Currentmoda_health_plan_incPolicy 2026
Idaho Individual Medical Policy — Moda Select Idaho Gold 2200 Plan
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This document governs benefit structure, member resources, networks, prior authorization, and detailed benefit sections for Idaho individual plan members.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy — Moda Select Idaho Gold 2200 Plan
Policy CodePolicy Policy 2026
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionProviders must contact Moda Health for prior authorization when a service requires it and authorize emergency admissions within 48 hours.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
2200Plan deductible
Moda SelectPrimary network
Many servicesPrior auth required
50% up to $2,500PA penalty
Coverage Criteria and Benefit Details
Table of Contents — Benefit Areas
Benefit areas enumerated in the Table of Contents (selected examples).
Table of Contents — Benefit Areas
Examples
- Urgent & Emergency Care (ambulance, ER, urgent care)
- Preventive Services (colorectal screening, immunizations, women's health)
- Maternity Care (prenatal, delivery, postpartum)
- Pharmacy & Prescription Benefits
- Behavioral Health and Substance Use Disorder Services
- Surgery, Transplants and Therapeutic Radiology/Chemotherapy
- Durable Medical Equipment, Enterostomal Therapy and Home Healthcare
- Vision, Hearing and Dental (includes pediatric vision/hearing; pediatric dental excluded from this policy)
- Virtual Care (telemedicine)
Essential Health Benefits / Pediatric Dental
Essential health benefits statement and pediatric dental exclusion.
Policy covers essential health benefits as defined by HHS; annual and lifetime dollar maximums do not apply to essential health benefits.
Pediatric dental care is not included in this policy and must be purchased as a stand-alone product in the market.
COV ERAGE CRITERIA — Member resources and access to policy tools and information
Member resources and access to policy tools and information.
Members can access the Member Dashboard at www.modahealth.com/idaho 24/7 for policy information, provider search (Find Care), prescription price estimates and to check prior authorization requirements.
Customer Service phone numbers and vendor contacts for medical, behavioral health, disease management and virtual care are provided in Section 2.1 and on the Member Dashboard.
Schedule of Benefits excerpts
Selected Schedule of Benefits excerpts showing example cost sharing and frequency limits.
Annual medical deductible (in-network) per member: $2,200; out-of-network per member: $4,400; in-network out-of-pocket maximum per member: $7,600; out-of-network out-of-pocket maximum per member: $76,000.
Ambulance transportation (in-network): 10% with deductible and out-of-pocket maximums applying (Section 7.2.1).
Emergency room facility (in-network): 10% with deductible and out-of-pocket maximums applying (Section 7.2.2).
Urgent care office visit (in-network): $30 per visit; out-of-network: 60% after deductible (Section 7.2.3).
Colonoscopy preventive frequency: one per 10 years starting at age 45 (preventive coverage rules apply; see Section 7.3.1).
Schedule of Benefits summary
Summary of Schedule of Benefits key points.
Cost sharing differs by service and whether care is in-network or out-of-network; preventive services required by the ACA are covered with no cost sharing when obtained in-network.
Some services have annual or per-year visit limits (e.g., rehabilitation/habilitation outpatient limits, skilled nursing days, spinal manipulation visit limits); limits accrue on a calendar year basis unless noted otherwise.
Pharmacy benefit includes tiered copays/coinsurance with options for up to 90-day retail or mail-order supplies for eligible medications; specialty pharmacy and supply limits may apply (see Section 7.6).
Deductible & Out-of-Pocket rules
Deductible and out-of-pocket maximum rules and exclusions.
You must meet the deductible before the plan shares costs unless a benefit is stated as deductible-exempt. In-network and out-of-network deductibles and out-of-pocket maximums are separate.
Disallowed charges, copayments, prior authorization penalties and manufacturer discounts/copay assistance do not count toward the deductible or out-of-pocket maximums.
Out-of-pocket limits may not apply to certain transplant charges or services not performed at a Center of Excellence; amounts over the Maximum Plan Allowance (MPA) remain member responsibility.
Network coverage and out-of-area children
Network coverage and service-area rules; out-of-area child assignment.
