OEBB

Medical benefits

What is a deductible?

A deductible is the amount of money that members pay out of their own pocket before the plan begins to pay benefits.

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What does the term “coinsurance” mean?

Coinsurance enables members to split their eligible healthcare costs with the insurance carrier. It is the percentage of the cost of healthcare services that members pay. For example, if a health plan has an 80/20 in-network coinsurance rate for specific services, after the deductible has been satisfied, the insurance company is then responsible for 80 percent of the eligible charges and the member is responsible for the balance. (Out-of-network coinsurance levels will differ from in-network coinsurance levels.) Once members reach their plan-year out-of-pocket maximum, the insurance carrier will pay for 100 percent of the eligible expenses (subject to plan limitations).

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What does the term “out-of-pocket maximum” mean?

This is the most you pay in a plan year for covered medical services before benefits are paid in full. Once you meet your out-of-pocket maximum, the plan covers all eligible medical expenses at 100 percent. For PPO plans, the out-of-pocket maximum includes medical deductibles, coinsurance, and most copayments. It does not include Additional Cost Tier (ACT) copayments, pharmacy copayments/coinsurance, disallowed charges or balance billing amounts for out-of-network providers. For Synergy and Summit plans, the out-of-pocket maximum includes medical and Rx copays (excluding ACT), coinsurance and deductibles. It does not include ACT copayments, disallowed charges or balance billing amounts for out-of-network providers.

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What does the term “maximum cost share” mean?

The maximum cost share applies to Moda plans Alder and Dogwood. This is different than the out-of-pocket maximum. This plan year limit includes ACT copays, pharmacy copays and coinsurance, as well as the eligible medical expenses that accrue toward your in-network out-of-pocket maximum. Once the maximum cost share is reached, the plan covers all eligible medical and pharmacy expenses at 100 percent.

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What is a reference price?

A reference price means a set price for a specific covered service, established for certain medical services for which a wide variation of provider charges exists. Moda's networks include providers whose charges are at or below the reference price. If a member chooses to use a provider who charges above the reference price threshold, the member will be responsible for paying the difference between the reference price and the provider's contracted rate.

Current Services that have a reference price on OEBB plans include:

  • Knee and hip replacement*
  • Oral appliances for sleep apnea
  • Bariatric surgery

*Applies to PPO plans only; does not apply to Synergy or Summit plans.

For a list of providers who are at below the reference price amount, call the customer service team at 866-923-0409.

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Do all expenses apply to a member’s medical maximum out-of-pocket cost?

No. On a PPO plan, the maximum out-of-pocket includes medical deductibles, coinsurance and copays. It does not include ACT copays, pharmacy expenses, disallowed charges or balance billing amounts for out-of-network providers. On a Synergy or Summit plan, the maximum out-of-pocket includes medical and Rx copays (excluding ACT), coinsurance and deductibles. It does not include ACT copays, disallowed charges or balance billing amounts for out-of-network providers.

Members are responsible for the following costs. They do not accrue toward the out-of-pocket maximum and members must pay for them even after the out-of-pocket maximum is met:

  1. The out-of-pocket expenses for bariatric surgery not performed at a Center of Excellence facility, or out-of-pocket expenses above the Center of Excellence $20,000 benefit maximum
  2. The out-of-pocket expense for a sleep apnea appliance above the $1,800 benefit maximum per appliance
  3. The out-of-pocket expenses for hip and knee replacements above the $25,000 benefit maximum (applies to PPO plans only)
  4. Cost containment penalties (applies to PPO plans only)
  5. Disallowed charges

Please note that the out-of-pocket for pharmacy expenses works differently depending on whether you are enrolled in a PPO plan or a CCM (Synergy or Summit) plan. For more information please refer to the Pharmacy FAQ.

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If a member is on a plan that requires some medical copayments, does the deductible need to be met before the services with copayments are paid?

Some services with copayments such as Moda Medical Home, office visits, incentive care visits, mental health and urgent care visits are paid without the deductible needing to be met. The member is only responsible for the copayment and Moda Health pays the balance.

Services such as emergency room visits, additional cost-tier procedures, and bariatric surgery require the member to pay the copayment, then the annual deductible and then benefits will pay at the appropriate coinsurance level.  

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Does the deductible for in- and out-of-network commingle (meaning that there is one deductible for both in- and out-of-network services combined)?

