Group health plan enrollment

We want to make group health plan enrollment as easy as possible for you and your clients. Here, you can download the application and enrollment forms you need to get started. You also can search for available networks.

Agent Responsibility

Provide the following information to Moda Health at least 15 working days prior to the first of the month the coverage is to be effective.

Moda Health Responsibility

Moda Health will provide the following information to you:

  • Group Application
  • Enrollment Packets: (depending upon plan selected, some material may vary)
    • Member Guides
    • Benefit Summaries
    • Enrollment Form
    • Prescription Drug Claim Form (medical only)
    • Mail Service Prescription Program (medical only)
  • Declination of Coverage Forms

Learn more about our group medical plans
Learn more about our group dental plans

Producer’s role in group enrollment

Please provide the following information no later than the 20th of the month for an effective date on the first of the following month:

  • One month’s premium
  • A completed group medical and/or dental application, signed by both the group and producer
  • Group Application 1-50 (2017)
  • Group Application 51+ (Excel) (2017)
  • A completed enrollment or declination form for each eligible employee

Group Size 2-4

Group Size 5-50

Group Size 51-99

Group Size 100+

Affidavit of Domestic Partnership

Declination of coverage — all eligible individuals waiving coverage must complete a declination of coverage form. Please refer to the eligibility and enrollment guidelines located in the Forms section.

Oregon Continuation Coverage

Moda Health's role in group enrollment

Moda Health will provide the following information to you:

  • Upon request, a group application containing the full description of the plan(s) purchased
  • Enrollment packets (depending on the plan(s) selected, some material may vary)
  • Benefit summaries
  • Member enrollment application and change of information form
    Note: If a member enrolls in a managed care or point of service medical plan, be sure each member lists a primary care physician (PCP) from the participating provider directory on the enrollment form. Each insured family member may select a different PCP; however, all family members must select PCPs from the same directory.
  • Mail-order prescription drug order form (medical only)
  • Declination of coverage forms

We're sorry, this information is not available in . Please use the dropdown at the top of the page if you would like to view information for another state.

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Hello.

We have exciting news to share. ODS is changing its name to Moda Health.

Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.

Together, we can be more, be better.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

Hello.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

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