Health coverage FAQs

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Why do I need health insurance?

Having health coverage is a smart idea. Almost everyone needs medical care at some point, and a health plan helps pay for these costs. It also protects you from large, unexpected medical bills.


How does healthcare coverage work?

When you have a plan, your health insurance company pays part of your medical costs if you get sick or hurt. You are responsible for paying some costs as well, such as:

  • Premium:The monthly amount you pay for your plan
  • Deductible: What you pay in a calendar year for care that requires you to cover some costs before the health plan starts paying
  • Copayment (copay): A fixed dollar amount you pay for a covered healthcare service or supply, usually at the time of receiving it
  • Coinsurance: The percentage you pay for a covered healthcare service or supply, separate from a deductible
  • Non-covered charges: Including out-of-network charges on EPO plans

What do health plans cover?

Most Moda Health plans cover essential health benefits, like preventive care. There is no dollar limit on in-network coverage for essential health benefits, so you can keep receiving the care that you need. Our plans also pay for part of your other healthcare costs. Members pay the cost of care until the deductible is met. Once you meet your out-of-pocket maximum, which includes deductible, coinsurance and copays, Moda Health pays the remainder of your covered medical expenses.

What are essential health benefits?

Essential health benefits are the following 10 categories of services that health insurance plans must cover under the Affordable Care Act:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions to gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

What is preventive care?

Preventive care services keep you healthy before you ever get sick. Services include periodic health exams, well-baby care, women’s annual exams, many immunizations and cancer and other health screenings. Moda Health plans cover most preventive care.

What determines the monthly premium I pay for my plan?

The plan, your age and the ages of your dependents — your spouse or domestic partner and your children — affect your premium. In some cases, the region also plays a part.

Your rate will go up a little each year until you turn 65, when you’ll be eligible for Medicare. If you are covering children under age 21, they each have the same rate based on the plan. Child dependents age 21 through 25 have a rate based on their actual age.

Should I choose a health plan with a higher or lower deductible?

A high deductible will save you money on your monthly premiums. However, you’ll have to spend more out of pocket before your plan pays for benefits. With a low deductible, your plan will cover benefits earlier, but you’ll pay a higher premium every month.

What’s the difference between a copay and coinsurance?

A copay is a specific dollar amount you pay for a service. For example, you might pay $25 for a visit to your doctor’s office. Often, you don’t have to meet your deductible for services that are covered with copays (but check your plan details to make sure).

Coinsurance is the percentage of costs you must pay after your deductible is met. For example, you may pay 20% of the cost of a $200 bill, or $40. Moda Health would pay the rest.

Can I add my family members to my health plan?

Yes, you can add a family member only during Open Enrollment, unless you qualify for Special Enrollment. These family members are known as dependents. You can include your qualified spouse or partner. You can also add your dependent children under age 26. Keep in mind that you will pay a higher premium for each dependent you add.

When will my medical coverage begin?

See the dates for 2022 Open Enrollment. When you apply directly with us during this new Open Enrollment period, your coverage will be effective the first of the month after a complete application is submitted.

Can my employer pay for my Individual coverage?
Individual plans cannot be employer-sponsored plans but employers may offer a Qualified Small Employer Health Reimbursement (QSEHRA) or Individual Coverage Health Reimbursement (ICHRA) and pay for individual premiums. Check with your employer if these options are available and how reimbursement is made. Otherwise, you will be responsible for paying your monthly premium directly to Moda Health.
Can I switch to a different plan at any time?

No. You will only be able to change medical plans during Open Enrollment. If you experience a qualifying event, such as getting married or moving to a new state, you may be able to apply for Special Enrollment outside of the Open Enrollment period.

Open and special enrollment FAQs

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When is Open Enrollment for Individual medical and dental plans?

Each year, Open Enrollment for Individual coverage starts in the fall and lasts approximately 6 weeks.

For 2022 coverage, the Open Enrollment period is from Nov. 1, 2021 to Jan.15, 2022.

After open enrollment ends, you can only enroll or change plans if you qualify for Special Enrollment. Certain life changes, like getting married, having a baby or moving to a new area, could make you or those your plan covers eligible for Special Enrollment.

Can I enroll in a plan only during Open Enrollment?

Yes, unless you qualify for Special Enrollment.

When I enroll, how can I apply for federal financial assistance, like tax credits?

If you qualify for and want to use federal financial assistance, you must enroll in a health plan through HealthCare.gov. Once you submit your household and income information, you’ll find out if you qualify for a premium tax credit that lowers what you pay each month. You’ll also find out if you qualify for cost-sharing reductions. With cost-sharing reductions, you’ll pay less out of your own pocket when you get medical care.

How do I qualify for Special Enrollment?

Certain life events might qualify you for Special Enrollment. For example, getting married, having a baby or moving to a new state could make you or those you cover eligible. See if you qualify.

Moda Health and Delta Dental plan FAQs

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What plans do Moda Health and Delta Dental offer?