No. Effective 10/1/2016, there are separate in-network and out-of-network deductibles. Only in-network expenses apply to the in-network deductible, and only out-of-network expenses apply to the out-of-network deductible. For all plans, the out-of-network deductible is twice the in-network deductible.

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How does deductible carryover work?

On medical plans Alder, Birch, Cedar and Dogwood, if a member does not meet their deductible (individual or family) during a plan year, any expenses applied to their deductible during the last 3 months of that plan year will be carried over and applied to the deductible for the following plan year. Deductibles are accumulated on a plan year basis.

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Does the out-of-pocket maximum for in- and out-of-network service commingle?

No. Effective 10/1/2016, there are separate in-network and out-of-network out-of-pocket maximums. Only in-network expenses apply to the in-network out-of-pocket maximum, and only out-of-network expenses apply to the out-of-network out-of-pocket maximum. For all plans, the out-of-network out-of-pocket maximum is twice the in-network out-of-pocket maximum.

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What are members’ benefits while traveling?

Members have access to the Moda Health travel network. The travel network allows medical plan members to receive emergency and nonemergency care outside of their primary service area while traveling. Eligible members need to seek care from a First Health Network provider to receive in-network benefits.

Dependents living outside of the primary network area can also use the Moda Health travel network to receive care at an in-network benefit level. More information about setting up dependents in "out-of-area" status can be found on the eligibility FAQ.

The Moda Health travel network is not an alternative primary network. Members must seek in-network services whenever possible, and preauthorization is required for in-patient services.

If a member is traveling out of the service area and seeks care from an out-of-network physician or provider, the benefit will be paid at the out-of-network benefit level. Out-of-network benefits are subject to the maximum plan allowable.  

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What is the “maximum plan allowable”?

The medical plan includes maximum plan allowance (MPA) pricing. MPA is the maximum amount that Moda Health will reimburse a non-contracted provider. A non-contracted provider may bill a member for any amount over and above the MPA. This may leave members with a high out of pocket balance. A member considering using a non-contracted provider should call customer service to inquire as to whether MPA would apply.

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What if a member is out of the service area and has a medical emergency?

If a member is out of the service area and has a medical emergency, the member should go to the nearest emergency room or urgent care facility. Benefits will be paid at the in-network benefit level, subject to the maximum plan allowable for urgent and emergency services.

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If a member has a specific rare condition and needs to continue to see a provider that is not in the network, will Moda Health pay at the in-network benefit level?

Moda Health will follow its standard Transition of Care healthcare services policy. Transition of Care services may be approved under extraordinary circumstances for a finite period of time for a member who, while actively receiving medically necessary services, moves from a health plan with another carrier to Moda Health and, as a result, has ongoing medical services that become out of network. The member must complete a Transition of Care form that Moda Health will review and approve.

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How does medical Plan Evergreen, the HSA-compliant plan, work?

HSA-compliant plans give consumers incentives to manage their own healthcare costs by coupling a tax-favored health savings account (HSA) used to pay medical expenses with a high-deductible health plan (HDHP) that meets certain requirements for deductibles and out-of-pocket expense limits. HDHPs cover preventive care services (e.g., routine medical exams, immunizations, etc) without requiring the enrollee to first meet the deductible. OEBB Plan Evergreen is a HSA-compliant plan.

This plan has a high deductible that must be met prior to any benefits being paid out (except for specific preventive services when performed by in-network providers). It is important to understand that the family deductible is a shared deductible. Therefore, for any subscriber enrolled with one or more dependents on the plan, the entire family deductible must be satisfied before benefits are payable for services subject to the deductible (basically everything, including prescriptions, except preventive services). This is different from how the deductibles work on the other plans, where each individual can separately meet a deductible. Please note: IRS regulations may prohibit coordination of benefits in order to receive HSA benefits tax-free.

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What is a Moda Medical Home?

The Moda Health Medical Home is a group of clinics who have either received or are working towards recognition through the state-run PCPCH (Patient-Centered Primary Care Home) program and are contracted with one of Moda's network offerings. PCPCHs are clinics that have been recognized for their commitment to quality and coordinated care. At its heart, this model of care fosters strong relationships with patients and their families. Clinics improve care by catching problems earlier, focusing on prevention, wellness and management of chronic conditions. As contracted network providers achieve the recognition, they will be added as medical homes to their respective network(s). For more information about Medical Homes, go to modahealth.com/medicalhome

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How do members find a Moda Medical Home provider?