Primary medical network: Moda Select (listed Idaho counties). Pharmacy network: Navitus. Vision network: VSP.
Enrolled children who live outside the service area may be assigned to an out-of-area network if they are full-time students or under a Qualified Medical Support Order (QMCSO); assignment is effective the first day of the month after required documentation is received.
When receiving care outside the service area, members may use additional networks (e.g., Affinity Limited, Aetna® PPO) but out-of-area providers may be paid at a lower benefit level and balance billing rules apply per the policy.
Coverage Criteria Overview
Coverage Criteria Overview — general conditions when benefits are payable and common requirements.
Benefits are payable only when member meets eligibility, is enrolled, and premiums are paid for the current month; benefits are payable after services are provided.
Services and supplies must be medically necessary to diagnose or treat a condition or be preventive to be covered; many outpatient and all nonemergency inpatient/residential services require prior authorization (Section 6).
Emergency care
- Emergency services are covered at the in-network benefit level and covered worldwide for emergency medical conditions.
- Prior authorization is not required for emergency medical screening exams or stabilization; notify your PCP as soon as possible after emergency care.
Coverage criteria and limitations
Coverage criteria and limitations — selected policy-level criteria and common limitations.
Emergency services and urgent care: emergency services paid at in-network level; medically necessary ambulance transport to nearest appropriate facility covered; stretcher/wheelchair car services are custodial and not covered.
Preventive services: ACA-required preventive services covered at no cost in-network; colorectal screening begins at age 45 with specified intervals per modality; one preventive women's health visit per year; supplemental breast screening covered for increased-risk members with no cost sharing in-network.
Prior authorization: many outpatient services and all nonemergency inpatient and residential care must be prior authorized; failure to obtain required prior authorization may result in noncoverage or penalties, and some services (e.g., advanced imaging, ABA, TMS) require prior authorization.
Anticancer and specialty medications: most anticancer medications require prior authorization and specialty medications must be obtained from Moda-designated specialty pharmacy unless prior authorization is obtained.
Rehabilitation & habilitation: covered when medically necessary, part of a written treatment plan, and subject to outpatient session limits (e.g., up to 20 outpatient sessions per year); only one session of each therapy type covered per day; maintenance therapy is not covered.
Infusion therapy and DME: medically necessary infusion services and DME covered but may require prior authorization and use of preferred suppliers; DME replacement/repair covered only when not abused and within specifications.
Balance billing and in-network protections: when you receive emergency services, out-of-network providers in the emergency facility may not balance bill you beyond applicable cost sharing when prohibited by law.
Mental health covered services
Covered mental health services when provided by a mental health provider.
Covered mental health services include office or home visits (psychotherapy), intensive outpatient programs, case management, skills training, ACT and STAR programs, TMS and ECT, partial hospitalization, inpatient and residential care when medically necessary.
Substance use disorder covered services
Covered substance use disorder services.
Covered substance use disorder services include outpatient treatment programs and room/treatment services for detoxification by state-licensed treatment programs; services are provided as described in Section 7.4.
Biofeedback
Biofeedback coverage and limits.
Biofeedback therapy is covered only to treat tension or migraine headaches.
A lifetime visit limit applies to biofeedback services (see Schedule of Benefits for the specific limit).
Clinical trials
Clinical trial coverage rules and prior authorization requirement.
Usual care costs associated with participation in an approved clinical trial are covered; items and services required only for the trial, investigational products, or those not covered outside the trial are excluded.
Participation in a clinical trial must be prior authorized.
Approved clinical trials are limited to those funded or supported by specified federal agencies, conducted under IND/IDE/BLA to the FDA, or exempt by federal law.
Dental injury
Limited dental injury coverage criteria.
Dental services are not covered except to treat accidental injury to natural teeth when all conditions are met: injury due to foreign object or acute trauma, diagnosis within 6 months, treatment completed within 12 months, treatment is medically necessary and provided while covered, and restricted to restoring functional state; implants are not covered.
Diabetes services
Diabetes services and pharmacy benefit linkage.
Insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, continuous glucose monitors) are covered under the pharmacy benefit when obtained from a pharmacy with a valid prescription using a preferred manufacturer.
