Moda Health Beacon Silver 3500 - 39424OR1620002 Health Insurance Plan

Moda Health Plan, Inc. health insurance plan with the Plan ID 39424OR1620002. The plan is called Moda Health Beacon 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 39424OR1620002
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 39424OR1620002-00
Provider Network(s) ['ORN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Oregon All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 39424OR1620002-00

Standard On Exchange Plan - 39424OR1620002-01

Open to Indians below 300% FPL - 39424OR1620002-02

Open to Indians above 300% FPL - 39424OR1620002-03

73% AV Silver Plan - 39424OR1620002-04

87% AV Silver Plan - 39424OR1620002-05

94% AV Silver Plan - 39424OR1620002-06

Last Plan Update Date Fri, 09 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Moda Health Beacon Silver 3500 Health Insurance Plan, 39424OR1620002-00

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%

Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 Attributes

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 Off 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 ORN001
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) 39424OR1620002-00
Plan Marketing Name Moda Health Beacon Silver 3500
Plan Type EPO
Plan Variant Marketing Name Moda Health Beacon 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 ORS001
Source Name SERFF
Plan ID 39424OR1620002
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

Copay & Coinsurance of Moda Health Beacon Silver 3500 Health Insurance Plan, 39424OR1620002

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Moda Health Beacon Silver 3500, 39424OR1620002 Health Insurance Plan, 39424OR1620002

  • Does Moda Health Beacon Silver 3500 Health Insurance Plan, 39424OR1620002 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (39424OR1620002) Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (39424OR1620002) Health Insurance Plan, Variant (39424OR1620002-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (39424OR1620002) Health Insurance Plan, Variant (39424OR1620002-00) have Out of Service Area Coverage?

    Yes. Details: Emergency care covered, Out of Area dependents covered who are students or under QMCSO

    Does (39424OR1620002) Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Asthma?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Asthma.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Heart disease?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Heart disease.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Depression?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Depression.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Diabetes?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Diabetes.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Low back pain?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Low back pain.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Pregnancy?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Pregnancy.

    Does Moda Health Beacon Silver 3500 Health Insurance Plan, Variant (39424OR1620002-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Moda Health Beacon Silver 3500 Health Insurance Plan Variant 39424OR1620002-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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