We recommend that you log into your myModa account and go to the Medical Home tab to search for Medical Homes. But if you are not a member or don’t have access to myModa, you can follow these simple steps:

  1. Go to Find Care, our online provider directory
  2. Choose Medical care
  3. In the search criteria for Provider Type, choose "Medical Home Clinics & Medical Groups"
  4. Choose your appropriate network.

The medical customer service team can also help locate participating Medical Homes and can be reached at 866-923-0409.

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What is a Moda Medical Home Wellness Visit?

The Wellness Visit is covered once annually in full for members age 21 and over when seeing a Moda Medical Home provider and is in addition to an annual preventive exam/physical. The visit will be a dialogue focused on overall wellness rather than treating a specific condition. The discussion could focus on exercise, weight management, physical activity, depression, or tobacco or substance use.

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What is an incentive office visit?

On Plans Alder, Birch, Cedar and Dogwood, members will pay a lower office visit copay or coinsurance for visits to manage certain conditions. These conditions include:

  • Asthma
  • Heart conditions
  • Cholesterol
  • High blood pressure
  • Diabetes

If enrolled in a Synergy or Summit plan, the member will need to use their preselected Moda Medical Home to receive the in-network benefit.

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What is the Additional Cost Tier?

The Additional Cost Tier refers to select procedures on medical plans Alder, Birch, Cedar and Dogwood including:

$100 cost tier:

  • Upper endoscopy
  • Spinal injections
  • Viscosupplementation
  • Lumbar discography
  • Tonsillectomy for a member under age 18 with chronic tonsillitis or sleep apnea
  • Sleep studies
  • Imaging procedures

$500 cost tier:

  • Arthroscopy (knee and shoulder)
  • Spine surgery
  • Uncomplicated hernia repair
  • Knee / Hip Replacement (subject to reference pricing limitations)

Members are encouraged to start a dialogue with their provider and to explore less invasive treatment alternatives if possible.

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What is the benefit for alternative care providers?

Alternative care refers to spinal manipulation, acupuncture services and naturopathic care. If a member seeks services from an alternative care provider, covered services are paid at 80 percent in-network or 50 percent out-of-network, after deductible, up to an aggregate plan year maximum of $2,000. Some services, including chiropractic and acupuncture, may require a prior authorization.

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What is the Healthy Futures program?

Healthy Futures is a program designed to encourage OEBB members to learn their individual health risks and how to take action to reduce or eliminate risks whenever possible. If members complete their Health Assessment and two wellness activities, they will receive a deductible credit for the following plan year. In order to qualify for the credit, both the plan subscriber and covered spouse/partner (if applicable) will need to complete their own Health Assessment and two wellness activities. Members will need to log in to their separate myModa accounts to complete their Health Assessment. Wellness activities will need to be logged in the MyOEBB system during open enrollment. Additional information on the Healthy Futures program can be found on the OEBB website.

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What is the Health Assessment and where do I find it?

OEBB members who have signed up for a Moda medical plan have access to a Health Assessment offered through Momentum. The Health Assessment is a short survey designed to help determine one's overall health, risk level for several conditions and overall "health age." To access the survey members will need to log in to myModa and click on "Momentum, powered by Moda Health," and then "Visit Momentum now" on the following page. Here you will click on "Health Assessment" on the top left to get started. The Health Assessment must be completed in order to qualify for the Healthy Futures benefit. Members can retake their assessment at any time.

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What disease management programs does Moda Health offer?

Moda Health offers the following health coaching programs:

  • Diabetes
  • Cardiac care
  • Respiratory care
  • Depression
  • Maternity
  • Spine and joint care
  • Weight management
  • Lifestyle coaching

To enroll, call a Moda Health health coach at 800-913-4957 or 503-243-3957

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What are the benefits for weight management?

Benefits for weight management include one obesity screening and risk assessment per plan year, health coaching, online educational resources and Weight Watchers support. OEBB medical plans cover bariatric surgery for OEBB plan subscribers only. The plan provides coverage for Roux-en-Y surgery or gastric sleeve surgery. There will be a $500 copay, plus deductible and then coverage will be at 80 percent. Members must use one of the approved Centers of Excellence (COE) in order to be covered; there is no out-of-network benefit.

