Moda Health Plan, Inc. health insurance plan with the Plan ID 17933TX0010004. The plan is called Moda Select Silver 4800 ($0 Virtual Care $2 Rx Value Tier).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.59% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.41% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 17933TX0010004 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Texas | ||||||||||||||||||
Health Insurance Issuer | Moda Health Plan, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 17933TX0010004-05 | ||||||||||||||||||
Provider Network(s) | ['TXN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | Standard On Exchange Plan - 17933TX0010004-01 Open to Indians below 300% FPL - 17933TX0010004-02 Open to Indians above 300% FPL - 17933TX0010004-03 73% AV Silver Plan - 17933TX0010004-04 |
||||||||||||||||||
Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
Except in the case of a medical emergency of a pregnant woman |
NO | ||
Accidental Dental
Covered if completed within 24 months of initial treatment |
YES | 35.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
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: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including outpatient rehabilitation services |
YES | $40.00 |
100.00% |
Cosmetic Surgery
Only for correction of congenital deformities, conditions resulting from accidental injuries, reconstructive surgery following cancer surgery, breast reconstruction in the event of a mastectomy, and gender confirming surgery. |
NO | ||
Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
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
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 35.00% Coinsurance after deductible |
35.00% Coinsurance after deductible |
Eye Glasses for Children
Covered once per year |
YES | No Charge |
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
Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order |
YES | $20.00 |
$20.00 |
Habilitation Services
Limit: 35.0 Visit(s) per Year Limited to 35 visits per year, separate from rehabilitation services |
YES | 35.00% Coinsurance after deductible |
100.00% |
Hearing Aids
The hearing aid must be prescribed, fitted and dispensed by a licensed audiologist or hearing aid specialist with the approval of a licensed physician |
YES | 35.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
Hospice Services
Preauthorization is required. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Preauthorization is required for some imaging services |
YES | 35.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
Preauthorization is required |
YES | 35.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
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
Preauthorization is required. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Certain services require preauthorization. |
YES | $20.00 |
100.00% |
Non-Preferred Brand Drugs
Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Nutritional Counseling
|
NO | ||
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $40.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order |
YES | 40.00% |
40.00% |
Prenatal and Postnatal Care
|
YES | 35.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
ACA age and frequency limits apply |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
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
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limited to combined 35 visits per year, including Chiropractic. |
YES | $40.00 |
100.00% |
Rehabilitative Speech Therapy
Limited to combined 35 visits per year, including Chiropractic. |
YES | $40.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $10.00 |
100.00% |
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | 35.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $40.00 |
100.00% |
Specialty Drugs
Up to 30-day supply per prescription |
YES | 40.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | $20.00 |
100.00% |
Transplant
Preauthorization is required. |
YES | 35.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Excludes any non-surgical or non-diagnostic services or supplies |
YES | 35.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $40.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
ACA age and frequency limits apply |
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 | 87% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
EHB Percent of Total Premium | 0.99 |
First Tier Utilization | 100% |
Formulary ID | TXF002 |
Formulary URL | URL |
HIOS Product ID | 17933TX001 |
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 | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 87.59% |
Issuer ID | 17933 |
Issuer Marketplace Marketing Name | Moda Health, 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 | TXN001 |
Out of Country Coverage | No |
Out of Country Coverage Description | Emergency only |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency care covered, Out of Area children covered who are enrolled under QMCSO |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 17933TX0010004-05 |
Plan Marketing Name | Moda Select Silver 4800 ($0 Virtual Care $2 Rx Value Tier) |
Plan Type | EPO |
Plan Variant Marketing Name | Moda Select Silver 4800 ($0 Virtual Care $2 Rx Value Tier) |
QHP/Non QHP | On the Exchange |
SBC Scenario, Having a Baby, Coinsurance | $1,250 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $750 |
SBC Scenario, Having a Baby, Limit | $50 |
SBC Scenario, Having Diabetes, Coinsurance | $1,400 |
SBC Scenario, Having Diabetes, Copayment | $200 |
SBC Scenario, Having Diabetes, Deductible | $400 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $700 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $750 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | TXS001 |
Source Name | HIOS |
Plan ID | 17933TX0010004 |
State Code | TX |
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 | $1500 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $750 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $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 | $4000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,000 |
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 |
---|
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, 01 Oct 2024 06:11 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