Resources
Explore the policies, documents, notices and resources that define how Moda Health does business with our members, providers, employers and other partners.
Moda Health at-a-glance
Moda Health has nearly 1,000 employees, living and serving members in four states: Alaska, Idaho, Oregon and Texas. We offer affordable, quality health plans for individuals, families, and businesses, small and large. At Moda Health, we're passionate about helping you on your journey to be better. Since 1955, we've been helping our members with evidence-based health plans, diverse provider networks, innovative member programs, and our signature, caring customer service.
At Moda, we believe there's always a better way. Being – and doing – better is at the core of everything we do. It's in our DNA. Our companies offer insurance services, healthcare business solutions, care services and delivery, all working together to build healthy communities.
At Moda, we're committed to making healthcare work better for everyone. This goal isn't one of equality; it's one of equity. That's why we have been working for many years to weave the pillars of DEI into everything we do.
Diversity: We value, respect and celebrate people of all backgrounds, identities and abilities, and we actively seek to identify how uniqueness makes us better.
Equity: We strive to understand the underlying causes of outcome disparities and work toward increasing justice and fairness in our processes, procedures and systems – within both our company and our communities.
Inclusion: We are committed to creating environments wherein every individual has an equal opportunity to belong and can be recognized for their inherent worth and dignity.
The Policy Committee of the Moda Health Board of Directors oversees all our quality programs. Our Medical Quality Improvement Committee (MQIC) does the legwork to make sure our programs run smoothly. We represent key service areas of our health plan by including senior executives and the company’s chief medical officer as members of the MQIC. Using tools designed specifically for healthcare, our committee monitors, measures and evaluates the quality of services our members receive.
Moda Health annual work plan
Each year, we write a work plan of our quality initiatives and goals to improve member experience and satisfaction. The work plan keeps us on track and helps us monitor our progress throughout the year.
Moda Health annual quality evaluation
Our annual quality evaluation documents our quality improvement activities. These activities include specific initiatives, goals and outcomes. We study the results to find out how much our efforts improved member experience and satisfaction. We identify issues that kept us from reaching our goals. This annual assessment directs our work plan and priorities for the following year.
What the No Surprises Act means to you
Unexpected bills can be stressful. Even more so when they are emergency medical bills. Now, if you are on an individual medical plan or on most group health plans, the federal No Surprises Act (NSA) protects you from these unexpected costs by reducing the amount you are billed.
Here's how it works
Starting Jan. 1, 2022, out-of-network providers caring for you at in-network facilities, air ambulance providers and providers of emergency services may only charge you the cost-sharing, such as your deductible and coinsurance, that you would have paid for in-network services. These providers cannot charge you more than this – this is called balance billing is prohibited under the NSA.
This applies to most insured and self-funded group health plans and individual medical plans. It applies in all states. It does not apply to short-term medical plans, dental only, vision only, Medicaid, Medicare Supplemental or Medicare Advantage plans.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in- network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact Idaho Department of Insurance by visiting the department's website at doi.idaho.gov/nosurprises or calling the Consumer Affairs section at 1-208-334-4319 or toll-free in Idaho at 1-800-721-3272.
Visit doi.idaho.gov/nosurprises for more information about your rights under this law.