Roux-en-Y and gastric sleeve surgery are subject to a $20,000 "reference price." This means that the maximum Moda Health will pay for the facility charge for bariatric surgery is $20,000. For a list of hospitals whose contracted rates are below $20,000 contact customer service. If there are no COEs in an area that fall under the reference price, members can utilize the travel benefit, as outlined in the member handbook.

This benefit is based on specific medical criteria and is a program that must be followed for 6 months (referred to as a waiting period) before the surgery benefit can be utilized. To be eligible for this benefit, please see the specific medical criteria located on the OEBB website or in your member handbook.

Weight Watchers is a covered value-added benefit, limited to the program’s monthly fee only.

  • Moda Health will pay Weight Watchers 100 percent for up to four 13-week programs per year.
  • Members must attend 10 of the 13 weeks to be eligible for the next 13-week program.
  • If they do not attend at least 10 weeks out of the 13, they pay for the next 13-week program themselves, and must attend at least 10 of these sessions, before becoming eligible for another 13-week program.
  • Call Weight Watchers for full program details at 866-531-8170.

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What benefits are covered under the cardiovascular screening preventive care benefit?

When members go for their annual physical, the preventive care benefit also includes an EKG and treadmill test.

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What benefits are covered under the hearing evaluation preventive care benefit?

This benefit is for children and adults. A brief hearing evaluation during a well-child examination is eligible for benefits. An adult hearing evaluation is covered when performed in conjunction with an adult periodic exam.

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Are midwives and birthing centers covered?

Yes. Moda Health covers both midwives (as long as they are licensed and certified) and birthing centers.

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What are my benefits for hearing aids under state mandate?

The plan covers one hearing aid per hearing-impaired ear every 48 months for members under age 26. One pair of hearing aids is covered up to a $4,000 maximum every 48 months for members age 26 and older. A member must be examined by a physician before obtaining a hearing aid that is prescribed, fitted and dispensed by a licensed audiologist or hearing aid specialist.

Covered benefits include the following every 48 months:

  • A hearing aid (monaural or binaural) prescribed as a result of the examination
  • Ear molds
  • Hearing-aid instruments
  • Initial batteries, cords and other necessary supplementary equipment
  • A warranty
  • Repairs, servicing or alteration of the hearing- aid equipment

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What is a cost containment penalty?

All inpatient services, partial hospitalization, residential stays and some outpatient procedures and prescription drugs require providers to get a pre-service authorization from Moda Health before performing the procedure. If an in-network provider fails to obtain prior authorization when authorization is required, the provider will be responsible for the full charges (provider write off). If a member utilizes an out-of-network provider and fails to obtain prior authorization when authorization is required, Moda will deny the charges and the member will be responsible for the full charges.

The prior authorization penalty does not apply toward the plan’s deductible or out-of-pocket maximum. The penalty will not apply in the case of an emergency admission.

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Coordination of benefits is confusing. Can you provide some examples for dual coverage with medical plans so I can get a better understanding of how benefits will be coordinated?

In most cases, once the deductibles and out-of-pocket maximums are satisfied, members will not have any further out-of-pocket costs, unless other limitations or maximums are involved. If members seek services from out-of-network providers, they will be responsible for any charges in excess of the Moda Health maximum plan allowance (MPA). If a member has secondary coverage through a non-Moda Health plan, he or she should check with that plan’s insurance carrier on how it handles coordination of benefits. Please see below for sample scenarios.

Medical coordination of benefit examples for members double covered under OEBB:

All examples assume use of in-network providers.

Example #1

A claim for a Moda Medical Home primary care office visit for a member on plan Cedar primary and plan Birch secondary. Assuming the billed amount and allowed amount is $140, the claim would be processed as follows. For a Moda Medical Home primary care office visit, there is a $30 copayment and the deductible is waived for both Cedar and Birch.

Claim amount: $140

Plan Cedar payment:
$0 is applied to deductible on plan Cedar since the deductible is waived on Moda Medical Home primary care visits.
$30 member copay which applies to the annual out-of-pocket maximum but not the annual deductible.

Total payment under plan Cedar is $110.

