Want to learn more about PCP 360? This page answers some of the most commonly asked questions.
How is the new coordinated care plan different than the Synergy or Summit plan?
All Moda plans will use the same provider network going forward, so Synergy and Summit plans are being converted to Connexus. This change benefits OEBB members by providing access to the Connexus Network, the largest selection of providers in Oregon.
Members choosing to coordinate their care to receive enhanced benefits will now choose a PCP 360 for their primary care, instead of a Moda Medical Home. Each individual family member will make this choice and will decide to choose their own PCP 360. This means that some family members will receive enhanced benefits for choosing a PCP 360 and agreeing to coordinate their care; and family members that that don’t select a PCP 360 to coordinate their care will not receive enhanced benefits.
The enhanced benefits for coordinating care include lower individual deductibles, lower individual out-of-pocket maximums, and lower copays for urgent care, specialist and alternative care office visits. See the plan documents for details on the benefit differences.
Members can choose to participate in coordinated care at any time during the plan year by selecting a PCP 360, not just at open enrollment. The enhanced benefits will be effective the first of the month in which the member chose their PCP 360.
What is a PCP 360?
A PCP 360 is a primary care provider who delivers full-circle care, coordinating your care with other providers as needed. They are high-quality providers who are willing to partner with you and be held accountable for your health. You can count on your PCP 360 to provide higher quality care with lower out-of-pocket costs.
Members (and individually covered family members) who choose a PCP 360 will receive enhanced benefits, including lower individual deductible, lower individual out-of-pocket maximum, and lower copays for office, specialist and alternative care visits.
Do I have to choose a PCP 360 on my plan?
All plans have the option of “coordinated” or “non-coordinated” benefits. Members choosing “coordinated” benefits must choose a PCP 360 in order to receive the enhanced benefits. Members who do not choose a PCP 360 will receive the non-coordinated benefit levels.
Can I keep the primary care provider I am using today?
First, you will need to confirm that your current PCP is part of our Connexus Network and find out if they are a PCP 360. There is a directory of in-network PCP 360s on the Member Dashboard under Find Care, or you may contact Moda Medical Customer Service at 866-923-0409 for help.
You will receive enhanced coordinated benefits if your current primary care provider is part of the Connexus Network AND is a PCP 360. You will need to choose your current provider as a PCP 360 in the Member Dashboard, or by calling Moda Medical Customer Service at 866-923-0409.
You will receive the “non-coordinated” benefit level if you wish to stay with your current provider who is part of the Connexus Network but NOT a PCP 360.
What if I see a primary care provider (PCP) that is not my PCP 360?
If your PCP 360 is unavailable, but a provider at the same location can see you, the benefit will be paid the same as your PCP 360 benefit. If you seek primary care services from an in-network provider who is not your chosen PCP 360 at different clinic, then you will receive a higher copayment.
Where can I find a list of PCP 360s?
There is a directory of in-network PCP 360s via the Member Dashboard. Using Find Care to search for in-network providers, or you may contact Moda Medical Customer Service at 866-923-0409 for help.
If you are not yet a Moda Health member: Find Care is located on the left hand side of modahealth.com/oebb website. You can search for PCP 360s near you by using the “Search by Network” feature and choosing the Connexus Network.
Moda’s designated medical customer service line for OEBB members is also a great tool if you’d like help finding a PCP 360. They can be reached at 866-923-0409.
How do I choose my PCP 360?
Once you have completed your enrollment with OEBB and it has been loaded in the Moda system, you will choose your PCP 360 through Moda Health. If you are new to the plan, Moda Health will mail your ID cards and a step-by-step instructions on choosing a PCP 360 after you enroll.
You can select a PCP 360 for you, your spouse or any covered dependent one of the following ways:
When do I need to choose my PCP 360?
You can choose your PCP 360 as soon you have completed your enrollment with OEBB and it has been loaded in the Member Dashboard. You should wait 5-10 business days after you enrolled in myOEBB. Your enhanced “coordinated” benefits will be effective the first of the same month in which you make your selection.
You and your family members can choose a PCP 360 at any other point during the year, too. The enhanced “coordinated” benefits will be effective the first of the same month in which you choose your PCP 360 with the Member Dashboard.
Can I change my PCP 360 throughout the year?
Yes. You and your family members can change your PCP 360 at any time of the year. You will just need to choose your new PCP 360 with Moda using the options provided above. This change will be effective the first of the same month in which you or your family member made the selection.
Do I have to re-choose my PCP 360 each year?
No. Your selection will carry over from year to year.
After enrolling, what can I expect when calling into Moda customer service?
The Customer Service Representative (CSR) will confirm which members of your family have chosen a PCP 360 and the appropriate level of benefits for each person. If there is no PCP 360 on file, the CSR can assist you in locating and choosing one over the phone. The CSR will then review with you the enhanced benefits of choosing a PCP 360 to ensure you receive the highest level of benefits possible.
If I visit a walk-in clinic at a time when my PCP 360 is not open, how will my claim be paid?
It depends whether you are visiting for an urgent care need or for a primary care need.
To find urgent care providers in the Connexus Network, please visit Find Care, use the Provider Search tool, and search under the urgent care specialty.
If you are receiving primary care or specialty services, rather than urgent care services, that care would fall under the primary care or specialty benefits on your plan. When you use someone other than your chosen PCP 360 for primary care services, you will pay a higher copay.
I see a naturopath for my primary care. Can I choose my naturopath as my PCP 360?
You can only choose a naturopath as your PCP 360 if they are credentialed and registered in our system as a PCP 360. Generally, naturopaths and other alternative care providers like chiropractors and acupuncturists are considered specialists.
If you see an in-network naturopath who is not registered in our system as a PCP 360, you may still see this provider and receive care at the specialist benefit level. You will still need to select an available PCP 360 in order to receive the enhanced “coordinated” plan benefits.
What about my dependent who does not live in the Connexus service area? Can they still choose coordinated care (PCP 360) and receive the enhanced benefit?
Dependents (for example: college students) who live part-time out of the Connexus service area can still choose a PCP 360 for enhanced coordinated benefits when they see their PCP 360, while receiving access to our travel network for when they are away from home. Please let your employer and Moda Customer Service know their out-of-area address. That way, they can still have access to our travel network to use in-network benefits for services they receive away from home. For primary care outside the service area, as they will not be seeing their selected PCP 360, they will pay a higher copay just as if they had seen any other primary care provider who is not their PCP 360.
I am an OEBB retiree or COBRA member living outside the Connexus service area. Can I choose the coordinated care benefits?
Subscribers who live full-time outside of the Connexus Network are not eligible for coordinated care plans.
What if there is no nearby specialist in-network?
If there is no in-network provider available with a particular specialty, the PCP 360 will work with Moda Health to coordinate the referral to ensure in-network benefits.
Are there referral requirements?
No. Moda does not require referrals to see in-network providers. Your PCP 360 will work with other providers, as needed to coordinate your care, including specific recommendations to certain specialists and hospitals. While these providers may require a referral from your PCP 360, you do not need a referral to be on file with Moda Health. It is important to note that you must still make sure that you are using in-network providers for all care. Otherwise, benefits will be paid at a lower benefit level and may be subject to the higher out-of-network deductible and out-of-pocket maximum.
What about emergency care?
Claims for emergency care will be paid at the in-network benefit level, and emergency care does not need to be coordinated by your PCP 360. Members may be responsible for paying anything over the maximum plan allowance for out-of-network facilities.
What is a medical out-of-pocket maximum?
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%. 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.
What is a Maximum Cost Share and what does it mean?
The maximum cost share applies to Moda plans 1 through 5. 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%.
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