FAQs about your PEBB coverage

Coordinated Care Plan:

• Members who live in Oregon and surrounding counties can select the Coordinated Care plan.
• Through this plan, you must select and use a PCP 360 to receive in-network benefits.
• For care outside of the Connexus service area, members will utilize the Aetna PPO® Network through Aetna Signature Administrators^®.
• Subscribers who have dependents who live outside the Connexus service area, can still enroll in Coordinated Care plan. These dependents will use the Aetna PPO® Network, when outside of the service area.

PPO Plan:

• The PPO plan is available is nationwide. Members can select this plan if they live in Oregon or throughout the country.
• Members on the plan who live in Oregon, Southwest Washington, Idaho, or Alaska will utilize the Connexus network. If you are outside of the service area, you will use the Aetna PPO network through Aetna Signature Administrators.

If you are transitioning to Moda from another health plan and need assistance logging into your Moda 360 member Dashboard or have questions have benefit offerings and coverage, please contract the Moda 360 Health Navigator team by calling: 844-776-1593.

All of your benefits, including medical and dental, are administered on a calendar-year basis. The plan year runs from Jan. 1 through Dec. 31.

You can compare plans with the plan summaries found on the Documents page. You can find complete plan information in your member handbook.

Your deductible is the amount you pay for covered services before your plan begins to pay benefits.

Your plan has separate deductibles for in-network and out-of-network services. Out-of-network services do not count toward your in-network deductible, and in-network services do not count toward your out-of-network deductible.

On medical plans 1-5, if you do not meet your deductible (individual or family) during a plan year, any expenses applied to your deductible during the last 3 months carry over and apply to your deductible for the next year.

After paying the deductible, you’ll split the cost of eligible services with Moda Health. The percentage you pay is called coinsurance. For example, if your plan has a 20% coinsurance for a $300 service, you would pay $60 and the plan would pay $240. You can find the percentage for each service in your member handbook.

Some services have a copayment (or copay), which is a fixed dollar amount. For example, if your plan allows $300 for a service and has a $50 copay, you would pay $50 and the plan would pay $250. You can find copay amounts in your member handbook.

For some services with copayments (such as PCP 360 primary care office visits, mental health and urgent care visits), you don’t need to meet your deductible. You only need to pay the copay, and your plan pays the rest.

For other services, such as emergency room visits, additional cost-tier procedures and bariatric surgery, you must pay the copay plus the amount up to the annual deductible. The plan will then pay coinsurance.

Once you have paid enough coinsurance, copay and deductible amounts to reach your out-of-pocket maximum, Moda Health pays 100% of eligible expenses for the rest of the plan year. The out-of-pocket maximum is the most you pay in a plan year for covered pharmacy and medical services.

Your plan has separate out-of-pocket maximums for in-network and out-of-network services. Out-of-network services do not count toward your in-network maximum, and in-network services do not count toward your out-of-network maximum.

Some expenses do not apply toward your out-of-pocket maximum. These include:

• Premiums
• Disallowed charges
• Fees above your maximum plan allowance (e.g., balance billing for out-of-network providers)
• Services in excess of any maximum
• Expenses incurred due to brand substitution
• The out-of-pocket expenses for bariatric surgery not performed at a Center of Excellence facility, or out-of-pocket expenses above the Center of Excellence $20,000 benefit maximum
• The out-of-pocket expense for an oral appliance above the $1800 reference price per appliance
• The out-of-pocket expenses for hip and knee replacements above the $25,000 benefit maximum
• The out-of-pocket expenses for infertility treatment

The maximum plan allowance (MPA) is the most Moda Health will reimburse a non-contracted provider. A non-contracted provider may bill you for any amount over the MPA, leaving you with high out-of-pocket costs. 

If you’re considering using a non-contracted provider, contact the Health Navigator team for help understanding any additional charges you may have to pay.

PEBB members have access to Moda’s national network, Aetna PPO® Network through Aetna Signature Administrators^®

You can find an in-network provider by calling the Health Navigator team at 844-776-1593. You can also use Find Care and search by the applicable network (Aetna PPO Network though Aetna Signature Administrators).

Any time you have a medical emergency, you should go to the nearest emergency room or urgent care facility.

If the facility is within the out-of-area network, you’ll receive in-network benefits up to the facility's contracted allowable amount.

If the facility is outside the out-of-area network, you’ll receive in-network benefits up to the maximum plan allowable. You could be responsible for any additional charges.

We may approve Transition of Care services under extraordinary circumstances for a set period if you, while actively receiving medically necessary services, move from a health plan with another carrier to Moda Health and, as a result, have ongoing medical services that become out of network. You or your doctor must complete a Transition of Care form that we’ll review for approval.

Other than when you originally become eligible, you can only enroll during the annual open enrollment period, unless you have a qualified status change. Members who don’t enroll in the dental plan when originally eligible and enroll later during open enrollment are only eligible for preventive services for the first 12 months of coverage.

