Oregon

Rates Starting January 1st, 2015 for all plans offered.

Review all our medical and dental plans in Oregon:
2015 Oregon individual and family plans brochure

Medical plan summaries

• Be Aligned (CCN)
• Be Aligned (Rose City)
• Be Balanced (Connexus)
• Be Bold (Connexus)
• Be Connected (CCN)
• Be Connected (Rose City)
• Be Focused (CCN)
• Be Focused (Rose City)
• Be Prepared (Connexus)
• Be Protected (Connexus)
• Be Savvy (HSA) (Connexus)
• Be Smart (Connexus)
• Moda Health Oregon Standard Bronze Plan (Connexus)
• Moda Health Oregon Standard Gold Plan (Connexus)
• Moda Health Oregon Standard Silver Plan (Connexus)

Dental plan summaries

• Delta Dental Exclusive Provider Option (EPO)
• Delta Dental Preferred Provider Option (PPO)
• Delta Dental Individual - Pediatric Plan

Dental Plan Brochure & Rates    Dental Application

What health plans cover

Your way to better health

Health plans make it easier to get well sooner and stay healthy longer. That’s partly because they cover part of the costs of the care you receive.

That might include a doctor visit, hospital stay, preventive services, prescriptions drugs, mental health treatment or even physical therapy.

Many plans also come with extras, like free health coaching, fitness tips and a nurse advice line. For example, Moda Health plans include all of these resources, plus lots more. Members can access them by logging in to myModa from their desktop or mobile device.

What plans cover

When you buy a health plan, the coverage company, like Moda Health, pays part of your medical costs if you get sick or hurt. Some plans cover nearly all of your care up to a certain dollar amount. Other plans kick in only after you meet your deductible.

Most Moda Health plans include free preventive care. That covers women’s annual exams, well-baby care, routine physicals, immunizations and more. Benefit amounts vary for other types of care and procedures. And, after you meet your out of pocket maximum, care is covered at 100 percent, up to what your plan allows.

You are responsible for paying some costs as well, such as:

• Premium – Your monthly cost for your plan.
• Deductible – The amount you pay before the plan starts to cover most services beyond preventive care.
• Copayment (copay) – A set dollar amount you pay for a service, like a doctor’s appointment.
• Coinsurance – The percentage of a medical bill you pay, usually after you meet your deductible. You’ll pay either coinsurance or a copay for a service, but not both at the same time.
• Out-of-pocket maximum – The total amount you could pay for covered services each year. After reaching your out-of-pocket maximum, plans pay 100 percent for the rest of your eligible healthcare expenses, up to what your plan allows.

How Health Care Reform affects you

How will your health insurance change?

You’ve probably heard the news. The health insurance industry is changing. Those changes are all part of “Health Care Reform.” You may wonder how it affects you. It’s different for everyone.

Whatever your situation, health reform brings new rights and protections. Those include more choice and control over your health coverage.

Where to find your health coverage

If you get health benefits through your job, your health plan may change. Just check with your group administrator to learn more. If you have your own individual coverage, you may need to re-enroll. Or, you can buy a new health plan. Explore Moda Health plans to get started.

For those who don’t have health insurance, you’ll need to follow a new federal law, which requires everyone have health coverage. Never fear — Moda Health can make that part easy.

What you need to know about the new healthcare law

• The Affordable Care Act is a federal law designed to make it easier for you to get medical care. If you don’t already have health insurance, you’ll probably need to buy it starting in 2014 or face a fine. You can enroll in a new individual and family plan starting Oct. 1, 2013.
• If you do need to buy health coverage and live in Oregon, Alaska or Washington, explore Moda Health plans here. You can also shop for plans on the health insurance marketplace.
• You may be able to get help paying for your health insurance. Learn about qualifying for the federal tax credit. If you do qualify for a tax credit and want to use it, you must apply for your plan on the marketplace.

Special enrollment

How do you qualify?

