2019 Moda Health PPO (PPO) H3813-001 By Moda Health Plan, Inc.

2019 Medicare Advantage Plan Services for
Moda Health PPO (PPO)


Moda Health PPO (PPO) H3813-001 is a 2019 Medicare Advantage or Medicare Part-C plan by Moda Health Plan, Inc. available to residents in Oregon. This plan does not provide additional Medicare prescription drug (Part-D) coverage. The Moda Health PPO (PPO) has a monthly premium of $24.00 and has an in-network Maximum Out-of-Pocket limit of $3,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,900 out of pocket. This can be a extremely nice safety net.

Moda Health PPO (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Moda Health Plan, Inc. works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Moda Health PPO (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Moda Health Plan, Inc. and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Moda Health Plan, Inc. except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2019 Moda Health Plan, Inc. Medicare Advantage Plan Details

Name:
Moda Health PPO (PPO)
ID:
H3813-001
Provider:Moda Health Plan, Inc.
Year:2019
Type: Local PPO *
Monthly Premium C+D: $24.00
Part C Premium:
MOOP: $3,900






Plan Services




Health plan deductible


$0



Emergency care/Urgent care


Emergency $65 per visit (always covered)
Urgent care $35 per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures Out-of-Network $0 copay
Diagnostic tests and procedures In-Network $0 copay
Lab services Out-of-Network $0 copay
Lab services In-Network $0 copay
Diagnostic radiology services (e.g., MRI) Out-of-Network 30%
Diagnostic radiology services (e.g., MRI) In-Network 20%
Outpatient x-rays Out-of-Network 30%
Outpatient x-rays In-Network 20%



Hearing


Hearing exam Out-of-Network $25
Hearing exam In-Network $25
Fitting/evaluation Not covered
Hearing aids Out-of-Network $0 copay
Hearing aids In-Network $699-999



Preventive dental


Oral exam Out-of-Network $0 copay
Oral exam In-Network $0 copay
Cleaning Out-of-Network $0 copay
Cleaning In-Network $0 copay
Fluoride treatment Out-of-Network $0 copay
Fluoride treatment In-Network $0 copay
Dental x-ray(s) Out-of-Network $0 copay
Dental x-ray(s) In-Network $0 copay



Comprehensive dental


Non-routine services Out-of-Network $0 copay
Non-routine services In-Network $0 copay
Diagnostic services Out-of-Network $0 copay
Diagnostic services In-Network $0 copay
Restorative services Out-of-Network $0 copay
Restorative services In-Network $0 copay
Endodontics Out-of-Network $0 copay
Endodontics In-Network $0 copay
Periodontics Out-of-Network $0 copay
Periodontics In-Network $0 copay
Extractions Out-of-Network $0 copay
Extractions In-Network $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Out-of-Network $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services In-Network $0 copay



Vision


Routine eye exam Out-of-Network $0 copay
Routine eye exam In-Network $0 copay
Other Not covered
Contact lenses Out-of-Network $0 copay
Contact lenses In-Network $0 copay
Eyeglasses (frames and lenses) Out-of-Network $0 copay
Eyeglasses (frames and lenses) In-Network $0 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Out-of-Network $0 copay
Upgrades In-Network $0 copay



Mental health services


Inpatient hospital - psychiatric Out-of-Network $350 per day for days 1 through 5
$0 per day for days 6 through 90
Inpatient hospital - psychiatric In-Network $250 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist Out-of-Network $20-35
Outpatient group therapy visit with a psychiatrist In-Network $20
Outpatient individual therapy visit with a psychiatrist Out-of-Network $20-35
Outpatient individual therapy visit with a psychiatrist In-Network $20
Outpatient group therapy visit Out-of-Network $20-35
Outpatient group therapy visit In-Network $20
Outpatient individual therapy visit Out-of-Network $20-35
Outpatient individual therapy visit In-Network $20



Skilled Nursing Facility


Out-of-Network $0 per day for days 1 through 20
$150 per day for days 21 through 100
In-Network $0 per day for days 1 through 20
$150 per day for days 21 through 100



Rehabilitation services


Occupational therapy visit Out-of-Network $35
Occupational therapy visit In-Network $35
Physical therapy and speech and language therapy visit Out-of-Network $35
Physical therapy and speech and language therapy visit In-Network $35



Ground ambulance


Out-of-Network $100
In-Network $100



Other health plan deductibles?


In-Network No



Transportation


Not covered



Foot care (podiatry services)


Foot exams and treatment Out-of-Network $35
Foot exams and treatment In-Network $35
Routine foot care Not covered



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 25% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 25% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Diabetes supplies Out-of-Network 0-25% per item
Diabetes supplies In-Network $0 per item



Wellness programs (e.g., fitness, nursing hotline)


Covered



Medicare Part B drugs


Chemotherapy Out-of-Network 25%
Chemotherapy In-Network 20%
Other Part B drugs Out-of-Network 25%
Other Part B drugs In-Network 20%



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)


$3,900 In and Out-of-network
$3,900 In-network



Optional supplemental benefits


Yes



Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?


In-Network No



Inpatient hospital coverage


Out-of-Network $450 per day for days 1 through 5
$0 per day for days 6 and beyond
In-Network $350 per day for days 1 through 5
$0 per day for days 6 through 90



Outpatient hospital coverage


Out-of-Network $300 per visit
In-Network $200 per visit



Doctor visits


Primary Out-of-Network $20-35 per visit
Primary In-Network $20 per visit
Specialist Out-of-Network $35 per visit
Specialist In-Network $35 per visit



Preventive care


Out-of-Network 30%
In-Network $0 copay




Ratings for Moda Health PPO (PPO) H3813

2018 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Moda Health PPO (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Moda Health PPO (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Moda Health PPO (PPO) Drug Plan Customer Service ratings

Total Rating
Call Center, TTY, Foreign Language
Appeals Auto
Appeals Upheld


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Coverage Area for Moda Health PPO (PPO)

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Source: CMS.
Data as of September 2, 2018.
Star Rating as of October 10, 2018.
For More Information on Ratings Please See the CMS Tech Notes.
Notes: Data are subject to change as contracts are finalized. For 2019, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2019 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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