No, you don’t need to use your Social Security number (SSN) as identification. We will need your SSN during enrollment. But once you’ve enrolled, OEBB will assign unique identification numbers, which Moda Health will use for your plan. Just present your Moda Health ID card when receiving services. Providers should bill Moda Health using your unique ID number.

If you have dual coverage, you must still meet your deductible before the plan will reimburse benefits.

In most cases, once you meet your deductibles and out-of-pocket maximums, you will not have any further out-of-pocket costs, unless other limitations or maximums are involved. If you see out-of-network providers, you will be responsible for any charges above the maximum plan allowance (MPA). If you have secondary coverage through a non-Moda Health plan, check with that plan's insurance carrier to learn how it handles coordination of benefits.

Here are some example scenarios for members double covered under OEBB. All examples assume that you are seeing only in-network providers.

Example #1

A PCP 360 primary care office visit with Medical Plan 3 as primary and Medical Plan 2 as secondary. This visit has a $25 copayment (deductible is waived) for Plan 3 and a $20 copayment (deductible is waived) for Plan 2.

Claim billed and allowed amount: $140

Medical Plan 3 payment:

• $0 applied to deductible since the deductible is waived.
• $25 copay

Total payment under Plan 3 is $115.

Medical Plan 2 payment:

• $0 applied to deductible since the deductible is waived.
• $20 copay

Total payment under Plan 2 without other coverage would be $120, but since Moda Health will not pay over the $140 allowed amount between the two plans, the actual payment is $25.

The total this member needs to pay is $0.

Example #2:

A minor office surgery for a member who has Medical Plan 3 as primary and Medical Plan 2 as secondary.

Once the deductible is met, the plan pays 75% of the remainder, and the member pays 25% coinsurance for Plan 3. The plan pays 80% and the member pays 20% coinsurance for Plan 2.

Claim billed and allowed amount: $1,250

Medical Plan 3 payment:

• $1,200 applied to deductible. The deductible is now met.
• The plan pays $37.50 (75% of the remaining $50).
• Member coinsurance is $12.50 (25% of that $50) before the secondary plan applies benefits.

• $800 applied to deductible. The deductible is now met.
• The plan pays $360 (80% of the remaining $450).

Since the primary plan paid $37.50 of the original $1,250 and the secondary plan paid an additional $360, the remaining amount this member must pay toward the deductible is $852.50.

Example #3

A knee replacement for a member who has Medical Plan 2 as primary and Medical Plan 3 as secondary.

The knee replacement is part of the Additional Cost Tier with a $500 copay that applies first, then the deductible is applied. Once the deductible is met, the plan pays 80% of the remainder, and the member pays 20% coinsurance.

Claim billed and allowed amount: $5,000

Medical Plan 2 payment:

• $500 copay
• $800 applied to deductible. The deductible is now met.
• The plan pays $2,960 (80% of the remaining $3,700).
• Member coinsurance is $740 (20% of $3,700) before the secondary plan applies benefits.

Medical Plan 3 payment:

• $500 copay
• $1,200 applied to deductible.
• The plan pays up to 75% of the remaining $3,300, which would be $2,475 if this was the only plan. However, since the plan will not pay more than the $5,000 allowable amount between the two plans, the actual payment is $2,040.

Example #4

An outpatient surgery for a member double-covered under Medical Plan 6 family coverage.

The $3,400 family deductible must be met first under both plans, and charges will apply to both deductibles. Once the deductible is met, the primary plan pays 80% and the secondary plan pays up to 80%, but does not pay more than the allowed amount.

Claim billed and allowed amount: $5,000

Primary Plan 6 payment:

• $3,400 applied to deductible. The deductible is now met.
• The plan pays $1,280 (80% of the remaining $1,600).
• Member coinsurance is $320 before the secondary plan applies benefits, for a total of $3,720.

Secondary Plan 6 payment:

• $3,400 applied to deductible. The deductible is now met.
• The plan pays 80% of the remaining $1,600, which is $1,280.

The total amount paid between both plans is $2,560 (each paid $1,280).

The total this member needs to pay is $2,440 ($5,000 allowable minus $2,560 in payments by the plans).

The full $3,400 deductible under each plan has been met, but the member only actually has to pay $2,440 out of pocket.

HSA-compliant plans are designed to work with a tax-favored health savings account (HSA). These high-deductible health plans (HDHPs) meet certain IRS requirements for deductibles and out-of-pocket expense limits. OEBB Plans 6 & 7 are HSA-compliant HDHPs. You can use HSA funds to pay for out-of-pocket expenses until you meet your deductible, though an HSA is not required to select Plans 6 and 7.

If more than one person is covered on the plan, you must meet your entire family deductible before benefits are paid. On HDHPs, the deductible applies to nearly all services, except preventive care. This is different from how deductibles work on the other plans, where each person can separately meet their own deductible.

If you use an HSA, the IRS requires that all plans covering you must be HSA-compliant HDHPs. This means you may not be able to coordinate benefits between two plans unless both are HSA-compliant.