We offer a variety of Individual medical and dental plans. Our plans vary by price, network, deductible and copays for covered services. Shop our plans to see what’s available.

How do I pick the right Moda Health plan?

You can find Moda Health plans here, and we’re confident there’s one to fit your needs.

Here are some things to consider as you shop:

  • Where do you get care? You can choose a plan that includes your doctors, practitioners, hospitals, labs and other provider type in the network. Remember, the Oregon medical plans and dental EPO plan do not include out-of-network coverage except for emergency and retail pharmacy. So if your provider is not in the network, you are responsible for the full cost of the services. Our Alaska plans do not cover out-of-state coverage except for emergency services, coverage through medical travel support program, coverage through out-of-state contracted providers and medically necessary nonemergency services that are prior authorized by us.
  • What if my child does not live with me? For medical plans in Oregon, there is no coverage outside the United States except for emergency care. If you have children you want to cover as dependents who live in the U.S. outside of Oregon, they may be eligible for out-of-area benefits if they are full-time students age 18 to 26, or if you have a qualified medical child support order (QMCSO). In Oregon, all of your family members must use providers in your network to be covered.
  • How much will you budget for monthly premiums? You can choose a plan with a lower monthly cost, but you will pay more out-of-pocket for care.
  • What kind of medical care do you use throughout the year? If you visit your doctor often, have a serious health condition or see specialists, you may want a lower deductible and better coverage.
  • Do you use a lot of prescription medications? If so, it may be worth purchasing a plan with strong prescription medication coverage.
  • Will you include dependents? If so, consider their health issues and what kind of care they’ll need.
  • How would you handle an unexpected medical bill? If you have a medical emergency, like a broken arm or serious illness, you could face thousands of dollars in medical bills. How much will you budget to pay out-of-pocket before needing coverage for the rest?
  • What other benefits and resources matter to you? It's important to consider customer service, gym discount programs, specialty provider service discounts, identity protection, education and online tools. We offer these things and more, at no extra cost. At Moda Health, we do everything we can to partner with you on your journey to better health.

Which plans can I purchase through HealthCare.gov?

You can enroll in all Moda Health Individual medical plans directly with us or via HealthCare.gov. Some plans may be available only through HealthCare.gov or directly with us.

Is my doctor in my health plan network?

It depends. Moda Health networks include a wide selection of providers. When you shop for a plan, you’ll search for providers that are in the network that comes with your plan.

Why do I need to choose an in-network primary care provider (PCP)?

In Oregon, our exclusive provider organization (EPO) plans connect you with your primary care provider (PCP), who works closely with Moda Health and the rest of your care team (other providers, specialists, etc.) to help you achieve better health and wellness. Moda Health will work with your selected PCP to make sure you can quickly access the care that is right for you.

In Alaska, you can see any licensed provider in the state to get care.
How do I find an in-network PCP?

To find a PCP, start by shopping for a plan. On the medical plans page, you’ll find an option to search for a PCP.

Do plans cover acupuncture and spinal manipulation?

Yes, all Oregon Moda Health medical plans cover medically necessary acupuncture and spinal manipulation. All Alaska Moda Health medical plans cover medically necessary acupuncture, spinal manipulation and massage therapy.

Is massage therapy covered?

Yes for all of our Alaska medical plans. No, our Oregon medical plans do not cover massage therapy.

Can I see a naturopath physician under my plan?

Yes. For Oregon plans, office visits with a naturopathic physician are covered at the specialist office visit amount. However, if your naturopathic physician is a credentialed PCP, your visit may be paid at the PCP office visit level.

For Alaska plans, naturopathic physicians are covered at the PCP office visit amount.

What payment methods do you accept?

We accept checks, money orders and electronic funds transfers (EFT) from a savings or checking account. Just select the billing and payment option that is best for you:

  • eBill, our electronic billing service. You can review your premium invoice and make payments online through the Member Dashboard, your personalized member website. Visit modahealth.com and follow the instructions to create a your Member Dashboard account.
  • Electronic funds transfer (EFT). To use EFT, contact us and complete an EFT authorization. Your premium invoice will be paperless and located in the eBill section of your Member Dashboard.
  • Paper bill. We’ll send you a paper bill in the mail every month. You can mail back your payment in the enclosed envelope or initiate a payment through eBill after logging in to your Member Dashboard.

How will I make my first premium payment?

You’ll receive your first premium invoice prior to your effective date, either by mail or by email. If you enrolled directly through us, use the payment method you chose during enrollment to pay your premium. If you enrolled through HealthCare.gov, make your payment using one of the methods listed in your welcome letter.

How can I use my benefits while traveling outside my health plan’s network service area?

For our Oregon medical plans, while traveling outside of Oregon, members can receive emergency care through the First Health Network.

For our Alaska medical plans, while travelling outside of Alaska, members can receive emergency or urgent care through the First Health Network and get Tier 1 benefits.

I am traveling outside of the United States. Am I covered under my Moda Health plan?

