Moda Assurance Company health insurance plan with the Plan ID 77963AK0040001. The plan is called Moda Pioneer Alaska Standard Bronze.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.86% (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 40.14% 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 | 77963AK0040001 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Alaska | ||||||||||||||||||
Health Insurance Issuer | Moda Assurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 77963AK0040001-00 | ||||||||||||||||||
Provider Network(s) | ['AKN001'] | ||||||||||||||||||
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 - 77963AK0040001-00 Standard On Exchange Plan - 77963AK0040001-01 |
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Last Plan Update Date | Thu, 23 Feb 2023 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 | No Charge after deductible |
No Charge after deductible |
Accidental Dental
Services must begin within 12 months of the date of injury; diagnosis made within 6 months of date of injury. |
YES | No Charge after deductible |
No Charge after deductible |
Acupuncture
Limit: 24.0 Visit(s) per Year Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition. |
YES | No Charge after deductible |
No Charge after deductible |
Allergy Testing
|
YES | No Charge after deductible |
No Charge after deductible |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Frequency limits apply to some services. |
YES | No Charge after deductible |
No Charge after deductible |
Chemotherapy
|
YES | No Charge after deductible |
No Charge after deductible |
Chiropractic Care
Limit: 24.0 Visit(s) per Year |
YES | No Charge after deductible |
No Charge after deductible |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
No Charge after deductible |
Dental Check-Up for Children
|
YES | No Charge |
No Charge after deductible |
Diabetes Education
|
YES | No Charge after deductible |
No Charge after deductible |
Dialysis
|
YES | No Charge after deductible |
No Charge after deductible |
Durable Medical Equipment
Orthotics or orthopedic shoes are covered when medically necessary. |
YES | No Charge after deductible |
No Charge after deductible |
Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
Emergency Transportation/Ambulance
Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit. |
YES | No Charge after deductible |
No Charge after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
50.00% |
Gender Affirming Care
Information about gender affirming care can be found in the policy. |
YES | No Charge after deductible |
No Charge after deductible |
Generic Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | No Charge after deductible |
No Charge after deductible |
Habilitation Services
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. |
YES | No Charge after deductible |
No Charge after deductible |
Hearing Aids
|
YES | 20.00% |
20.00% |
Home Health Care Services
Limit: 130.0 Visit(s) per Year 130 visits per year applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a licensed social worker. |
YES | No Charge after deductible |
No Charge after deductible |
Hospice Services
Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member. |
YES | No Charge after deductible |
No Charge after deductible |
Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
No Charge after deductible |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | No Charge after deductible |
No Charge after deductible |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
No Charge after deductible |
Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
No Charge after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
Frequency limits apply to some services. |
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
Mental/Behavioral Health Outpatient Services
Exclusions: Biofeedback is limited to the treatment of migraine headaches. |
YES | No Charge after deductible |
No Charge after deductible |
Non-Preferred Brand Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | No Charge after deductible |
No Charge after deductible |
Nutritional Counseling
|
YES | No Charge after deductible |
No Charge after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Medically necessary repair of disabling malocclusion or cleft palate and severe craniofacial defects impacting function of speech, swallowing and chewing. |
YES | No Charge after deductible |
No Charge after deductible |
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician. |
YES | No Charge after deductible |
No Charge after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
No Charge after deductible |
Outpatient Rehabilitation Services
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. |
YES | No Charge after deductible |
No Charge after deductible |
Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
Preferred Brand Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | No Charge after deductible |
No Charge after deductible |
Prenatal and Postnatal Care
|
YES | No Charge after deductible |
No Charge after deductible |
Preventive Care/Screening/Immunization
Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5. |
YES | No Charge |
No Charge after deductible |
Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
No Charge after deductible |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can?t be repaired, or replacement is prescribed by a physician because of a change in your physical condition. |
YES | No Charge after deductible |
No Charge after deductible |
Radiation
|
YES | No Charge after deductible |
No Charge after deductible |
Reconstructive Surgery
Breast reconstruction allowed. |
YES | No Charge after deductible |
No Charge after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. |
YES | No Charge after deductible |
No Charge after deductible |
Rehabilitative Speech Therapy
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. |
YES | No Charge after deductible |
No Charge after deductible |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year 1 exam per year |
YES | $10.00 |
50.00% |
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
50.00% |
Routine Foot Care
Covered if required for the member?s medical condition. |
YES | No Charge after deductible |
No Charge after deductible |
Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | No Charge after deductible |
No Charge after deductible |
Specialist Visit
|
YES | No Charge after deductible |
No Charge after deductible |
Specialty Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | No Charge after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
Transplant
|
YES | No Charge after deductible |
|
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5. |
YES | No Charge |
No Charge after deductible |
X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
No Charge after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.598552346 |
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 Bronze Off Exchange Plan |
Dental Only Plan | No |
Design Type | Design 1 |
EHB Percent of Total Premium | 0.995 |
First Tier Utilization | 100% |
Formulary ID | AKF007 |
Formulary URL | URL |
HIOS Product ID | 77963AK004 |
Import Date | 2/23/2023 1:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 77963 |
Issuer Marketplace Marketing Name | Moda Health |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Bronze |
Multiple In Network Tiers | No |
National Network | Yes |
Network ID | AKN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Out of Network |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 77963AK0040001-00 |
Plan Marketing Name | Moda Pioneer Alaska Standard Bronze |
Plan Type | PPO |
Plan Variant Marketing Name | Moda Pioneer Alaska Standard Bronze |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $9,100 |
SBC Scenario, Having a Baby, Limit | $50 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $5,400 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | AKS001 |
Source Name | HIOS |
Plan ID | 77963AK0040001 |
State Code | AK |
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 | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $18200 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $9100 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $9,100 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $54600 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $27300 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $27,300 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $54600 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $27300 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $27,300 |
Unique Plan Design | No |
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