Certain life events might qualify you for special enrollment. This means you can enroll for a health plan outside of the open enrollment period. For example, having a baby or moving to a new state could make you or those you cover eligible.

If you enrolled through Washington Healthplanfinder and have had issues with your 2014 health plan, you may be able to enroll in one of our 2014 plans. This temporary special enrollment period runs Aug. 27, 2014, through Nov. 14, 2014, in Washington.

Applying is easy

If you are a current member and think you qualify for regular special enrollment, please contact us. Just call toll-free at 877-605-3229 or email indunit@modahealth.com.

New to Moda Health? Explore our plans here and see if you qualify for special enrollment.

Special enrollment state guidelines

Each state treats special enrollment differently. Here are general guidelines for Oregon, Alaska and Washington. If you have experienced one of these qualifying events in the last 60 days, you may be eligible:

In Oregon:

• You have gained a dependent or become a dependent through marriage, domestic partnership, birth, adoption, foster adoption, or placement for adoption
• You have moved to a new service area
• You or your dependent lost healthcare coverage due to one of these reasons:
  • Termination of employment
  • Divorce or end of domestic partnership
  • Over-aged dependents
  • Expiration of COBRA
  • Loss of eligibility for Medicaid or CHIP
  • QHP decertification
  • QHP enrollment or disenrollment due to HHS error
  • QHP material violation
  • Other loss of eligibility
• Your income level changed and affects your ability to qualify for a health coverage tax credit or changes the amount of that tax credit
• If you are a member of a federally recognized Indian tribe, you may enroll or change plans once a month throughout the year. Visit HealthCare.gov for a definition and full list of federally recognized tribes. To learn more about benefits available to American Indians, visit CMS.gov.

Health terms glossary

Healthcare lingo explained

Words about health coverage can be confusing. To make it easier for you, we put together this cheat sheet. After all, how can you expect to find your way to better health if the signs aren't clear? But watch out – the more you learn, the closer you get to being a health smarty pants, like us.

Accident benefit

Your coverage for care when you have an accident. You may get better benefits than for regular care. For example, your deductible might be waived for treatment related to that accident.

Affordable Care Act (ACA)

The Patient Protection and Affordable Care Act (ACA). This federal law was signed by President Obama in 2010. Starting in 2014, the law requires you to have health insurance (with some exceptions) and gives you certain protections. For example, you cannot be rejected for having a pre-existing condition and your preventive care will be free. To learn more, visit healthcare.gov.

Alternative care

Services you receive from licensed alternative care professionals. The definition of alternative care can vary by state. In Oregon, some examples include naturopathy, acupuncture and chiropractic care. In Washington, some examples include acupuncture and spinal manipulation.

Balance billing

Charges for out-of-network care beyond what your health plan allows. Out-of-network providers may bill you the difference between the maximum plan allowance and their billed charges. In-network providers can't do this.

Be Better tools

Extras to help you stay healthy. Be Better tools come with every medical plan and are available through myModa. Examples include eDoc, a way to access licensed health specialists; Registered Nurse Advice Line, free phone support for health situations; health coaching services; and online tools to check drugs costs, review claims and find care.

Brand drugs

Patented drugs produced and marketed by a specific manufacturer.

Bronze tier plans

Plans that give you less coverage, but a lower monthly premium. Bronze plans cover more than the catastrophic tier, but less than silver and gold tiers.

Calendar year costs

What you pay each calendar year, January through December.

Catastrophic plan

Covers you if you have a serious accident, illness or other medical emergency. Catastrophic coverage is an affordable way to protect yourself from large, unplanned medical expenses. It usually has a high deductible and covers a very basic level of service.

Coinsurance

The percentage of medical costs you are responsible for paying. For example, you may pay 20 percent of a $200 bill, or $40. Moda Health pays the rest! Usually when you pay coinsurance, you will not have a copay.

