Patients’ rights and responsibilities

Moda Health recognizes the specific needs of its members and maintains a mutually respectful relationship with them.

Moda Health members have the right to:

  • Be treated with respect and dignity.
  • Know their rights and responsibilities. Members will be given information about their health plan and how to use it. Members also will be given information about the providers who care for them. This information will be provided in a way that members can understand.
  • Make recommendations regarding Moda Health's members' rights and responsibilities policy.
  • Participate in decision-making regarding their healthcare — members have a right to participate in a discussion of appropriate or medically necessary treatment options for their conditions, whether or not the cost or benefit is covered by Moda Health.
  • Have access to urgent and emergency services, 24 hours a day, seven days a week.
  • Refuse treatment and be informed of the possible medical result.
  • Receive services as described in their Member Handbook.
  • Have their medical and personal information remain private. Personal information will be handled in compliance with state and federal law and will be given to third parties only as necessary to administer the plan, as required by law or as permitted by the member.
  • Change to a new primary care physician (PCP) up to two times in a 12-month period. (Not all plans require members to choose a PCP.)
  • Appeal a decision or file a complaint about the policy, and to receive a timely response.
  • File a statement of wishes for treatment (i.e., an Advanced Directive), or give someone else the right to make healthcare choices for you when you are unable to (Power of Attorney)
  • Free language assistance services, including interpretation and translation services.

Members have the responsibility to:

  • Read the Member Handbook to make sure they understand the plan. Members are advised to call Medical Customer Service or Pharmacy Drug Benefit Customer Service with any questions.
  • Select a PCP for those plans that require it.
  • Treat all providers and their staff with courtesy and respect.
  • Communicate with professional staff and Moda Health so that they have the information necessary to provide good healthcare.
  • Understand their health problems and participate in making decisions about their medical care and forming a treatment plan, to the degree possible.
  • Follow plans and instructions for the care they have agreed to with their provider.
  • Seek health services from their chosen PCP, unless the plan states otherwise, such as in the case of an emergency. (Not all plans require members to choose a PCP)
  • Use urgent and emergency services appropriately.
  • If required by the plan, obtain approval from their PCP before going to a specialist.
  • Present their member identification card when seeking medical care.
  • Notify providers of any other insurance policies that might provide coverage.
  • Reimburse Moda Health for any third-party payments they receive.
  • Keep appointments and be on time. If this is not possible, members must call ahead to let the provider know they will be late or cannot keep their appointment.
  • Seek regular health checkups and preventive services.
  • Provide adequate information to the plan to properly administer benefits and resolve any issues or concerns that may arise.

Direct payments to healthcare providers: OR HB 2540

Oregon law (HB 2540) requires certain health plans to count qualifying payments that members make directly to healthcare providers toward their deductible and annual out-of-pocket maximum.

When can a direct payment count?

A payment you make directly to your healthcare provider may be credited toward your deductible and annual out-of-pocket maximum when all of these conditions are met:

  • The service or item is medically necessary
  • The service or item is covered under your plan
  • No claim for the service has already been sent to Moda Health
  • The amount you paid the provider is less than the average discounted rate for that service under your plan

How do I request credit for a direct payment?

Send Moda Health a written request for the payment to be credited toward your deductible or annual out-of-pocket maximum. Your request must include the following:

  • Provider’s name
  • Provider’s Tax ID number
  • Provider’s National Provider Identifier (NPI)
  • Procedure code
  • Diagnosis code
  • Date of service
  • Proof of payment (such as a cleared check, itemized receipt or a copy of your credit card statement)
  • Your name and Subscriber ID number

How to send your request

You can send your request by email or mail:

Important details

If your request meets all requirements, Moda Health will apply the amount you paid to your doctor to your deductible and out-of-pocket maximum based on your current balances when we process the credit

You can check your Member Dashboard anytime to see your current deductible and out-of-pocket maximum balances

EPO plan members

If you have an EPO plan, only payments made directly to in-network providers for covered services will count toward your deductible and out-of-pocket maximum.

Payments to out-of-network providers will not be credited to your deductible and out-of pocket maximum, because those services are not covered under EPO plans.

Members who have any questions about these rights and responsibilities can call the Moda Health Medical Customer Service team.