Examples of covered medical services to manage diabetes include HbA1c testing, kidney disease monitoring, annual dilated eye exam or retinal imaging, diabetes self-management programs, dietary/nutritional therapy and routine foot care as indicated.
Diagnostic procedures
Diagnostic procedures coverage and prior authorization note.
Diagnostic procedures (x-rays, lab tests, standard and advanced imaging, psychological/neuropsychological testing) must be medically necessary; most advanced imaging requires prior authorization and a full list is available on the Moda Health website.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) coverage, limits and exclusions.
DME, supplies and appliances that help manage a medical condition and are for repeated home use are covered when medically necessary; examples include CPAP, hospital beds, insulin pumps, wheelchairs and prosthetics.
Some DME requires prior authorization; replacement or repair is covered only if not abused and used within specifications; wheelchair/scooter replacement may be limited (one per year under age 19; one every 3 years age 19 and over).
Certain appliances used primarily for comfort, convenience or cosmetic purposes and specified excluded items (e.g., dental appliances) are not covered even if related to a covered condition.
Enterostomal therapy
Enterostomal therapy coverage.
Enterostomal therapy for patients with stomas, complex wounds and incontinence is covered when medically necessary.
Gender-affirming services
Gender-affirming services coverage and requirements.
Gender-affirming treatment is covered for members age 18 and over when procedures are performed by qualified providers, prior authorization is obtained for surgical procedures, and the treatment plan meets medical necessity criteria.
Covered services may include
- Mental health services
- Hormone therapy (including puberty suppression therapy for adolescents where applicable)
- Surgical procedures (breast/chest surgery, gonadectomy, genital reconstruction, gender-affirming facial surgery)
Hearing services and cochlear implants
Hearing services and cochlear implants coverage for dependents and others.
Hearing services covered for enrolled dependent children with congenital or acquired hearing loss that may impact development; includes hearing evaluations, ear molds, bone conduction processors, fittings and outpatient speech therapy up to 45 visits/year when billed for hearing loss.
One hearing aid per hearing-impaired ear every 3 years for eligible dependent children; hearing aids must be prescribed, fitted and supplied by an audiologist or hearing aid specialist with physician referral.
Cochlear implants are covered for members of all ages when medically necessary and prior authorized.
Home healthcare
Home healthcare coverage and limits.
Home healthcare services and supplies from a licensed home healthcare agency are covered for homebound members when medically necessary and ordered by a treating practitioner; visits must be intermittent and provided by qualified professional providers (RN/LPN, PT/OT/SLP, licensed social worker).
Home health aides are not covered except when provided under hospice benefits and employed by an approved hospice.
Coverage criteria (comprehensive list)
Coverage criteria — selected covered services and key conditions/limitations.
Hospice: medically necessary or palliative care covered when member is terminally ill, not receiving curative treatment, and services are part of a written hospice treatment plan certified by the treating provider (covered hospice home care services listed).
Hospital inpatient care: covered when medically necessary; covered expenses include room, ICU, facility charges, other hospital services and limited take-home prescriptions (3-day supply).
Infusion therapy: medically necessary infusion services and supplies covered; prior authorization required and use of preferred suppliers or treatment centers may be required; some infusion medications covered under pharmacy specialty benefit.
Rehabilitation & Habilitation: PT/OT/SLP, cardiac and pulmonary rehab covered when medically necessary, part of a written treatment plan, with outpatient annual limits (e.g., up to 20 outpatient sessions/year); only one session per therapy type per day; maintenance therapy not covered.
Skilled nursing facility: provides inpatient rehabilitative care with 24-hour nursing; a limited number of days are covered and covered expenses limited to daily semi-private room service rate; exclusions apply for admissions before coverage, dementia-focused care, routine nursing, non-medical self-help, and custodial care.
Pre-admission testing, podiatry for active problems, maxillofacial prosthetics, nutritional therapy (with limits), and office/home visit definitions and coverage are provided under respective sections and may require prior authorization or meet specified conditions.
Skilled nursing facility coverage and exclusions
Skilled Nursing Facility coverage and exclusions.
