PEBB Medical FAQs

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

After paying the deductible amount, you will split the cost of eligible healthcare services with the insurer. The percentage that you pay is called coinsurance. The specific percentage for each service is listed in the plan's member handbook. Once you have paid enough coinsurance to reach the out-of-pocket maximum, the insurer pays 100% of eligible expenses for the rest of the plan year.

For example, if a health plan has an 80/20 in-network coinsurance rate for a specific service, after the deductible has been satisfied the plan is responsible for 80 percent of the eligible charges and you are responsible for 20 percent. You will continue to pay coinsurance percentages until you reach your plan-year out-of-pocket maximum, at which point the plan will pay for 100 percent of the eligible expenses (subject to any limitations).

This is the most you pay in a plan year for covered medical services before benefits are paid in full by the plan. This includes your deductible, coinsurance and copay amounts. There are expenses that you may need to pay that do not apply toward your out-of-pocket maximum, such as disallowed charges or balance billing amounts for out-of-network providers. Once you meet your out-of-pocket maximum, the plan covers all eligible medical expenses at 100 percent.

New this year, effective January 1, 2023, all eligible medical and pharmacy expenses will now accrue towards the out-of-pocket maximum.

No. You are responsible for the following costs. They do not accrue toward the out-of-pocket maximum and you must pay for them even after the out-of-pocket maximum is met:

• 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 benefit maximum
• Expenses incurred due to brand substitution
• The out-of-pocket expense for an oral appliance above the $1800 reference price per appliance
• The out-of-pocket expenses for hip and knee replacements above the reference price.
• The out-of-pocket expenses for infertility treatment
• Services in excess of any maximum
• Fees in excess of maximum plan allowance
• Premiums
• Disallowed charges

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 expenses for medications apply to the pharmacy deductible.

You have access to the Moda Health travel network, Aetna PPO® through the Aetna Signature Administrators®. For medical plans, the travel network allows you to receive urgent and/or emergent care outside of your primary service area while traveling You'll need to seek care from an Aetna PPO Network provider to receive in-network benefits.

Your dependents living outside of the primary network area can also use the Moda Health travel network, Aetna PPO® Network through the Aetna Signature Administrators® to receive care at an in-network benefit level except if they live in Alaska or Idaho. 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. You must seek in-network services whenever possible, and preauthorization is required for in-patient services.

If traveling out of the service area and you seek 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 and providers may bill you for the difference.

You can find a travel network provider by using Find Care through the Member Dashboard or by contacting the Health Navigator team for assistance.

Maximum Plan Allowance (MPA) is the maximum amount that Moda Health will reimburse a non-contracted provider. A non-contracted provider may bill you for any amount over the MPA. This may leave you with a high out of pocket balance. If you are considering using a non-contracted provider, contact the Health Navigator team for help in understanding your out-of-network benefits and any additional charges that you may have to pay.

Any time you have a medical emergency, you should go to the nearest emergency room or urgent care facility.

If the facility is within the travel network, benefits will be paid at the in-network benefit level up to the facility's contracted allowable amount.

If the facility is outside the travel network, benefits will be paid at the in-network benefit level up to the maximum plan allowable. This means that you could be responsible for any charges that are more than the maximum amount allowed by the plan.

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. You must complete a Transition of Care form that Moda Health will review and approve.

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.

We recommend that you log in to your Member Dashboard and go to the PCP 360 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:

• Go to Find Care, our online provider directory
• Choose Medical care
• In the search criteria for Provider Type, choose PCP 360

Once you've decided on a PCP 360, log in to your Member Dashboard or contact the Health Navigator team at 844-776-1593 to select that provider as your designated PCP 360.

On all PEBB Medical plans, there will beno cost-sharing for office visits to manage certain conditions. These conditions include:

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

You will need to use your preselected PCP 360 or in-network specialist to receive the in-network, no cost-sharing benefit.

The Additional Cost Tier refers to select procedures that require you to pay a copay in addition to any deductible and coinsurance. These include

• $100 copays:
  • Bunionectomy
  • Hammertoe surgery
  • Morton's Neuroma
  • Spinal injections for pain
  • Uppergastrointestinal endoscopy
• $500 copays:
  • Knee arthroscopy
  • Knee, hip replacement
  • Knee, hip resurfacing
  • Shoulder arthroscopy
  • Sinus surgery
  • Spine procedures
  • Bariatric surgery

Alternative care refers to spinal manipulation, acupuncture services, and massage therapy. 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. Spinal manipulation is limited to 20 visits and acupuncture is limited 12 visits per year. Massage therapy is covered up to an aggregated plan ear maximum of $1,000.

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 coach at 800-913-4957 or 503-243-3957.

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 six months (referred to as a waiting period) before the surgery benefit can be used. 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:

Digital: gives members access to an easy-to-use app that has the tools they need, including food and activity tracking, thousands of recipes, 24/7 Expert Chat with a WW Coach, and so much more

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: oregon.gov/oha/pebb/pages/wellness-programs.aspx

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.

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

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 three years:

• One hearing aid per hearing-impaired ear
• Initial batteries, cords and other necessary supplementary equipment
• Warranty
• Repairs, servicing or alteration of the hearing aid equipment
• Bone conduction sound processors, if necessary, for appropriate amplification
• Hearing assistive technology system, if necessary, for appropriate amplification

In addition:

• Ear molds and replacement ear molds four times per year under age 8 and once per year age 8 and older
• One box of replacement batteries per year for each hearing aid

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 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 homepage 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% with the deductible waived. The benefit includes a 10-week supply of nicotine replacement therapy (patch or gum) and one-on-one phone coaching with a quit coach.

No. Members can self-refer

In-network medically necessary bariatric surgery services, limited to gastric bypass, gastric stapling, gastroplasty, gastric sleeve and the Lap Band adjustable gastric banding system are covered. There is no out-of-network benefit and services must be performed at an approved Center of Excellence facility. To be eligible for this benefit, please see the specific medical criteria located in the Member Handbook.