Moda Select Gold 1000 Separate Rx + Vision Exam - 80588ID0010001 Health Insurance Plan
Moda Health Plan, Inc health insurance plan with the Plan ID 80588ID0010001. The plan is called Moda Select Gold 1000 Separate Rx + Vision Exam.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.58% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.42% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 80588ID0010001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Idaho | ||||||||||||||||||
| Health Insurance Issuer | Moda Health Plan, Inc | ||||||||||||||||||
| Health Insurance Plan Variant | 80588ID0010001-01 | ||||||||||||||||||
| Provider Network(s) | ['IDN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 80588ID0010001-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Moda Select Gold 1000 Separate Rx + Vision Exam Health Insurance Plan Variant 80588ID0010001-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 15.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $500 per person | $1000 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Drug EHB Deductible, Out of Network, Family | $1000 per person | $2000 per group |
| Drug EHB Deductible, Out of Network, Individual | $1,000 |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Diabetes |
| EHB Percent of Total Premium | 99.79% |
| First Tier Utilization | 100% |
| Formulary ID | IDF001 |
| HIOS Product ID | 80588ID001 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 81.58% |
| Issuer ID | 80588 |
| 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 person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 15.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $1000 per person | $2000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,000 |
| Medical EHB Deductible, Out of Network, Family | $2000 per person | $4000 per group |
| Medical EHB Deductible, Out of Network, Individual | $2,000 |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | IDN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Network/ Travel Network |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 80588ID0010001-01 |
| Plan Marketing Name | Moda Select Gold 1000 Separate Rx + Vision Exam |
| Plan Type | POS |
| Plan Variant Marketing Name | Moda Select Gold 1000 Separate Rx + Vision Exam |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,700 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,000 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $1,100 |
| SBC Scenario, Having Diabetes, Copayment | $200 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| 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 | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IDS001 |
| Source Name | SERFF |
| Plan ID | 80588ID0010001 |
| State Code | ID |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group 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 | $8000 per person | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | $80000 per person | $160000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $80,000 |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Moda Select Gold 1000 Separate Rx + Vision Exam Health Insurance Plan, 80588ID0010001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Moda Select Gold 1000 Separate Rx + Vision Exam, 80588ID0010001 Health Insurance Plan, 80588ID0010001
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Does Moda Select Gold 1000 Separate Rx + Vision Exam Health Insurance Plan, 80588ID0010001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (80588ID0010001) Health Insurance Plan, Variant (80588ID0010001-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Diabetes
Does (80588ID0010001) Health Insurance Plan, Variant (80588ID0010001-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (80588ID0010001) Health Insurance Plan, Variant (80588ID0010001-01) have Out of Service Area Coverage?
Yes. Details: Out of Network/ Travel Network
Does (80588ID0010001) Health Insurance Plan, Variant (80588ID0010001-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Diabetes
Does Moda Select Gold 1000 Separate Rx + Vision Exam Health Insurance Plan, Variant (80588ID0010001-01) offer Disease Management Programs for Diabetes?
Yes, the Moda Select Gold 1000 Separate Rx + Vision Exam Health Insurance Plan Variant
80588ID0010001-01 offers Disease
Management Program for Diabetes.
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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