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Moda Health Plans 2014
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Paper Application 2014 Medical and Dental
Provider Look up
PHCS.Com "National Network"
Moda Drug Formulary "Covered Prescriptions" |
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A Real Person will Answer,
Call Doug Ellsworth 503-922-2903 |
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Oregon
Rates Starting January 1st, 2015 for all plans
offered.
Review all our medical and dental plans in Oregon:
2015 Oregon individual and family plans brochure
Medical plan summaries
Dental plan summaries
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Rate Sheet for all Plans "pdf" January 1st, 2014 |
Full Brochure with Plans and Rates "Detailed"
Dental Plan Brochure & Rates
Dental Application
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Gold Plans |
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Gold
Be Protected 750 Deductible
Full SBC Plan Description Protected |
Gold Be
Focused 500 Deductible |
Gold Be Focused-Rose City 500 Deductible |
Gold Oregon Standard Gold 1300 Deductible |
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Silver
Plans |
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Silver Be Prepared 1000 Deductible
Full SBC Plan Description Prepared |
Silver
Be Smart 3000 Deductible |
Silver Be Aligned 2500 Deductible |
Silver Be Aligned-Rose City 2500 Deductible |
Silver Oregon Standard Silver 2500 Deductible
Full SBC Plan Description Standard Silver |
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Bronze
Plans |
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Bronze Be Connected 4250 Deductible |
Bronze Be Connected-Rose City 4250 Deductible |
Bronze Be Savvy 5250 Deductible "HSA Qualified"
Full SBC Plan Description "HSA Be Savvy" |
Bronze Oregon Standard Bronze 5000 Deductible
Full SBC Plan Description Standard Bronze |
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Dental
Plans |
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Delta Dental Preferred (PPO) Delta Dental Exclusive (EPO)& Rates |
Moda Dental Application 2014 |
What health plans cover
Your way to better health
Health plans make it easier to get well sooner and stay healthy
longer. That’s partly because they cover part of the costs of the care
you receive.
That might include a doctor visit, hospital stay, preventive
services, prescriptions drugs, mental health treatment or even
physical therapy.
Many plans also come with extras, like free health coaching,
fitness tips and a nurse advice line. For example, Moda Health plans
include all of these resources, plus lots more. Members can access
them by logging in to
myModa from their desktop or mobile device.
What plans cover
When you buy a health plan, the coverage company, like Moda Health,
pays part of your medical costs if you get sick or hurt. Some plans
cover nearly all of your care up to a certain dollar amount. Other
plans kick in only after you meet your deductible.
Most Moda Health plans include free
preventive care. That covers women’s annual exams, well-baby care,
routine physicals, immunizations and more. Benefit amounts vary for
other types of care and procedures. And, after you meet your out of
pocket maximum, care is covered at 100 percent, up to what your plan
allows.
You are responsible for paying some costs as well, such as:
- Premium – Your monthly
cost for your plan.
- Deductible – The amount
you pay before the plan starts to cover most services beyond
preventive care.
- Copayment (copay) – A set
dollar amount you pay for a service, like a doctor’s appointment.
- Coinsurance – The
percentage of a medical bill you pay, usually after you meet your
deductible. You’ll pay either coinsurance or a copay for a service,
but not both at the same time.
- Out-of-pocket maximum –
The total amount you could pay for covered services each year. After
reaching your out-of-pocket maximum, plans pay 100 percent for the
rest of your eligible healthcare expenses, up to what your plan
allows.
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How Health Care Reform affects you
How will your health insurance change?
You’ve probably heard the news. The health insurance industry is
changing. Those changes are all part of “Health Care Reform.” You may
wonder how it affects you. It’s different for everyone.
Whatever your situation, health reform brings new rights and
protections. Those include more choice and control over your health
coverage.
Where to find your health coverage
If you get health benefits through your job, your health plan may
change. Just check with your group administrator to learn more. If you
have your own individual coverage, you may need to re-enroll. Or, you
can buy a new health plan.
Explore Moda Health plans to get
started.
For those who don’t have health insurance, you’ll need to follow a
new federal law, which requires everyone have health coverage. Never
fear — Moda Health can make that part easy.
What you need to know about the new
healthcare law
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The Affordable Care Act
is a federal law designed to make it easier for you to get medical
care. If you don’t already have health insurance, you’ll probably
need to buy it starting in 2014 or face a fine. You can enroll in a
new individual and family plan starting Oct. 1, 2013.
