Moda Assurance Company health insurance plan with the Plan ID 77963AK0010004. The plan is called Moda Pioneer Bronze HDHP 5500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 77963AK0010004 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Alaska | ||||||||||||||||||
Health Insurance Issuer | Moda Assurance Company | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 77963AK0010004-02 | ||||||||||||||||||
Provider Network(s) | ['AKN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 77963AK0010004-00 Standard On Exchange Plan - 77963AK0010004-01 |
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Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Accidental Dental
Services must begin within 12 months of the date of injury; diagnosis made within 6 months of date of injury. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Allergy Testing
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Frequency limits apply to some services. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Chemotherapy
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Chiropractic Care
Limit: 24.0 Visit(s) per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Diabetes Education
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Dialysis
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Durable Medical Equipment
Orthotics or orthopedic shoes are covered when medically necessary. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Emergency Room Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Emergency Transportation/Ambulance
Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Gender Affirming Care
Information about gender affirming care can be found in the policy. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Generic Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Habilitation Services
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Hearing Aids
Limit: 3000.0 Dollars per 3 Years |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Home Health Care Services
Limit: 130.0 Visit(s) per Year 130 visits per year 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 licensed social worker. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Hospice Services
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Inpatient Physician and Surgical Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Laboratory Outpatient and Professional Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
Frequency limits apply to some services. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Mental/Behavioral Health Inpatient Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Mental/Behavioral Health Outpatient Services
Exclusions: Biofeedback is limited to the treatment of migraine headaches. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Non-Preferred Brand Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Nutritional Counseling
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Rehabilitation Services
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Preferred Brand Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Prenatal and Postnatal Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Preventive Care/Screening/Immunization
Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Radiation
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Reconstructive Surgery
Breast reconstruction allowed. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Rehabilitative Speech Therapy
Limit: 45.0 Visit(s) per Year Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. 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. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Routine Foot Care
Covered if required for the member?s medical condition. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Specialist Visit
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Specialty Drugs
Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Transplant
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
|
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
X-rays and Diagnostic Imaging
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
Plan Attribute | Value |
---|---|
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Zero Cost Sharing Plan Variation |
Dental Only Plan | No |
Design Type | Not Applicable |
EHB Percent of Total Premium | 0.995 |
First Tier Utilization | 50% |
Formulary ID | AKF004 |
Formulary URL | URL |
HIOS Product ID | 77963AK001 |
Import Date | 2/23/2023 1:01 |
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 | 100.00% |
Issuer ID | 77963 |
Issuer Marketplace Marketing Name | Moda Health |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
Multiple In Network Tiers | Yes |
National Network | Yes |
Network ID | AKN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Out of Network |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 77963AK0010004-02 |
Plan Marketing Name | Moda Pioneer Bronze HDHP 5500 |
Plan Type | PPO |
Plan Variant Marketing Name | Moda Pioneer Bronze HDHP 5500 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $0 |
SBC Scenario, Having a Baby, Limit | $50 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 50% |
Service Area ID | AKS001 |
Source Name | HIOS |
Plan ID | 77963AK0010004 |
State Code | AK |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $0 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
Unique Plan Design | Yes |
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, 30 Apr 2024 06:06 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