Moda Select Texas Standard Gold - 17933TX0010009 Health Insurance Plan

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
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: 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 - 17933TX0010009-01

Open to Indians below 300% FPL - 17933TX0010009-02

Open to Indians above 300% FPL - 17933TX0010009-03

Last Plan Update Date Thu, 23 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Moda Select Texas Standard Gold Health Insurance Plan, 17933TX0010009-01

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%

Moda Select Texas Standard Gold Health Insurance Plan Variant 17933TX0010009-01 Attributes

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

Copay & Coinsurance of Moda Select Texas Standard Gold Health Insurance Plan, 17933TX0010009

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

Frequently Asked Questions(FAQ) about Moda Select Texas Standard Gold, 17933TX0010009 Health Insurance Plan, 17933TX0010009

  • Does Moda Select Texas Standard Gold Health Insurance Plan, 17933TX0010009 support Mail Ordering?

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

  • Does (17933TX0010009) Health Insurance Plan, Variant (17933TX0010009-01) 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 (17933TX0010009) Health Insurance Plan, Variant (17933TX0010009-01) have Out of Service Area Coverage?

    Yes. Details: Emergency care covered, Out of Area children covered who are enrolled under 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