- If you do need to buy health coverage and
live in Oregon, Alaska or Washington,
explore Moda Health plans
here. You can also shop for plans on the health insurance
marketplace.
- You may be able to get help paying for
your health insurance. Learn about qualifying for the
federal tax credit.
If you do qualify for a tax credit and want to use it, you must
apply for your plan on the marketplace.
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Special enrollment
How do you qualify?
Certain life events might qualify you for special enrollment. This
means you can enroll for a health plan outside of the open enrollment
period. For example, having a baby or moving to a new state could make
you or those you cover eligible.
If you enrolled through Washington Healthplanfinder and have had
issues with your 2014 health plan, you may be able to enroll in one of
our 2014 plans. This
temporary special enrollment period
runs Aug. 27, 2014, through Nov. 14, 2014, in Washington.
Applying is easy
If you are a current member and think you qualify for regular
special enrollment, please contact us. Just call toll-free at
877-605-3229 or email
indunit@modahealth.com.
New to Moda Health?
Explore our plans here and see if you
qualify for special enrollment.
Special enrollment state guidelines
Each state treats special enrollment differently. Here are general
guidelines for Oregon, Alaska and Washington. If you have experienced
one of these qualifying events in the last 60 days, you may be
eligible:
In Oregon:
- You have gained a dependent or become a
dependent through marriage, domestic partnership, birth, adoption,
foster adoption, or placement for adoption
- You have moved to a new service area
- You or your dependent lost healthcare
coverage due to one of these reasons:
- Termination of employment
- Divorce or end of domestic partnership
- Over-aged dependents
- Expiration of COBRA
- Loss of eligibility for Medicaid or CHIP
- QHP decertification
- QHP enrollment or disenrollment due to HHS error
- QHP material violation
- Other loss of eligibility
- Your income level changed and affects your
ability to qualify for a health coverage tax credit or changes the
amount of that tax credit
- If you are a member of a federally
recognized Indian tribe, you may enroll or change plans once a month
throughout the year. Visit HealthCare.gov
for a definition and full list of federally recognized tribes. To
learn more about benefits available to American Indians, visit
CMS.gov.
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Health terms glossary
Healthcare lingo explained
Words about health coverage can be confusing. To make it easier for
you, we put together this cheat sheet. After all, how can you expect
to find your way to better health if the signs aren't clear? But watch
out – the more you learn, the closer you get to being a health smarty
pants, like us.
- Accident benefit
- Your coverage for care when you have an accident. You may get
better benefits than for regular care. For example, your deductible
might be waived for treatment related to that accident.
- Affordable Care Act (ACA)
- The Patient Protection and Affordable Care Act (ACA). This
federal law was signed by President Obama in 2010. Starting in 2014,
the law requires you to have health insurance (with some exceptions)
and gives you certain protections. For example, you cannot be
rejected for having a pre-existing condition and your preventive
care will be free. To learn more, visit
healthcare.gov.
- Alternative care
- Services you receive from licensed alternative care
professionals. The definition of alternative care can vary by state.
In Oregon, some examples include naturopathy, acupuncture and
chiropractic care. In Washington, some examples include acupuncture
and spinal manipulation.
- Balance billing
- Charges for out-of-network care beyond what your health plan
allows. Out-of-network providers may bill you the difference between
the maximum plan allowance and their billed charges. In-network
providers can't do this.
- Be Better tools
- Extras to help you stay healthy. Be Better tools come with every
medical plan and are available through myModa. Examples include eDoc,
a way to access licensed health specialists; Registered Nurse Advice
Line, free phone support for health situations; health coaching
services; and online tools to check drugs costs, review claims and
find care.
- Brand drugs
- Patented drugs produced and marketed by a specific manufacturer.
- Bronze tier plans
- Plans that give you less coverage, but a lower monthly premium.
Bronze plans cover more than the catastrophic tier, but less than
silver and gold tiers.
- Calendar year costs
- What you pay each calendar year, January through December.
- Catastrophic plan
- Covers you if you have a serious accident, illness or other
medical emergency. Catastrophic coverage is an affordable way to
protect yourself from large, unplanned medical expenses. It usually
has a high deductible and covers a very basic level of service.
- Coinsurance
- The percentage of medical costs you are responsible for paying.