Outside the United States, Oregon members may access any provider for emergency care. Outside of the United States, Alaska members may access any provider for emergency or urgent care. You are required to pay your bill before submitting your claim to Moda Health. All other non-emergency and non-urgent care received outside the U.S. is not covered.

Affordable Care Act FAQs

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What is the Affordable Care Act (ACA)?

The ACA, sometimes called Obamacare, is a federal law that was created to make health benefits better and more accessible.

Can health benefit companies turn me down for a pre-existing condition?

No. The Affordable Care Act makes it illegal to deny coverage or charge more to someone based on a pre-existing health condition or issue.

What is a health plan Marketplace?

Also called an Exchange, a health plan Marketplace is an online hub where you can buy affordable health coverage.

In Oregon and Alaska, you can buy a medical and dental plan on the federal Marketplace, HealthCare.gov, if you qualify for financial assistance. If you don’t qualify for help, it’s easy to buy a health plan directly from Moda Health and Delta Dental. We offer a variety of Individual and family plans to fit everybody.

What is an advanced premium tax credit (APTC)?

This is a type of federal financial assistance. You can use a tax credit to help pay for your medical plan if you qualify. You must apply for this assistance through HealthCare.gov, and qualify based on household size and income and location before you enroll in a plan.

Am I eligible for a tax credit?

Shop our plans to see whether you qualify for this type of federal financial assistance. You will need to provide your location, income, age and household size.

Do I have to buy my plan on the Marketplace?

You don't have to buy a health plan on HealthCare.gov unless you qualify for federal financial assistance. If you do qualify for assistance and want to use it, you must enroll through HealthCare.gov.

Can I enroll directly through Moda Health and still use financial assistance?

If you enroll directly through us without visiting HealthCare.gov you won’t be able to use federal financial assistance. Shop plans here first to see if you might qualify. If you do qualify, we’ll send you to HealthCare.gov so you can apply for assistance and use it to lower your health plan costs.

Dental plan FAQs

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Who can enroll in a Delta Dental plan?

You must be an Oregon or Alaska resident and live in Oregon or the service area in Alaska at least six months out of the calendar year.

Who else can enroll with me?

Eligible members include you, your legal spouse or domestic partner (registered domestic partner in Oregon) and any children through age 25.

When can I enroll in a Delta Dental plan?

You can enroll in a Delta Dental plan with us during the Open Enrollment period.

After Open Enrollment ends, you can only enroll or change plans if you qualify for Special Enrollment. Certain life changes, like getting married, having a baby or moving to a new area, could make you or those your plan covers eligible for Special Enrollment.

If I cancel my Delta Dental coverage, when can I re-enroll?

If you cancel your Delta Dental plan with us, you’ll have to wait 12 months after the termination date to re-enroll in another dental plan with us.

Does it matter which dentist I see?

Yes. You’ll save money by seeing a dentist that’s in your plan network.

How do I confirm that my dentist is in-network?

Delta Dental has a large number of dentists in our networks in Alaska and Oregon, so it's likely that your dentist may be in one of our networks. You can look up your dentist and confirm when you review the available plans while shopping.

Can I switch to a different plan at any time?

If you are a current Delta Dental member, you will only be able to change your dental coverage during the Open Enrollment period. If you experience a qualifying event, such as getting married or adopting a child, you may be able to apply for Special Enrollment outside of the Open Enrollment period.

How soon can I use my dental benefits?

Delta Dental encourages prevention, so services such as cleanings, X-rays and exams are covered from day one.

Some benefits show a “exclusion period.” What does that mean?

Some services may not be covered right away and require an exclusion period for members age 19 and older who have not had continuous dental coverage. This means that those services will only be covered after you have had your Delta Dental plan with us for typically either six or 12 months. If you had previously been covered by another dental plan for a 12 months — with no more than a 90-day break in coverage from the end of your old policy until the effective date of your 2022 Delta Dental policy — this exclusion period may be waived. You can find the specific services that require a exclusion period on the dental plan details page(s).

Do your Delta Dental plans cover orthodontia?

Only in certain cases. Orthodontia is covered for members under age 19 for treatment of cleft palate in Oregon and for medically necessary treatment in Alaska.

Do your Delta Dental plans cover implants?

No. Our plans in Oregon and Alaska do not cover dental implants.

When will my dental plan become effective?

When you apply during Open Enrollment, your coverage will be effective on the first of the month after a complete application is submitted if you enroll directly with us. See the dates for 2022 Open Enrollment.

Can I be enrolled in a group plan and an Individual dental plan at the same time?

Yes, you can be covered by two dental plans. This is called “dual coverage.” It doesn’t double your coverage, although it may reduce your out-of-pocket costs. Delta Dental works with the other insurance company to coordinate your benefits.

What if I have a dental emergency and I'm out of town?

Each Delta Dental plan comes with a Delta Dental nationwide network. It includes quality dentists across the state and the country. You’ll save on out-of-pocket costs if you see a dentist that’s in the network.