) Health Insurance Plan, Variant (39424OR1680005-00) have Out Of Country Coverage?
Does (39424OR1680005) Health Insurance Plan, Variant (39424OR1680005-00) have Out of Service Area Coverage?
Does (39424OR1680005) Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for Asthma?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for Heart disease?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for Depression?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for Diabetes?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for Low back pain?
Does Moda Health Affinity Bronze 7750 Health Insurance Plan, Variant (39424OR1680005-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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