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v Moda Health
vModa Health
Moda Health Enrollment Service Area
Moda Health Medicare Supplement Plan and Moda Health non‐Medicare PPO
PERS Moda Health PPORX (Medicare Advantage)
The Value of Moda Health Plans and the PHIP Partnership
• The Medicare Part D prescription drug plan provides an extensive formulary
• Comprehensive dental plan – Delta Dental Plan of Oregon
• Moda Health offers two Medicare medical plans:
– Moda Health Medicare Supplement: Nationwide coverage; Supplements Medicare’s 80% reimbursement with an additional 20% reimbursement
– PERS Moda Health PPORX (PPO): Statewide Medicare Advantage plan with low copays and out‐of‐pocket maximum
Moda HealthPERS Moda Health PPORX(Medicare Advantage)
• Prior authorization is required for the following services:– In‐network:
• Advanced imaging (MRI/CT scans, etc.)• Musculoskeletal (interventional pain management, joint and spine surgery)
• Physical, occupational, and speech therapy
– Out‐of‐network:• No benefit changes (courtesy authorization recommended)
Plan ChangesPERS Moda Health PPORX (Medicare Advantage)
How our plan works
• Resident of the state of Oregon
• Choose any Medicare doctor nationwide
– Medicare Advantage Network –in‐network benefits
– Any Medicare provider nationwide – out‐of‐network benefits
PERS Moda Health PPORX (Medicare Advantage)
How our plan works
• Advantages– Low copays– No primary care physician (PCP) selection required
– No deductibles– No referrals, including specialists– Plan available statewide– Ability to see any Medicare provider
PERS Moda Health PPORX (Medicare Advantage)
Service Moda Health PPORX (PPO)Urgent Care (Worldwide coverage) $20 copay
Emergency Room (Worldwide coverage)
$65 copay
Ambulance ‐ ground or air $50 copay (one way)
Out of Area Travel:Inside the U.S.
Out‐of‐network copay applies
Out of Area Travel:Outside the U.S.
Covers urgent care, emergency and ambulance at out‐of‐network copay,
no lifetime max
12‐month visitor travel benefit
Emergency and Travel BenefitsPERS Moda Health PPORX (Medicare Advantage)
Moda HealthMedicare Supplement Plan
• No benefit changes
Plan ChangesModa Health Medicare Supplement
How Our Plan WorksModa Health Medicare Supplement
• Nationwide service area– Must be a resident of the U.S.
• Choose any Medicare doctor, specialist or hospital– Doctor bills Original Medicare– Original Medicare bills remaining balance to Moda Health– Virtually no paperwork
Medicare provider NOT accepting assignment
$150
$100
$115
$35
$80
$20
$15
Medicare provider accepting assignment
Billed amount $150
Medicare allows $100
Limiting charge (15%) N/A
Provider write‐off $50
Medicare pays 80% $80
Moda Health pays 20% $20
Patient owes $0
Non‐Medicareprovider
$150
N/A
N/A
$0
$0
$0
$150
After Medicare Part B deductible has been met… Moda Health Medicare Supplement
Urgent Care
Covered in full after deductible anywhere in U.S.
Emergency Room
Ambulance(ground or air)
Outside of the United States
Covers urgent care, ER and ambulance at 80% coinsurance. The member will pay 20% coinsurance.
