Moda Select Bronze 8700 - 17933TX0010006 Health Insurance Plan
Moda Health Plan, Inc. health insurance plan with the Plan ID 17933TX0010006. The plan is called Moda Select Bronze 8700.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 62.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 37.01% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 17933TX0010006 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| 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 | 17933TX0010006-01 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 09 Apr 2024 06:01 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 17933TX0010006-01 |
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| Last Plan Update Date | Sun, 15 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 09 Apr 2024 06:01 GMT |
Moda Select Bronze 8700 Health Insurance Plan Variant 17933TX0010006-01 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 | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Dental Only Plan | No |
| EHB Percent of Total Premium | 0.99 |
| First Tier Utilization | 100% |
| Formulary ID | TXF003 |
| Formulary URL | URL |
| HIOS Product ID | 17933TX001 |
| Import Date | 8/15/2021 0:38 |
| 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 Actuarial Value | 62.99% |
| 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 | Expanded Bronze |
| 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 | No |
| Out of Service Area Coverage Description | Emergency and OOA dependents on QMCSO |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 17933TX0010006-01 |
| Plan Marketing Name | Moda Select Bronze 8700 |
| Plan Type | EPO |
| Plan Variant Marketing Name | Moda Select Bronze 8700 |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,700 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $600 |
| SBC Scenario, Having Diabetes, Deductible | $4,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 17933TX0010006 |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $17400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8700 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,700 |
| 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 Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Moda Select Bronze 8700 Health Insurance Plan, 17933TX0010006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Moda Select Bronze 8700, 17933TX0010006 Health Insurance Plan, 17933TX0010006
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Does Moda Select Bronze 8700 Health Insurance Plan, 17933TX0010006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (17933TX0010006) Health Insurance Plan, Variant (17933TX0010006-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan). Details: Emergency only
Does (17933TX0010006) Health Insurance Plan, Variant (17933TX0010006-01) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan). Details: Emergency and OOA dependents on QMCSO
Disclaimer: This is based on the import(Date: Tue, 09 Apr 2024 06:01 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