Health coverage FAQs

Why do I need health insurance?

Having health coverage is a smart idea. Almost everyone needs medical care at some point, and a health plan helps pay for these costs. It also protects you from large, unexpected medical bills.

How does healthcare coverage work?

When you have a plan, your health insurance company pays part of your medical costs if you get sick or hurt. You are responsible for paying some costs as well, such as:

  • Premium:The monthly amount you pay for your plan
  • Deductible: What you pay in a calendar year for care that requires you to cover some costs before the health plan starts paying
  • Copayment (copay): A fixed dollar amount you pay for a covered healthcare service or supply, usually at the time of receiving it
  • Coinsurance: The percentage you pay for a covered healthcare service or supply, separate from a deductible
  • Non-covered charges: Including out-of-network charges on EPO plans

What do health plans cover?

Most Moda Health plans cover essential health benefits, like preventive care. There is no lifetime maximum or visit limit on in-network coverage for essential health benefits, so you can keep receiving the care that you need. Our plans also pay for part of your other healthcare costs. Members pay the cost of care until the deductible is met. Once you meet your out-of-pocket maximum, which includes deductible, coinsurance and copays, Moda Health pays the remainder of your covered medical expenses for the benefit year.

What are essential health benefits?

Essential health benefits are the following 10 categories of services that health insurance plans must cover under the Affordable Care Act:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions to gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits). Not all plans cover pediatric dental services. Please see the plan details for plan-specific coverage.

What is preventive care?

Preventive care services keep you healthy before you ever get sick. Services include periodic health exams, well-baby care, women’s annual exams, many immunizations and cancer and other health screenings. Moda Health plans cover most preventive care.

What determines the monthly premium I pay for my plan?

The plan, your age and the ages of your dependents — your spouse or domestic partner and your children — as well as tobacco use affect your premium. In some cases, the region also plays a part.

Your rate will go up a little each year until you turn 65, when you’ll be eligible for Medicare. If you are covering children under age 21, they each have the same rate based on the plan. Child dependents age 21 through 25 have a rate based on their actual age.

Should I choose a health plan with a higher or lower deductible?

A high deductible will save you money on your monthly premiums. However, you’ll have to spend more out of pocket before your plan pays for benefits. With a low deductible, your plan will cover benefits earlier, but you’ll pay a higher premium every month.

What’s the difference between a copay and coinsurance?

A copay is a specific dollar amount you pay for a service. For example, you might pay $25 for a visit to your doctor’s office. Often, you don’t have to meet your deductible for services that are covered with copays (but check your plan details to make sure).

Coinsurance is the percentage of costs you must pay after your deductible is met. For example, you may pay 20% of the cost of a $200 bill, or $40. Moda Health would pay the rest.

Can I add my family members to my health plan?

Yes, you can add a family member only during Open Enrollment, unless you qualify for Special Enrollment. These family members are known as dependents. You can include your qualified spouse or partner. You can also add your dependent children under age 26. Keep in mind that you will pay a higher premium for each dependent you add.

When will my medical coverage begin?

See the Enrollment Periods page for the effective dates for 2024 Open Enrollment.

Can my employer pay for my Individual coverage?

Individual plans cannot be employer-sponsored plans but employers may offer a Qualified Small Employer Health Reimbursement (QSEHRA) or Individual Coverage Health Reimbursement (ICHRA) and pay for individual premiums. Check with your employer if these options are available and how reimbursement is made. Otherwise, you will be responsible for paying your monthly premium directly to Moda Health.

Can I switch to a different plan at any time?

No. You will only be able to change medical plans during Open Enrollment. If you experience a qualifying event, such as getting married or moving to a new state, you may be able to apply for Special Enrollment outside of the Open Enrollment period.

What is Medicaid redetermination?

Medicaid redetermination is when the state checks to see if you still qualify for Medicaid. This eligibility review process happens every year and is called redetermination. Paused during the COVID-19 pandemic to enable most people to keep their Medicaid plan regardless of changes, redetermination resumed once the federal COVID-19 Public Health Emergency declaration ended on May 11, 2023.  Visit our Medicaid eligibility changes page to learn more.