Moda Select Silver 4800 - 17933TX0010004 Health Insurance Plan

Moda Health Plan, Inc. health insurance plan with the Plan ID 17933TX0010004. The plan is called Moda Select Silver 4800.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 67.87% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 32.13% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 17933TX0010004
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 17933TX0010004-01
Provider Network(s) ['TXN001']
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 Texas 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 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

87% AV Silver Plan - 17933TX0010004-05

94% AV Silver Plan - 17933TX0010004-06

Last Plan Update Date Sun, 15 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Moda Select Silver 4800 Health Insurance Plan Variant 17933TX0010004-01 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 Silver On Exchange Plan
Dental Only Plan No
EHB Percent of Total Premium 0.99
First Tier Utilization 100%
Formulary ID TXF002
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 67.87%
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 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) 17933TX0010004-01
Plan Marketing Name Moda Select Silver 4800
Plan Type EPO
Plan Variant Marketing Name Moda Select Silver 4800
QHP/Non QHP On the Exchange
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $4,800
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 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 $9600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $4800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $4,800
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 $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
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 Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Moda Select Silver 4800 Health Insurance Plan, 17933TX0010004

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

Frequently Asked Questions(FAQ) about Moda Select Silver 4800, 17933TX0010004 Health Insurance Plan, 17933TX0010004

  • Does Moda Select Silver 4800 Health Insurance Plan, 17933TX0010004 support Mail Ordering?

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

  • Does (17933TX0010004) Health Insurance Plan, Variant (17933TX0010004-01) 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 (17933TX0010004) Health Insurance Plan, Variant (17933TX0010004-01) 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: 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