The Wellness Visit is covered in full once per plan year in addition to an annual preventive exam for members 21 and over. You must see a Moda Medical Home provider if you are on a non-coordinated care plan, or your PCP 360 if you are on a coordinated care plan.

The visit is a discussion focused on overall wellness rather than treating a specific condition. This discussion could cover exercise, weight management, physical activity, depression, tobacco or substance use.

On Medical Plans 1-5, you pay a lower office visit copay or coinsurance for visits to manage certain conditions. These conditions include:

• Asthma
• Heart conditions
• Cholesterol
• High blood pressure
• Diabetes

This lower copay applies when you see your PCP 360 or an in-network specialist.

With Medical Plans 1-5, you will have a copay in addition to your deductible and coinsurance for certain procedures. These include:

$100 copay:

• Upper endoscopy
• Spinal injections
• Viscosupplementation
• Lumbar discography
• Tonsillectomy for a member under age 18 with chronic tonsillitis or sleep apnea
• Sleep studies
• Imaging procedures (CT, PET, MRI)

$500 copay:

• Arthroscopy (knee and shoulder)
• Spine surgery
• Uncomplicated hernia repair
• Knee/hip replacement (subject to reference pricing limitations)

We encourage you to discuss treatment options with your provider and explore less invasive alternatives to these services if possible.

A reference price is a set price for a specific covered service that typically has a wide variation in provider charges. Moda Health's networks include providers whose charges are at or below the reference price. If you use a provider who charges above the reference price, you will be responsible for paying the difference.

Services that have a reference price on OEBB plans include:

• Knee and hip replacement
• Oral appliances for sleep apnea
• Bariatric surgery

For a list of providers who charge below the reference price for knee and hip replacements, see the Reference Price Program. You can also call the Health Navigator team at 866-923-0409.

Alternative care refers to spinal manipulation and acupuncture services. If you see an in-network alternative care provider, you will pay either a copayment or coinsurance, depending on if you have chosen coordinated or non-coordinated care.

Out-of-network care applies to your out-of-network benefits and deductible, and you must pay any amount over the maximum plan allowance. Spinal manipulation and acupuncture services are limited to a maximum of 12 combined visits per plan year.

Moda Health offers health coaching programs for:

• Diabetes
• Cardiac care
• Respiratory care
• Depression
• Maternity
• Spine and joint care
• Weight management
• Lifestyle coaching

To enroll, call a Moda Health Coach at 800-913-4957 or 503-243-3957.

Benefits for weight management include one obesity screening and risk assessment per plan year, health coaching, online educational resources and Weight Watchers (WW) support.

OEBB medical plans cover bariatric surgery for OEBB plan subscribers only. The plan provides coverage for Roux-en-Y surgery or gastric sleeve surgery. There is a $500 copay, plus deductible and coinsurance. The service must be at one of the approved Centers of Excellence (COE) to be covered; there is no out-of-network benefit.

• This benefit is based on specific medical criteria. You must follow the program for 6 months (referred to as a waiting period) before you can use the surgery benefit. To check if you’re eligible, please see the specific medical criteria on the OEBB website or in your member handbook.
• Roux-en-Y and gastric sleeve surgery are subject to a $20,000 reference price. This means that the most Moda Health will pay for the facility charge for bariatric surgery is $20,000. If there are no COEs in your area, you can use the travel benefit outlined in the member handbook.

An EKG and stress (treadmill) test are included as part of your annual physical. For more information on covered preventive screenings, see the preventive service lists.

Both children and adults can receive a brief hearing evaluation as part of a routine preventive exam. For more information on covered preventive screenings, see the preventive service lists.

Hearing tests are covered separately; see your member handbook for details.

You must see a physician first to get a prescription for hearing aids. Then, you can have them fitted and dispensed by a licensed audiologist or hearing aid specialist.

Your plan covers one hearing aid per hearing-impaired ear every 36 months for members under age 26 and every 48 months for members 26 and over. There is a $4,000 maximum every 48 months for members 26 and older.

Covered benefits include:

• A hearing aid (monaural or binaural) prescribed as a result of the examination
• Ear molds
• Hearing-aid instruments
• Initial batteries, cords and other necessary supplementary equipment
• A warranty
• Repairs, servicing or alteration of the hearing- aid equipment

Review your member handbook for full benefits.

Yes. Moda Health covers both midwives (if they are licensed and certified) and birthing centers.

You can enroll by:

• Calling the program at 866-784-8454 or TTY 877-777-6534 (hours of operation: 5 a.m. to midnight Pacific Time)
• Logging in to your Member Dashboard or visiting http://www.quitnow.net

Contact the Health Navigator team if you have questions about your tobacco cessation benefits.

Moda Health requires providers to get a pre-service authorization before performing some procedures. If an in-network provider does not get prior authorization when authorization is required, the provider will be responsible for the full charges (provider write off).

If you use an out-of-network provider who does not get prior authorization when authorization is required, the plan will deny the charges and you will be responsible for paying the full charges.