Moda Health Plan, Inc. health insurance plan with the Plan ID 39424OR1620053. The plan is called Moda Health Affinity Silver 3500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.22% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.78% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 39424OR1620053 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 39424OR1620053-01 | ||||||||||||||||||
Provider Network(s) | ['ORN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 20 Aug 2024 06:14 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 39424OR1620053-00 Standard On Exchange Plan - 39424OR1620053-01 Open to Indians below 300% FPL - 39424OR1620053-02 Open to Indians above 300% FPL - 39424OR1620053-03 73% AV Silver Plan - 39424OR1620053-04 |
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Last Plan Update Date | Fri, 09 Sep 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 20 Aug 2024 06:14 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
YES | 0.00% |
100.00% |
Accidental Dental
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Acupuncture
Limit: 12.0 Visit(s) per Year Other services such as office visits or diagnostic services are under the plan?s standard benefit for the type of service provided. Acupuncture and spinal manipulation services must be prior authorized as medically necessary. |
YES | $35.00 |
100.00% |
Allergy Testing
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 20.0 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. Acupuncture and spinal manipulation services must be prior authorized as medically necessary. |
YES | $35.00 |
100.00% |
Cosmetic Surgery
Not covered except for reconstructive surgery following a mastectomy, or when medically necessary. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Delivery and All Inpatient Services for Maternity Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
Out-of-network providers may bill members for charges over the maximum plan allowance |
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
6 trips per year |
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses. Lenses at $0 for codes V2100-2299, V2300-2399, V2121, V2221, V2321; for other codes cost shares may apply |
YES | 35.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
Information about gender affirming care can be found in the policy |
YES | 35.00% Coinsurance after deductible |
100.00% |
Generic Drugs
Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications. 30-day supply standard retail; 90-day supply for retail 90 program/mail order (per fill) Insulin: $75 max out of pocket for 30 day supply, no deductible. |
YES | $20.00 |
$20.00 |
Habilitation Services
Limit: 30.0 Visit(s) per Year Visit limit does not apply to mental health/chemical dependency |
YES | $70.00 |
100.00% |
Hearing Aids
One hearing aid per hearing impaired ear every 3 years, and additional hearing services as required by state law |
YES | 35.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Hospice Services
Respite care provided in the most appropriate setting subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $35.00 |
100.00% |
Non-Preferred Brand Drugs
Non-preferred brand 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. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication. 30-day supply standard retail; 90-day supply for retail 90 program/mail order (per fill) Insulin: $75 max out of pocket for 30 day supply, no deductible. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Nutritional Counseling
Auth required after first 5 visits for eating disorders. No visit limit. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $35.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year 30-visit limit may be expanded to up to 60 sessions for treatment of neurological conditions. Visit limits are not applicable to mental health/chemical dependency. |
YES | $70.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication. 30-day supply standard retail; 90-day supply for retail 90 program/mail order (per fill) Insulin: $75 max out of pocket for 30 day supply, no deductible. |
YES | 40.00% |
40.00% |
Prenatal and Postnatal Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
7 exams age 1-4 and one per year age 5+. |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $35.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
Treatment covered when medically necessary. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 30-visit limit (combined with speech therapy) may be expanded to up to 60 sessions for treatment of neurological conditions. Visit limits are not applicable to mental health/chemical dependency. |
YES | $70.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year 30-visit limit (combined with occupational and physical therapy) may be expanded to up to 60 sessions for treatment of neurological conditions. Visit limits are not applicable to mental health/chemical dependency. |
YES | $70.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Once per year for members through the end of the month in which they reach age 19. Exams at $0 for these codes: 92002/92004, 92012/92014, S0620/S0621; for other codes cost shares may apply. |
YES | $35.00 |
100.00% |
Routine Foot Care
Covered for treatment of a specific current problem, including diabetes mellitus. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Skilled Nursing Facility
Limit: 60.0 Days per Year Routine nursing and custodial care are not covered. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Specialist Visit
Includes office visits by naturopaths |
YES | $70.00 |
100.00% |
Specialty Drugs
Specialty medications often require special handling techniques, careful administration and a unique ordering process. Moda provides enhanced member services for these medications. Information about the clinical services and a list of eligible specialty medications is available on the Member Dashboard or by contacting Customer Service. If a member does not purchase these medications at the exclusive specialty pharmacy, the expense will not be covered. Up to 30-day supply. Nonpreferred specialty medications are paid at 50% coinsurance, deductible applies. Insulin: $75 max out of pocket for 30 day supply, no deductible. |
YES | 40.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $35.00 |
100.00% |
Telehealth - PCP
Telehealth is limited to synchronous 2-way video-audio visits |
YES | $10.00 |
100.00% |
Telehealth - Specialist
Telehealth is limited to synchronous 2-way video-audio visits |
YES | $10.00 |
100.00% |
Transplant
$7500 travel and housing limit per transplant. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | $70.00 |
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 | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Silver On 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, Weight Loss Programs |
EHB Percent of Total Premium | 0.9985 |
First Tier Utilization | 100% |
Formulary ID | ORF004 |
Formulary URL | URL |
HIOS Product ID | 39424OR162 |
Import Date | 9/9/2022 20:01 |
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 | 70.22% |
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 | Silver |
Multiple In Network Tiers | No |
National Network | No |
Network ID | ORN002 |
Out of Country Coverage | No |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency care covered, Out of Area dependents covered who are students or under QMCSO |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 39424OR1620053-01 |
Plan Marketing Name | Moda Health Affinity Silver 3500 |
Plan Type | EPO |
Plan Variant Marketing Name | Moda Health Affinity Silver 3500 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $3,200 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $3,500 |
SBC Scenario, Having a Baby, Limit | $50 |
SBC Scenario, Having Diabetes, Coinsurance | $1,700 |
SBC Scenario, Having Diabetes, Copayment | $300 |
SBC Scenario, Having Diabetes, Deductible | $400 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | ORS002 |
Source Name | SERFF |
Plan ID | 39424OR1620053 |
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 | 35.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
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 | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 20 Aug 2024 06:14 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