PHIP 2017 Plan Change PPT FINAL
Transcript of PHIP 2017 Plan Change PPT FINAL
vModa HealthModa HealthModa HealthModa Health
Moda Health Enrollment Service Area
1. The Medicare Part D prescription drug plan provides an extensive formulary
2. Comprehensive dental plan
3. 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
The Value of Moda Health Plans
and the PHIP Partnership
Moda HealthMedicare Plans
Moda HealthPERS Moda Health PPORX (PPO)
Medical Plan
Resident of the state of Oregon
Choose any Medicare doctor
• Low copays
• No primary care physician (PCP) selection required
• No deductibles
• No referrals, including specialists
• Prior authorizations may be required for some in-network services and
medications
• Accepted by every hospital
PERS Moda Health PPORX (PPO) Medical Plan
How Our Plan Works
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
PERS Moda Health PPORX (PPO) Medical Plan
Emergency and Travel Benefits
12-month visitor travel benefit
Moda HealthMedicare Supplement Plan
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
Moda Health Medicare Supplement Plan
How Our Plan Works
Moda Health Medicare Supplement Plan
After individual Medicare Part B deductible is met…
Medicare-contracted
provider accepting
assignment
Medicare-contracted
provider NOT
accepting assignment
Non-
Medicare
provider
Billed amount $150 $150 $150
Medicare allows $100 $100 N/A
Limiting charge (15%) N/A $115 N/A
Provider write-off $50 $35 N/A
Medicare pays 80% $80 $80 N/A
Moda Health pays 20% $20 $20 N/A
Patient owes $0 $15 $150
Urgent Care
Covered in full after deductible anywhere in
U.S.
Emergency Room
Ambulance(ground or air)
Outside of the United
StatesCovers urgent care, ER and ambulance at 80% coinsurance. The
member will pay 20% coinsurance.
Coverage limited to $50,000 lifetime per member
Moda Health Medicare Supplement Plan
Emergency and Travel Benefits
MEMBER PAYS:
Personal 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 7:30 a.m. – 5:30 p.m., Mon – Fri
Online resources (www.modahealth.com)
• Be Better Tools
• Claims information
• Physician finder
• Treatment Cost Navigator
• Dedicated PERS website at www.modahealth.com/pers
Moda Health Special Attributes
Moda Health Services
Be Better 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
Your Membership Includes*:
• Membership at a participating fitness facility
• The choice to enroll in a Home Fitness Program and choose 2 kits out of 17
• For more information and locations visit www.silverandfit.com
Exercise & Healthy Aging Program
Moda HealthNon-Medicare Plans
Moda Health Non-Medicare Plans
FeaturesModa Health
Core Value Plan
Moda Health
Select 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
• PPO (Preferred Provider Organization) available to PHIP non-
Medicare members throughout the U.S.
• Network is dependent on where the member lives
• Travel Network allows members to use in-network providers while
traveling around the U.S.
• Plan provides comprehensive medical coverage, as well as emergency
& urgent care services
• Moda Health non-Medicare plans include pharmacy benefits
Moda Health Non-Medicare Medical Benefit
Plans
Moda HealthPrescription Drug Plan
• Comprehensive list of covered medications
• Prescription formulary and pharmacy finder at: www.modahealth.com/pers
• Personal assistance with medications through medication therapy
management (MTM) and prescription safety programs
• Free 1:1 comprehensive personalized medication review
• Outcomes include decreased medication adverse side effects, improved disease
management, and decreased hospitalization
• Our Prescription Price Check Tool through myModa allows you to get
information about medications, including prices and generic options
• Mail order medications available through our mail order companies
• Local pharmacy customer service available 7:00 am – 8:00 pm, Mon–Fri
Moda Health Rx
Pharmacies BenefitNationwide pharmacy network with more than 71,000
participating pharmacies
Our chain pharmacies are available throughout the
United States
Network also includes: long term care pharmacies,
home infusion, Indian, tribal and urban Indian health
program pharmacies, Payless Drug special service
pharmacy
Network Pharmacies
Bartell Drugs Rite Aid Pharmacy
Bi-Mart Safeway Pharmacy
Costco Pharmacy Savon Pharmacy
CVS Pharmacy Shopko Pharmacy
Fred Meyer Target Pharmacy
Kmart Pharmacy Walgreens Pharmacy
QFC Pharmacy Wal-Mart Pharmacy
Mail Order Pharmacies
Costco Mail Order
OHSU Mail Order
Postal Prescription Services
Walgreens Mail Service - Arizona
Walmart Mail Order
Wellpartner
*Not all contracted network pharmacies are listed. Pharmacies contracted with your health plan may change at any time. Your health plan
will notify you if your pharmacy is no longer included in the network. Please contact your health plan for more details.
Payless Drug Special Service Pharmacy
www.PayLessDrug.com
Delta Dental Plan of Oregon
Delta Dental Plan of Oregon
Who are we?
• We started as in 1955, providing dental coverage for the
ILWU (International Longshoremen & Warehouse Union)
What can you expect?
• Flexibility in choosing your dentist
• 4 out of 5 of the nation’s dentists participate in the Delta Dental
Premier network
• Savings on dental procedures achieved through contracts with our
providers
• Cost predictability through predetermination of benefits
• No balance billing if you go to a Premier network provider
Delta Dental Plan 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 Plan of Oregon
Please note that if you did not have 12 months of continuous employer-sponsored dental insurance
immediately prior to enrolling in the PHIP plan, you could have a 12-month waiting period for basic and
major services.
Access to the Delta Dental Premier
National Network
• More than 151,000 participating providers nationwide
• Worldwide dental care with our Passport Dental program
• Includes the Oral Health Total Health program
• Up to a total of 4 periodontal maintenance cleanings in a
calendar year for members with periodontal disease