Moda Pioneer Alaska Standard Gold - 73836AK0940001 Health Insurance Plan

Moda Health Plan, Inc. health insurance plan with the Plan ID 73836AK0940001. The plan is called Moda Pioneer Alaska Standard Gold.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.94% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 73836AK0940001
Health Insurance Plan Year 2025
State Alaska
Health Insurance Issuer Moda Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 73836AK0940001-00
Provider Network(s) PREFERRED NON-PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Alaska All US States
All 3609 68933
PCP 516 1232
Allergy N/A 1
OB/GYN 14 62
Dentists 166 221
Available Variants of the Health Plan

Standard Off Exchange Plan - 73836AK0940001-00

Standard On Exchange Plan - 73836AK0940001-01

Open to Indians below 300% FPL - 73836AK0940001-02

Open to Indians above 300% FPL - 73836AK0940001-03

Last Plan Update Date Thu, 29 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Moda Pioneer Alaska Standard Gold Health Insurance Plan, 73836AK0940001-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Accidental Dental

Services must begin within 12 months of the date of injury; diagnosis made within 6 months of date of injury.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture

Limit: 24.0 Visit(s) per Year

Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.

YES

$30.00

50.00% Coinsurance after deductible
Allergy Testing
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Frequency limits apply to some services.

YES

0.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chemotherapy
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 24.0 Visit(s) per Year

Plan uses the term "spinal manipulation." Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided.

YES

$30.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children

1 exam and cleaning every 6 months

YES

0.00%

50.00% Coinsurance after deductible
Diabetes Education
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dialysis
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment

Orthotics or orthopedic shoes are covered when medically necessary.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport.

YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Adults

1 pair of lenses per year and 1 pair of frames every 2 years. In-network benefits up to $130 maximum.

YES

$25.00

50.00%
Eye Glasses for Children

1 pair of glasses per year. Frames from the Otis & Piper collection only.

YES

0.00%

50.00%
Gender Affirming Care

Information about gender affirming care can be found in the policy.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs

Up to 90-day supply per prescription. One copay per a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.

YES

$15.00

$15.00
Habilitation Services

Limit: 45.0 Visit(s) per Year

Habilitation includes physical, speech and occupational therapy combined, subject to an annual visit limit except for care for autism spectrum disorders provided for members under age 21. Limits apply separately to rehabilitative and habilitative services.

YES

$30.00

50.00% Coinsurance after deductible
Hearing Aids

$3,000 maximum every 3 years

YES

20.00%

20.00%
Home Health Care Services

Limit: 130.0 Visit(s) per Year

130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master's degree in social work.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services

Limit: 6.0 Months per Lifetime

Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Frequency limits apply to some services.

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Massage Therapy

Limit: 24.0 Visit(s) per Year

Prior authorization is required.

YES

$30.00

50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services

In-network: Office visits and intensive outpatient visits $30 copay; other outpatient services 25% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay.

YES

$30.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs

Up to 90-day supply per prescription. One copay per a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers.

YES

$60.00

$60.00
Nutritional Counseling

Covered for some medical conditions. Prior authorization required after first 5 visits.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Medically necessary repair of disabling malocclusion or cleft palate and severe craniofacial defects impacting function of speech, swallowing and chewing.

YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)

Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician.

YES

$30.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 45.0 Visit(s) per Year

Outpatient rehabilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, subject to an annual visit limit except for care for autism spectrum disorders provided for members under age 21. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition. A 'visit' is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers.

YES

$30.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs

Up to 90-day supply per prescription. One copay per a 30-day supply. Preferred tier includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications.

YES

$30.00

$30.00
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization

Preventive exams: 3 exams age 2-4; one exam per year age 5 and over. Newborn Hearing Screening within 30 days of birth and additional tests up to age 24 months. Routine Vision Screening age 3-5.

YES

0.00%

50.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

$30.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices

Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can't be repaired, or replacement is prescribed by a physician because of a change in your physical condition.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery

Breast reconstruction allowed.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

YES

$30.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

YES

$30.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)

1 exam per year

YES

$10.00

50.00%
Routine Eye Exam for Children

1 exam per year

YES

$0.00

50.00%
Routine Foot Care

Covered if required for the member?s medical condition.

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit

In-network: Virtual care visits $30 copay; in-person visits $60 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay. / Includes office visits by naturopathic practitioners.

YES

$60.00

50.00% Coinsurance after deductible
Specialty Drugs

Up to 30-day supply per prescription at a designated specialty pharmacy. Non-Preferred Specialty tier may have higher cost sharing.

YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services

In-network: Office visits and intensive outpatient visits $30 copay; other outpatient services 25% after deductible. / For Zero Cost Sharing plans: All outpatient visits $0 copay.

YES

$30.00

50.00% Coinsurance after deductible
Transplant

In-network level for centers of excellence. $7,500 per transplant for travel and lodging.

YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities

In-network: Virtual care visits $30 copay via CirrusMD; in-person visits $45 copay. / For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay.

YES

$45.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care

Well Baby Exams covered for the first 24 months of life.

YES

$0.00

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7806125763529309
Begin Primary Care Cost-Sharing After Number Of Visits 0
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
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
EHB Percent of Total Premium 0.99
First Tier Utilization 100%
Formulary ID AKF008
Formulary URL URL
HIOS Product ID 73836AK094
Import Date 2024-08-29 01:02:15
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 ID 73836
Issuer Marketplace Marketing Name Moda Health Plan, Inc.
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID AKN002
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 For emergency care during travel and for out-of-area dependents
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 73836AK0940001-00
Plan Marketing Name Moda Pioneer Alaska Standard Gold
Plan Type PPO
Plan Variant Marketing Name Moda Pioneer Alaska Standard Gold
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,800
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 $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AKS002
Source Name HIOS
Plan ID 73836AK0940001
State Code AK
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $9000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $4500 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $4,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,800
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $52200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $26100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $26,100
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Moda Pioneer Alaska Standard Gold Health Insurance Plan, 73836AK0940001

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Moda Pioneer Alaska Standard Gold, 73836AK0940001 Health Insurance Plan, 73836AK0940001

  • Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, 73836AK0940001 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (73836AK0940001) Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does (73836AK0940001) Health Insurance Plan, Variant (73836AK0940001-00) have Out Of Country Coverage?

    Yes. Details: Emergency care only

    Does (73836AK0940001) Health Insurance Plan, Variant (73836AK0940001-00) have Out of Service Area Coverage?

    Yes. Details: For emergency care during travel and for out-of-area dependents

    Does (73836AK0940001) Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for Asthma?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for Asthma.

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for Heart disease?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for Heart disease.

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for Depression?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for Depression.

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for Diabetes?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for Diabetes.

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for Low back pain?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for Low back pain.

    Does Moda Pioneer Alaska Standard Gold Health Insurance Plan, Variant (73836AK0940001-00) offer Disease Management Programs for Pregnancy?

    Yes, the Moda Pioneer Alaska Standard Gold Health Insurance Plan Variant 73836AK0940001-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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