Plan Summary

Insurance Type
Medicare Advantage Plan (Part C)
Insurance Provider
Moda Health
CMS Rating
Plan Type
Annual Deductible

What To Know About This Plan

  • This is a health coverage only plan

Plan Details

Costs and Other Important Information

Plan Year:
Optional Supplemental Benefits?
Choice of Doctors?
Any Doctor
Prescription Drugs Covered?
Out-Of-Pocket Spending Limit
$3,400 In-Network$3,400 In and Out-of-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$50 In and Out-of-Network
Monthly Drug Plan Premium
Not Applicable
Monthly Health Plan Premium


In Network
Out of Network
Doctor Office Visits
$20 maximum per visit
$20 maximum per visit
Specialist Office Visit
$35 maximum per visit
$35 maximum per visit
Outpatient Services
$200 maximum per visit
$300 maximum per visit
Emergency Care
$65 maximum per visit
Not Applicable
Ambulance Services
$100 maximum
$100 maximum
Kidney Disease and Conditions
20% maximum per visit
20% maximum per visit
Home Health Care
$0 maximum per visit
Durable Medical Equipment
20% maximum per item
20% maximum per item
Inpatient Hospital Care
Days 1-5: $250 copay per day. Days 6-90: $0 copay per day
Days 1-5: $350 copay per day. Days 6-90: $0 copay per day
Skilled Nursing Facility (SNF)
Days 1-10: $0 copay per day. Days 11-100: $50 copay per day
Days 1-10: $0 copay per SNF day. Days 11-100: $50 copay per SNF day
Inpatient Mental Health Care
Days 1-5: $250 copay per day. Days 6-90: $0 copay per day
Days 1-5: $350 copay per day. Days 6-90: $0 copay per day

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Not Rated
Monitoring physical ability
Not Rated
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

Physician Finder

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