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 | ||||||||||||||||||
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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). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 73836AK0940001-00 Standard On Exchange Plan - 73836AK0940001-01 |
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Last Plan Update Date | Thu, 29 Aug 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
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 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
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