Plan Birch payment:

$0 is applied to deductible on plan Birch since the deductible is waived on Moda Medical Home primary care visits.
$30 member copay which applies to the annual out-of-pocket maximum but not the annual deductible.

Total payment under plan Birch would be$110 but since Moda Health will not pay over the $140 allowed amount, the actual payment is $30.

Total that the member is responsible for paying is $0.

Claim 2:
A claim comes in for minor office surgery. Assuming the billed amount and allowed amount is $1,250, the claim would be processed as follows. Once the deductible is met, Moda Health pays 80 percent of the remainder, and the member pays 20 percent.

Claim amount: $1,250

Plan Cedar payment:
$1,200 is applied to deductible on plan Cedar. The deductible is now met.
Moda Health pays 80% on the remaining $50.

Total payment under plan Cedar is $40.

Plan Birch payment:
$800 is applied to deductible on plan Birch. The deductible is now met.
Moda Health pays 80% on the remaining $450.

Total payment under plan Birch is $360.

Total that the member is responsible for paying is $850.

Example #2

A claim for knee replacement comes in for a member on plan Birch primary and plan Cedar secondary. Assuming the billed amount and allowed amount is $5,000, the claim would be processed as follows. The knee replacement is part of the Additional Cost Tier with a $500 copay. This comes out first, then the annual deductible is applied. Once the deductible is met, Moda Health pays 80 percent of the remainder, and the member pay 20 percent.

Claim amount: $5,000

Plan Birch payment:
$500 copay applied to Additional Cost Tier – this amount is applied to the maximum cost share but not the annual deductible or out-of-pocket maximum.
$800 is applied to deductible on plan Birch. The deductible is now met.
Moda Health pays 80% on the remaining $3,700. 

Total payment under plan Birch is $2,960.

Plan Cedar payment:
$500 copay applied to Additional Cost Tier – this amount is applied to the maximum cost share but not the annual deductible or out-of-pocket maximum.
$1,200 is applied to deductible on plan Cedar.
Moda Health pays up to 80% on the remaining $3,300. 

Total payment under plan Cedar would be $2,640 but since Moda Health will not pay over the $5,000 allowed amount, the actual payment is $2,040.

Total that the member is responsible for paying is $0.

Plan Evergreen double coverage coordination of benefits examples:

The following example is for members who cover each other under two Evergreen plans. This example assumes use of in-network providers.

Example

A claim is received for an outpatient surgery for a member double-covered on plan Evergreen family coverage. The $3,200 family deductible must be met first under both plans, and charges will apply to both deductibles. Once the deductible is met, the primary pays 80% and the secondary will pay up to 80%, not to exceed the allowed amount. Assuming the billed amount and allowed amount is $5,000, the claim would be processed as follows:

Claim amount: $5,000

Primary Plan Evergreen payment:
$3,200 is applied to deductible on primary plan Evergreen.
The deductible is now met.
Moda Health will pay 80% on the remaining $1,800, which is $1,440.

Secondary Plan Evergreen payment:
$3,200 is applied to deductible on secondary plan Evergreen. The deductible is now met.
Moda Health will pay up to 80% on the remaining $1,800, which is $1,440.

Total benefits paid under primary and secondary are $2,880.

Total member responsibility is $2,120.

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What are the different ways to enroll in the tobacco cessation program?

An OEBB member can enroll by:

  • Directly calling the program: 866-784-8454 or TTY 877-777-6534 (hours of operation: 5 a.m. to midnight Pacific Time)
  • Calling Moda Health Medical Customer Service and asking for the Quit for Life Program
  • Logging in to MyModa or visiting www.quitnow.net and registering online.
  • Using myModa to request a call from Alere Quit for Life. After logging in to myModa, OEBB members can get information about the Alere Quit For Life Program on the home page or in the myHealth section. A link takes users to an online call back form.
  • Faxing an enrollment form from a provider or a Moda Health clinician with contact information to 800-483-3114.

The standard medical plan will cover tobacco cessation services. This benefit is subject to the plan’s deductible and copayment. However, if members use our exclusive tobacco cessation program, telephone coaching, counseling and supplies are paid at 100 percent with the deductible waived. The benefit includes a 10 week supply of nicotine replacement therapy (patch or gum) and one-on-one telephonic coaching with a quit coach.

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Is a physician referral to the tobacco cessation program necessary?

No. Members can self-refer.

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Hello.

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