Community Care Network (CCN)

This network serves Portland and Salem communities. It includes a select group of Legacy Health, Salem Health, Adventist Health and OHSU providers that work together to give you the best care. Enjoy access in Multnomah, Washington, Clackamas, Yamhill, Marion and Polk counties.

Copayment (copay)

A specific dollar amount you pay for a service. For example, you might pay $25 for each visit to a doctor's office. Moda Health pays the rest! Usually, you will not pay coinsurance if you have a copay.

Covered services

Services for which your plan pays a portion. Check your policy to make sure your care is a covered service. If you seek care that is not covered, you will have to pay for the entire cost yourself.

Deductible

The amount you pay before your plan starts to cover services. However, deductibles don't apply to preventive care, which is free, or to some services that have a copay instead.

Dependent

A family member who is on your health plan. Dependents can be your spouse or registered domestic partner and children.

Delta Dental

One of the largest networks of dentists in the country.

Dental plan

A plan that helps you pay for dental care.

eBill

Electronic billing services that allow you to pay your monthly premium online via your myModa account.

eDoc

Part of our Be Better tools, eDoc lets you get free online advice from board certified healthcare providers. Moda Health members can log in and ask physicians, pharmacists, psychologists, dentists, dietitians and fitness experts about any health concern.

Embedded pediatric dental

Dental coverage for children that comes as part of your family’s overall medical plan.

Exclusive Provider Organization (EPO)

A type of provider network. These are doctors, hospitals and other medical offices that accept your insurance. Participating providers agree to your insurance carrier's payments for specific services. Usually, in EPOs, costs are not covered if you visit a provider outside the network.

Explanation of benefits (EOB)

The statement that shows how your care was paid for. Your EOB lists the services you received, the dollar amount your provider charged, the amount covered by insurance and your share.

First Choice Health Network

If you live in Washington this is your medical network. It includes doctors, hospitals and other medical providers.

Generic drugs

Drugs with similar ingredients as brand-name counterparts, but sold for less

Gold tier plans

Plans that give you the highest level of coverage from Moda Health. They also have the highest monthly premiums.

Health Care Reform

Changes caused by the Affordable Care Act (ACA). The ACA is a federal law signed by President Obama. It requires certain changes to make insurance more affordable and higher in quality. Its goal is to give more people access to healthcare.

Health insurance marketplace

Also called an "exchange," a health insurance marketplace is an online hub where you can buy affordable health coverage. States either run their own health insurance marketplace or refer residents to the federal marketplace. If you qualify for a federal tax credit based on your income, you must buy your health plan through a marketplace in order to receive your credit.

Health plan / medical plan

Your health insurance policy. The health plan you choose will have its own set of benefits and monthly premium. Moda Health and other insurance carriers offer a variety of health plans.

Health savings account (HSA)

A way to save for qualified medical costs with tax-free dollars. With an HSA, you can pay for deductibles, coinsurance and other out-of-pocket expenses not covered by health plans, such as Lasik eye surgery or orthodontia. To be eligible, you must have a qualifying high-deductible health plan and open a HSA with a qualified trustee, such as a bank.

Inpatient care

Care you receive while you are checked in to a hospital or treatment center. Usually, you are admitted to a hospital only if you are seriously hurt or sick.

Marketplace navigators

These certified agents help folks navigate the health insurance marketplace, enroll in a health plan and apply for financial assistance. Their services are free. Oregon individuals who qualify for financial assistance and wish to receive it must use a navigator to enroll on the marketplace. CoverOregon.com is working on an online solution that will eventually allow individuals to do this for themselves.

myModa

Your personalized member website. Log in at modahealth.com/myModa to see your claims, benefits and Member Handbook. You can also use Be Better tools to help manage your health. Members can access myModa from a desktop computer or mobile device.

Network

A group of doctors, hospitals and other providers. If providers are in your network, they've agreed to accept your insurance at lower rates. Using an in-network provider keeps your out-of-pocket costs low.

