Moda Health Plan, Inc. health insurance plan with the Plan ID 17933TX0010009. The plan is called Moda Select Texas Standard Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 17933TX0010009 | ||||||||||||||||||
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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 | 17933TX0010009-01 | ||||||||||||||||||
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). |
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Available Variants of the Health Plan | Standard On Exchange Plan - 17933TX0010009-01 |
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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 | 25.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | 25.00% 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 | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% 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 | 25.00% 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 | $15.00 |
$15.00 |
Habilitation Services
Limit: 35.0 Visit(s) per Year Limited to 35 visits per year, separate from rehabilitation services |
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
Hospice Services
Preauthorization is required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
Preauthorization is required for some imaging services |
YES | 25.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
Preauthorization is required |
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Certain services require preauthorization. |
YES | $30.00 |
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 | $60.00 |
$60.00 |
Nutritional Counseling
|
NO | ||
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% 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 | $30.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% 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 | $30.00 |
$30.00 |
Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
ACA age and frequency limits apply |
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limited to combined 35 visits per year, including Chiropractic. |
YES | $30.00 |
100.00% |
Rehabilitative Speech Therapy
Limited to combined 35 visits per year, including Chiropractic. |
YES | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $60.00 |
100.00% |
Specialty Drugs
Up to 30-day supply per prescription |
YES | $250.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | $30.00 |
100.00% |
Transplant
Preauthorization is required. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Excludes any non-surgical or non-diagnostic services or supplies |
YES | 25.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $45.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.780017779 |
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 Gold On Exchange Plan |
Dental Only Plan | No |
Design Type | Design 1 |
EHB Percent of Total Premium | 0.99 |
First Tier Utilization | 100% |
Formulary ID | TXF005 |
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 | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
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 | Gold |
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) | 17933TX0010009-01 |
Plan Marketing Name | Moda Select Texas Standard Gold |
Plan Type | EPO |
Plan Variant Marketing Name | Moda Select Texas Standard Gold |
QHP/Non QHP | On the Exchange |
SBC Scenario, Having a Baby, Coinsurance | $2,600 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $2,000 |
SBC Scenario, Having a Baby, Limit | $50 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,200 |
SBC Scenario, Having Diabetes, Deductible | $400 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $90 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | TXS001 |
Source Name | HIOS |
Plan ID | 17933TX0010009 |
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 | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
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 | 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, 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