For example, you may pay 20 percent of a $200 bill, or $40. Moda
Health pays the rest! Usually when you pay coinsurance, you will not
have a copay.
- Community Care Network (CCN)
- This network serves Portland and Salem communities. It includes
a select group of Legacy Health, Salem Health, Adventist Health and
OHSU providers that work together to give you the best care. Enjoy
access in Multnomah, Washington, Clackamas, Yamhill, Marion and Polk
counties.
- Copayment (copay)
- A specific dollar amount you pay for a service. For example, you
might pay $25 for each visit to a doctor's office. Moda Health pays
the rest! Usually, you will not pay coinsurance if you have a copay.
- Covered services
- Services for which your plan pays a portion. Check your policy
to make sure your care is a covered service. If you seek care that
is not covered, you will have to pay for the entire cost yourself.
- Deductible
- The amount you pay before your plan starts to cover services.
However, deductibles don't apply to preventive care, which is free,
or to some services that have a copay instead.
- Dependent
- A family member who is on your health plan. Dependents can be
your spouse or registered domestic partner and children.
- Delta Dental
- One of the largest networks of dentists in the country.
- Dental plan
- A plan that helps you pay for dental care.
- eBill
- Electronic billing services that allow you to pay your monthly
premium online via your myModa account.
- eDoc
- Part of our Be Better tools, eDoc lets you get free online
advice from board certified healthcare providers. Moda Health
members can log in and ask physicians, pharmacists, psychologists,
dentists, dietitians and fitness experts about any health concern.
- Embedded pediatric dental
- Dental coverage for children that comes as part of your family’s
overall medical plan.
- Exclusive Provider Organization (EPO)
- A type of provider network. These are doctors, hospitals and
other medical offices that accept your insurance. Participating
providers agree to your insurance carrier's payments for specific
services. Usually, in EPOs, costs are not covered if you visit a
provider outside the network.
- Explanation of benefits (EOB)
- The statement that shows how your care was paid for. Your EOB
lists the services you received, the dollar amount your provider
charged, the amount covered by insurance and your share.
- First Choice Health Network
- If you live in Washington this is your medical network. It
includes doctors, hospitals and other medical providers.
- Generic drugs
- Drugs with similar ingredients as brand-name counterparts, but
sold for less
- Gold tier plans
- Plans that give you the highest level of coverage from Moda
Health. They also have the highest monthly premiums.
- Health Care Reform
- Changes caused by the Affordable Care Act (ACA). The ACA is a
federal law signed by President Obama. It requires certain changes
to make insurance more affordable and higher in quality. Its goal is
to give more people access to healthcare.
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Health insurance marketplace
- Also called an "exchange," a health insurance marketplace is an
online hub where you can buy affordable health coverage. States
either run their own health insurance marketplace or refer residents
to the federal marketplace. If you qualify for a federal tax credit
based on your income, you must buy your health plan through a
marketplace in order to receive your credit.
- Health plan / medical plan
- Your health insurance policy. The health plan you choose will
have its own set of benefits and monthly premium. Moda Health and
other insurance carriers offer a variety of health plans.
- Health savings account (HSA)
- A way to save for qualified medical costs with tax-free dollars.
With an HSA, you can pay for deductibles, coinsurance and other
out-of-pocket expenses not covered by health plans, such as Lasik
eye surgery or orthodontia. To be eligible, you must have a
qualifying high-deductible health plan and open a HSA with a
qualified trustee, such as a bank.
- Inpatient care
- Care you receive while you are checked in to a hospital or
treatment center. Usually, you are admitted to a hospital only if
you are seriously hurt or sick.
- Marketplace navigators
- These certified agents help folks navigate the health insurance
marketplace, enroll in a health plan and apply for financial
assistance. Their services are free. Oregon individuals who qualify
for financial assistance and wish to receive it must use a navigator
to enroll on the marketplace. CoverOregon.com is working on an
online solution that will eventually allow individuals to do this
for themselves.
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myModa
- Your personalized member website. Log in at
modahealth.com/myModa to see your
claims, benefits and Member Handbook. You can also use Be Better
tools to help manage your health. Members can access myModa from a
desktop computer or mobile device.
- Network
- A group of doctors, hospitals and other providers. If providers
are in your network, they've agreed to accept your insurance at
lower rates. Using an in-network provider keeps your out-of-pocket
costs low.