ODS Plus Network

This is one of the largest PPO networks in the state of Oregon. It includes thousands of primary care physicians working with Moda Health to help keep you healthy.

ODS + Providence Alaska Network

This Alaska network covers participating physicians, clinics and ancillary providers throughout the state. It includes Providence Alaska Medical Center as the preferred provider of acute care services in the Anchorage area.

ODS Alaska Select Network

This Alaska network covers participating physicians, clinics and ancillary providers throughout the state. It includes Alaska Regional Hospital as the preferred provider of acute care services in the Anchorage area.

Out-of-pocket maximum

The total amount you could pay for care each year. After reaching your out-of-pocket maximum, Moda Health will pay 100 percent for the rest of your eligible healthcare expenses.

Out-of-pocket payments

Anything you pay to providers. This is your share of medical costs after Moda Health pays a portion.

Outpatient care

Care you receive from a doctor's office or other provider, without being checked into a hospital or treatment center. These are usually routine office visits.

Plan tiers

Plan categories of gold, silver, bronze and catastrophic. Our gold plans cost a little more, but they cover more, too. Silver plans fall somewhere in the middle. Bronze plans provide a little less coverage, but you’ll save money on monthly premiums.

We also have a catastrophic tier, which includes one plan. If you’re under 30 and meet some eligibility requirements, this plan offers coverage just in case of an emergency.

Each plan tier meets the requirements of the ACA. Knowing about these tiers may help you find and choose the best plan for you.

Pre-existing condition

A health problem or illness you had before applying for health insurance. Because of the Affordable Care Act, health plans can’t turn you down or charge you more for a pre-existing condition starting in 2014.

Preferred brand drugs

Medications for which you'll get better coverage under your Moda Health plan. If you have prescription coverage, these are certain brands of drugs that will cost you less out of pocket.

Preferred provider organization (PPO)

A type of provider network. These are doctors, hospitals and other medical offices that accept your insurance. Participating providers agree to your insurance carrier's payments for specific services. Usually, this means you pay lower out-of-pocket costs than if you visit a provider outside the network.

Premium

The monthly amount you pay for your health plan.

Preventive care

Medical services that help keep you healthy before you ever get sick. Examples of preventive care are vaccines, regular check-ups with your doctor and screenings. Preventive care is free with your health plan.

Primary care physician (PCP)

The type of doctor who treats you when you have a routine illness or injury. This doctor focuses on preventive care.

Provider

Any group or professional that provides you with care. Examples are hospitals, doctors and rehabilitation centers.

Registered Nurse Advice Line

Free phone support for basic health situations. The toll-free line is available to members, 24 hours a day, 7 days a week. Friendly nurses offer advice about symptoms, treating minor injuries, choosing cold and flu remedies, and knowing when to come in for care.

Rose City Network

This network includes Providence Health System physicians, clinics and facilities in the Portland metro area. You can access these providers in Multnomah, Washington, Clackamas and Yamhill counties.

Silver tier plans

Plans that give you a great combination of coverage and value, with mid-range monthly premiums. Silver plans give you better coverage than catastrophic and bronze plans, but less than gold plans.

Specialty care

Medical services that usually go beyond your primary doctor. Examples are oncology (cancer treatment), neurology (brain and nervous system) and many others. Specialty care almost always has different benefits than non-specialty care, so check your policy or call Moda Health Customer Service with questions.

Tax credit

Federal tax credits to help people pay for health insurance. You might qualify based on your income. To use a tax credit, you must buy insurance through your state's health insurance marketplace website.

Urgent care

Walk-in medical care you receive at a clinic that is not an emergency. You may visit an urgent care facility if you need medical help right away but your situation isn't serious enough for the emergency room.

Value drugs

Select, commonly prescribed products used to treat chronic medical conditions and preserve health.

Other resources for you

Find even more definitions about health coverage, medical claims and the Affordable Care Act on healthcare.gov/glossary. If you want a printable version, check out this handy Glossary of Health Coverage and Medical Terms PDF.