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PEBB Medical FAQs

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.

What does the term "coinsurance" mean?

The percentage members pay for a covered healthcare service after they meet their deductible.

What does the term "out-of-pocket maximum" mean?

Out of Pocket Maximum means the maximum amount a member pays out-of-pocket every plan year for some covered care and services before benefits are paid in full up the allowable amount or up to any dollar limit. If a member obtains both in-network and out-of-network services, 2 separate out-of-pocket maximums apply. If a member reaches the out-of-pocket maximum in a plan year, Moda will pay 100% of eligible expenses for the remainder of the year.

The out-of-pocket maximum includes deductible, coinsurances and copays. It does not include additional cost tier (ACT) copays, pharmacy expenses, disallowed charges or balance billing amounts from out-of-network providers.

What does the term "maximum cost share" mean?

The maximum cost share 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.

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

No. The out of pocket maximum is the most members pay in a calendar year for some covered care and services before benefits are paid in full up to the allowable amount or up to any visit or dollar limit . Once members meet their out-of-pocket maximum, the plan covers eligible expenses at 100 percent, except for services that are not applicable to the out-of-pocket maximum or do not qualify as essential health benefits. The out-of-pocket maximum includes deductibles, coinsurance and copays. It does not include ACT copays, pharmacy, disallowed charges or balance billing from out-of-network providers.

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?

Yes, the deductible needs to be met before the services with copayments are paid. There are two exceptions:

  1. Your first 4 visits with your PCP360 per calendar year
  2. Mental health services

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

No. 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. Pharmacy has a separate deductible, and only medications apply to the pharmacy deductible.

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 non-emergency 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.

What is the "Maximum Plan Allowance"?

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.

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 allowance for urgent and emergency services.

How will Moda Health assist members joining their health plan who are currently undergoing complex treatment with an out-of-network provider?

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.

What is a PCP 360?

A PCP 360 delivers full-circle care, coordinating your care with other providers as needed. They are high quality primary care providers who are willing to partner with you and be accountable for your health. You can count on your PCP 360 to provider higher quality care with lower out-of-pocket costs.

How do members find a PCP 360?

We recommend that you log into your Member Dashboard and go to the PCP360 tab to search for a PCP 360.If you are not a member yet or don’t have access to your Member Dashboard, 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 “PCP 360”

Your Moda 360 Health Navigators can also help locate participating PCP 360s and can be reached at 844-776-1593.

What is a chronic condition office visit?

On all PEBB Medical plans, members will have no cost sharing for office visits to manage certain conditions. These conditions include:

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

The member will need to use their preselected PCP360 or in-network specialist to receive the in-network, no cost sharing benefit.

What is the Additional Cost Tier?

  1. $100 cost tier:
    1. Bunionectomy
    2. Hammertoe surgery
    3. Morton’s Neuroma
    4. Spinal injections for pain
    5. Uppergastrointestinal endoscopy
  2. $500 cost tier:
    1. Knee arthroscopy
    2. Knee, hip replacement
    3. Knee, hip resurfacing
    4. Shoulder arthroscopy
    5. Sinus surgery
    6. Spine procedures
    7. Bariatric surgery

What is the benefit for alternative care providers?

Alternative care refers to spinal manipulation, acupuncture services, massage therapy and naturopathic care. If a member seeks services from an alternative care provider, in-network covered services are paid with a $10 visit after deductible or 30 percent coinsurance out-of-network, after deductible, up to an aggregate plan year maximum of $1,000.

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

As part of PEBB’s Health Engagement Model (HEM), you could earn payment incentives by taking a health assessment through Momentum, Moda Health’s interactive wellness tool. Existing Moda PEBB members who already participate in the HEM program do not have to take their Health Assessment this 2021 plan year.

If you are an existing Moda PEBB member who doesn’t yet participate in the HEM program, you can opt in for this plan year by following these steps:

  1. Enroll in your medical plan in the PEBB enrollment system (opt in to take part in HEM)
  2. Take a private, 15-minute assessment by logging into your Member Dashboard and choosing Momentum (Moda’s health interactive wellness tool).

Save your email confirmation. Are you already a PEBB member but NEW to Moda?  If  you are and want to participate in the HEM, follow these steps:

  1. Enroll in your Moda medical plan in the PEBB enrollment system (opt in to take part in HEM).
  2. Take a private 15-minute assessment with your current medical carrier.
  3. Save your email confirmation.

Newly hired Moda PEBB members who want to take part in HEM will follow the same steps. Call PEBB (503-373-1102) to get instructions on where to take the assessment.

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

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 WW (formerly Weight Watchers) support. PEBB medical plans cover bariatric surgery for PEBB plan subscribers only. The plan provides coverage for Roux-en-Y surgery or gastric sleeve surgery. Bariatric Surgery is subject to an additional cost tier copay of $500, and then there will be a $50 copay per day, up to $250 per admission, once the deductible is met. The services must be received at a Center of Excellence facility.

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 or in your member handbook.

Members can also take advantage of PEBB’s WW program in the format that works best for their lifestyle:

  1. Digital – gives members access to an easy-to-use app that has the tools you need, including food and activity tracking, thousands of recipes, 24/7 Expert Chat with a WW Coach, and so much more.
  2. Digital + Workshops - gives members access to WW's digital tools, and weekly WW Workshops in the community or WW Workshops in the workplace (where applicable).

For more information visit: https://www.oregon.gov/oha/PEBB/Pages/WW-Experience.aspx

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.

Are midwives and birthing centers covered?

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

What are my benefits for hearing aids?

Hearing tests, hearing aid checks and aided testing are covered twice per year for members under age 4 and once per year for members age 4 and older.

The following items are covered once every 3 years:

  1. One hearing aid per hearing impaired ear
  2. Initial batteries, cords and other necessary supplementary equipment
  3. Warranty
  4. Repairs, servicing, or alteration of the hearing aid equipment
  5. Bone conduction sound processors, if necessary, for appropriate amplification
  6. Hearing assistive technology system, if necessary, for appropriate amplification

In addition:

  1. Ear molds and replacement ear molds 4 times per year under age 8 and once per year age 8 and older
  2. One box of replacement batteries per year for each hearing aid

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

A PEBB 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 360 Health Navigators at 844-776-1593 and asking for the Quit for Life Program
  • Logging in to your member dashboard or visiting www.quitnow.net and registering online.
  • Using your member dashboard to request a call from Alere Quit for Life. After logging in, PEBB 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.

Is a physician referral to the tobacco cessation program necessary?

No. Members can self-refer.

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