- ODS Plus Network
- This is one of the largest PPO networks in the state of Oregon.
It includes thousands of primary care physicians working with Moda
Health to help keep you healthy.
- ODS + Providence Alaska Network
- This Alaska network covers participating physicians, clinics and
ancillary providers throughout the state. It includes Providence
Alaska Medical Center as the preferred provider of acute care
services in the Anchorage area.
- ODS Alaska Select Network
- This Alaska network covers participating physicians, clinics and
ancillary providers throughout the state. It includes Alaska
Regional Hospital as the preferred provider of acute care services
in the Anchorage area.
- Out-of-pocket maximum
- The total amount you could pay for care each year. After
reaching your out-of-pocket maximum, Moda Health will pay 100
percent for the rest of your eligible healthcare expenses.
- Out-of-pocket payments
- Anything you pay to providers. This is your share of medical
costs after Moda Health pays a portion.
- Outpatient care
- Care you receive from a doctor's office or other provider,
without being checked into a hospital or treatment center. These are
usually routine office visits.
- Plan tiers
- Plan categories of gold, silver, bronze and catastrophic. Our
gold plans cost a little more, but they cover more, too. Silver
plans fall somewhere in the middle. Bronze plans provide a little
less coverage, but you’ll save money on monthly premiums.
We also have a catastrophic tier, which includes one plan. If you’re
under 30 and meet some eligibility requirements, this plan offers
coverage just in case of an emergency.
Each plan tier meets the requirements of the ACA. Knowing about
these tiers may help you find and choose the best plan for you.
- Pre-existing condition
- A health problem or illness you had before applying for health
insurance. Because of the Affordable Care Act, health plans can’t
turn you down or charge you more for a pre-existing condition
starting in 2014.
- Preferred brand drugs
- Medications for which you'll get better coverage under your Moda
Health plan. If you have prescription coverage, these are certain
brands of drugs that will cost you less out of pocket.
- Preferred provider organization (PPO)
- A type of provider network. These are doctors, hospitals and
other medical offices that accept your insurance. Participating
providers agree to your insurance carrier's payments for specific
services. Usually, this means you pay lower out-of-pocket costs than
if you visit a provider outside the network.
- Premium
- The monthly amount you pay for your health plan.
- Preventive care
- Medical services that help keep you healthy before you ever get
sick. Examples of preventive care are vaccines, regular check-ups
with your doctor and screenings. Preventive care is free with your
health plan.
- Primary care physician (PCP)
- The type of doctor who treats you when you have a routine
illness or injury. This doctor focuses on preventive care.
- Provider
- Any group or professional that provides you with care. Examples
are hospitals, doctors and rehabilitation centers.
- Registered Nurse Advice Line
- Free phone support for basic health situations. The toll-free
line is available to members, 24 hours a day, 7 days a week.
Friendly nurses offer advice about symptoms, treating minor
injuries, choosing cold and flu remedies, and knowing when to come
in for care.
- Rose City Network
- This network includes Providence Health System physicians,
clinics and facilities in the Portland metro area. You can access
these providers in Multnomah, Washington, Clackamas and Yamhill
counties.
- Silver tier plans
- Plans that give you a great combination of coverage and value,
with mid-range monthly premiums. Silver plans give you better
coverage than catastrophic and bronze plans, but less than gold
plans.
- Specialty care
- Medical services that usually go beyond your primary doctor.
Examples are oncology (cancer treatment), neurology (brain and
nervous system) and many others. Specialty care almost always has
different benefits than non-specialty care, so check your policy or
call Moda Health Customer Service with questions.
- Tax credit
- Federal tax credits to help people pay for health insurance. You
might qualify based on your income. To use a tax credit, you must
buy insurance through your state's health insurance marketplace
website.
- Urgent care
- Walk-in medical care you receive at a clinic that is not an
emergency. You may visit an urgent care facility if you need medical
help right away but your situation isn't serious enough for the
emergency room.
- Value drugs
- Select, commonly prescribed products used to treat chronic
medical conditions and preserve health.
Other resources for you
Find even more definitions about health coverage, medical claims
and the Affordable Care Act on
healthcare.gov/glossary. If you want
a printable version, check out this handy Glossary
of Health Coverage and Medical Terms PDF.
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Why choose Moda Health plans?
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