Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) - 17933TX0010005 Health Insurance Plan
Moda Health Plan, Inc. health insurance plan with the Plan ID 17933TX0010005. The plan is called Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier).
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 | 17933TX0010005 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Moda Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 17933TX0010005-02 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard On Exchange Plan - 17933TX0010005-01 Open to Indians below 300% FPL - 17933TX0010005-02 Open to Indians above 300% FPL - 17933TX0010005-03 73% AV Silver Plan - 17933TX0010005-04 |
||||||||||||||||||
| Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) Health Insurance Plan, 17933TX0010005-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Except in the case of a medical emergency of a pregnant woman |
NO | ||
| Accidental Dental
Covered if completed within 24 months of initial treatment |
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including outpatient rehabilitation services |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
Only for correction of congenital deformities, conditions resulting from accidental injuries, reconstructive surgery following cancer surgery, breast reconstruction in the event of a mastectomy, and gender confirming surgery. |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
100.00% |
| Dialysis
|
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Covered once per year |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Information about gender affirming care can be found in the policy. |
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Limited to 35 visits per year, separate from rehabilitation services |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
The hearing aid must be prescribed, fitted and dispensed by a licensed audiologist or hearing aid specialist with the approval of a licensed physician |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Preauthorization is required for some imaging services |
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Preauthorization is required |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. |
YES | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Certain services require preauthorization. |
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
Limit to 30-day supply per prescription for retail and 90-day supply per prescription for mail order |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
ACA age and frequency limits apply |
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
100.00% |
| Radiation
|
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limited to combined 35 visits per year, including Chiropractic. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limited to combined 35 visits per year, including Chiropractic. |
YES | $0.00, 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
Up to 30-day supply per prescription |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | $0.00, 0.00% |
100.00% |
| Transplant
Preauthorization is required. |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Excludes any non-surgical or non-diagnostic services or supplies |
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
ACA age and frequency limits apply |
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) Health Insurance Plan Variant 17933TX0010005-02 Attributes
| 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 | 0.99 |
| First Tier Utilization | 100% |
| Formulary ID | TXF002 |
| Formulary URL | URL |
| HIOS Product ID | 17933TX001 |
| 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 | 17933 |
| Issuer Marketplace Marketing Name | Moda Health, Inc. |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Emergency only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency care covered, Out of Area children covered who are enrolled under QMCSO |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 17933TX0010005-02 |
| Plan Marketing Name | Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) |
| Plan Type | EPO |
| Plan Variant Marketing Name | Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) |
| QHP/Non QHP | On the Exchange |
| 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 |
| Service Area ID | TXS001 |
| Source Name | HIOS |
| Plan ID | 17933TX0010005 |
| State Code | TX |
| 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 | 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, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| 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), 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 Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) Health Insurance Plan, 17933TX0010005
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier), 17933TX0010005 Health Insurance Plan, 17933TX0010005
-
Does Moda Select Silver 6400 ($0 Virtual Care $2 Rx Value Tier) Health Insurance Plan, 17933TX0010005 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (17933TX0010005) Health Insurance Plan, Variant (17933TX0010005-02) have Out Of Country Coverage?
Does (17933TX0010005) Health Insurance Plan, Variant (17933TX0010005-02) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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