Moda Health Oregon Standard Gold Affinity - 39424OR1670001 Health Insurance Plan
Moda Health Plan, Inc. health insurance plan with the Plan ID 39424OR1670001. The plan is called Moda Health Oregon Standard Gold Affinity.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.99% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.01% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 39424OR1670001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oregon | ||||||||||||||||||
| Health Insurance Issuer | Moda Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 39424OR1670001-00 | ||||||||||||||||||
| Provider Network(s) | NON-PREFERRED PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Jun 2025 12:51 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 39424OR1670001-00 Standard On Exchange Plan - 39424OR1670001-01 |
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| Last Plan Update Date | Wed, 14 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 17 Jun 2025 12:51 GMT |
Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant 39424OR1670001-00 Attributes
| Plan Attribute | Value |
|---|---|
| Begin Primary Care Cost-Sharing After Number Of Visits | 3 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Design 3 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9984 |
| First Tier Utilization | 100% |
| Formulary ID | ORF032 |
| Formulary URL | URL |
| HIOS Product ID | 39424OR167 |
| Import Date | 2024-08-14 20:01:41 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.99% |
| Issuer ID | 39424 |
| Issuer Marketplace Marketing Name | Moda Health Plan, Inc. |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ORN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency care only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency care and out-of-area dependent coverage for students or children under a QMCSO |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 39424OR1670001-00 |
| Plan Marketing Name | Moda Health Oregon Standard Gold Affinity |
| Plan Type | EPO |
| Plan Variant Marketing Name | Moda Health Oregon Standard Gold Affinity |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ORS003 |
| Source Name | SERFF |
| Specialty Drug Maximum Coinsurance | $500 |
| Plan ID | 39424OR1670001 |
| State Code | OR |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $14000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Moda Health Oregon Standard Gold Affinity Health Insurance Plan, 39424OR1670001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Moda Health Oregon Standard Gold Affinity, 39424OR1670001 Health Insurance Plan, 39424OR1670001
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Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, 39424OR1670001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (39424OR1670001) Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does (39424OR1670001) Health Insurance Plan, Variant (39424OR1670001-00) have Out Of Country Coverage?
Yes. Details: Emergency care only
Does (39424OR1670001) Health Insurance Plan, Variant (39424OR1670001-00) have Out of Service Area Coverage?
Yes. Details: Emergency care and out-of-area dependent coverage for students or children under a QMCSO
Does (39424OR1670001) Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for Asthma?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for Asthma.
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for Heart disease?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for Heart disease.
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for Depression?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for Depression.
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for Diabetes?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for Diabetes.
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for Low back pain?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for Low back pain.
Does Moda Health Oregon Standard Gold Affinity Health Insurance Plan, Variant (39424OR1670001-00) offer Disease Management Programs for Pregnancy?
Yes, the Moda Health Oregon Standard Gold Affinity Health Insurance Plan Variant
39424OR1670001-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 17 Jun 2025 12:51 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API