Coverage limited to $50,000 per member (lifetime)
M EM BER PAYS:
Emergency and Travel BenefitsModa Health Medicare Supplement
Differences between the Moda Medicare Plans
Moda Health Medicare Supplement
PERS Moda Health PPORX (Medicare Advantage)
Calendar year deductible Part B deductible None
Out‐of‐pocket max None $2,500
Skilled nursing facility Covered in full only after 3 full days in hospital Covered in full *
Inpatient & outpatient care Covered in full Low copays and coinsurance
Vision Discounts available through VSP
Eye exams ‐ $20 copayHardware ‐ $100 credit every
24 months
* See ANOC for additional details
Differences between the Moda Medicare Plans
Moda Health Medicare Supplement
PERS Moda Health PPORX (Medicare Advantage)
Residency Requirement Resident of U.S. Resident of Oregon
Provider Access Any Medicare provider
Moda Medicare Advantage providers: In‐network benefits______________________
Any Medicare provider: Out‐of‐network benefits
Coverage for travel outside the U.S. $50,000 lifetime limit No lifetime limit
Personal Assistance Programs(Health coaching, Nurse care coordinators, Medical case managers)
Available – voluntary enrollment
Available – Moda will contact you to enroll
Your Membership Includes*:
• Membership at a participating fitness center or 2 Home Fitness Program kits per year
• For more information and locations visit www.silverandfit.com
Exercise & Healthy Aging Program
Moda HealthNon‐Medicare Plans
• No benefit changes
Plan ChangesModa Health Non‐Medicare Plans
Features Moda HealthCore Value Plan
Moda HealthSelect Value Plan
Type of Plan PPO
Deductible $500 $1,000
Provider Access In‐Plan or Out‐of‐Plan
Primary Care Physician Not Required
Referral Requirement Not Required
NetworkConnexus (Oregon, Idaho & SW Washington)
First Choice Health (Remainder of Washington)
Private Healthcare Systems (PHCS) (All other states)
Alternative Care Included
Moda Health Non‐Medicare Plans
Moda Health Special AttributesPersonal assistance
• Nurse care coordinators• Medical case managers• Health coaching programs
Phone resources• Local customer service with calls answered in 30 seconds• Customer service hours are 7:00 a.m. – 8:00 p.m., Mon – Fri
Online resources • Be Better Tools• Claims information• Find Care • Cost estimating tools• Dedicated PERS website at www.modahealth.com/pers
Health Tools on myModa
• 24‐hour Registered Nurse Advice Line
• Cost‐estimating tools:• Treatment Cost Navigator (medical)• Prescription Price Check (pharmacy)• Dental Optimizer (dental)
Mobile ID Card App
Moda HealthPrescription Drug Plan
Medicare Plans• The prescription drug out‐of‐pocket maximum per individual per calendar year is $5,000
Non‐Medicare Plans• No benefit changes
Plan ChangesPrescription Drug Plan
Prescription Drug Plan• Comprehensive list of covered medications
– Prescription formulary and pharmacy finder at: www.modahealth.com/pers
• Medication therapy management (MTM) program for members with Medicare Part D coverage
– Free 1:1 comprehensive personalized medication review– Outcomes include decreased medication adverse side effects, improved disease management, and decreased hospitalization
• Prescription Price Check Tool• Local pharmacy customer service available 7:00 am – 8:00 pm, Mon–Fri
Pharmacy Network BenefitNationwide pharmacy network with more than 71,000 participating pharmacies
Network also includes: long term care pharmacies, home infusion, Indian, tribal and urban Indian health program pharmacies, specialty pharmacies, Payless Propac special service pharmacy
PharmaciesBartell Drugs Safeway
Bi‐Mart Savon
Costco Shopko
CVS Pharmacy Target
Fred Meyer/Kroger/QFC Walgreens
Rite Aid Wal‐Mart
Mail Order Pharmacies
Costco
OHSU Mail Order
Postal Prescription Services
Walgreens Mail Service
Walmart Mail Service
Wellpartner
Please note: Not all contracted network pharmacies are listed. Pharmacies contracted with Moda may change at any time. Moda will notify you if your pharmacy is no longer included in the network. Contact pharmacy customer service for more details.
Delta Dental of Oregon
Delta Dental of Oregon
Who are we?
We started providing dental coverage in 1955 as
What can you expect?• Flexibility
• 4 out of 5 of the nation’s dentists participate in our Premier network
• Savings on dental procedures
• Cost predictability through predetermination of benefits
• No balance billing
• Composite fillings are covered for posterior (back) teeth
• Full mouth debridement:– Covered for members under age 19 once in a 2 year period– Covered for members over age 19 once in a 2 year period only if there has been no cleaning within 24 months
Dental Plan ChangesDelta Dental of Oregon
Delta Dental of Oregon
• Calendar Year Deductible . . . . . . . . . . . . . . . . . . . . . . . $25
• Calendar Year Benefit Maximum . . . . . . . . . . . . . . . . . $1,500
• Preventive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100%*
• Basic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80%
• Major . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50%
* Deductible waived for preventive services; and preventive charges do not accumulate to calendar year benefit maximum
Delta Dental of Oregon
• Additional Dental Benefits:
– Oral Health Total Health Program
• Additional cleanings available if you are diabetic or in your third trimester of pregnancy
• 4 Periodontal maintenance cleanings per calendar year for members with periodontal disease
Delta Dental of Oregon
Access to the Delta Dental Premier National Network
• More than 151,000 participating providers nationwide
• Worldwide dental care with our Passport Dental program