Skilled nursing facilities provide inpatient rehabilitative and 24-hour nursing care; a limited number of days are covered and covered expenses are limited to the daily semi-private room rate.
Skilled nursing services are not covered if admission occurred before coverage began, if care is mainly for cognitive decline or dementia (including Alzheimer's), routine nursing care, non-medical self-help or training, or personal hygiene/custodial care.
Spinal manipulation visit limits and billing
Spinal manipulation visit limits and billing notes.
A limited number of spinal manipulation visits are covered each year; other services provided during that visit (office visits, labs, x-rays, physical therapy) are paid under the plan's standard benefit for that service type.
If copayments differ for spinal manipulation and related services at the same visit, the highest copayment applies; chiropractor office visits are treated as specialist visits.
Surgery coverage and reconstructive criteria
Surgery coverage and reconstructive criteria.
Surgery and associated facility and professional services are covered when medically necessary; certain procedures may require outpatient surgery setting; cosmetic surgery is not covered.
Reconstructive surgery is covered when medically necessary and prior authorized; reconstructive surgery following mastectomy (reconstruction, symmetry procedures, prostheses, treatment of complications, and inpatient care) is covered.
Surgery for breast enhancement or elective implant changes is not covered except to treat gender dysphoria or following mastectomy; complications of cosmetic surgery are not covered except to stabilize emergencies.
Therapeutic injections and therapeutic radiology/chemotherapy
Therapeutic injections and therapeutic radiology/chemotherapy coverage summary.
Administrative services for therapeutic injections administered in a professional provider's office are covered; when equivalent results can be achieved with self-administered medications at home, administrative injection services may not be covered.
Therapeutic radiology and chemotherapy covered expenses include treatment planning/simulation, professional services for administration and supervision, and treatments including therapist, facility and equipment charges.
Transplant coverage and limits
Transplant coverage rules, limits and prior authorization guidance.
Medically necessary transplants that follow standard medical practice and are not experimental/investigational are covered; providers should obtain prior authorization as soon as possible for transplant candidates.
If transplant occurs outside a Center of Excellence, deductible and coinsurance may not accumulate toward the out-of-pocket maximum and coinsurance still applies; donor costs, travel and housing (recipient and one caregiver) covered up to a per-transplant maximum with specified limits and exclusions.
Certain transplant-related treatments (e.g., chemotherapy with autologous/allogenic bone marrow transplant for cancers not approved for coverage) are excluded.
Virtual care visit coverage criteria
Virtual care visit coverage criteria.
Live, interactive audio-video virtual visits are covered for diagnosis and treatment of chronic or minor medical conditions when services can be safely and effectively provided virtually and technology meets privacy/security standards.
Virtual care visits using the preferred vendor are covered at no cost sharing (see Section 3); members can access virtual care via specified vendor links on the Member Dashboard.
Pediatric and adult vision benefits and exclusions
Pediatric and adult vision benefits and common exclusions/limits.
Pediatric vision (under age 19): one well-vision exam and one pair of eyeglasses and frames or contact lenses once per year; contact lens supply minimums depend on lens type (standard one pair/year; monthly 6-month supply; bi-weekly 3-month supply; daily 3-month supply).
Optional lens features and certain lens types/requests are limited as listed; specified items (plano lenses with < ±.50 diopter, two pairs instead of bifocals, artistically painted/non-prescription lenses, contact lens modification/polishing) are not covered.
Adult vision: one complete eye exam annually for members age 19 and older; VSP provides benefit authorization to in-network providers and some vision services may require prior authorization.
Maternity coverage, supports, and limits
Maternity coverage, supports, and hospitalization limits.
Pregnancy care, childbirth and related conditions are covered when received from a professional provider; midwives covered only if licensed and certified.
Breastfeeding support and counseling, and purchase or rental of breast pumps and supplies are covered; hospital-grade pumps covered when medically necessary; MPA applies for retail purchases.
Circumcision within 3 months of birth is covered without prior authorization; after 3 months must be medically necessary and prior authorized.
Diagnostic maternity procedures (labs, ultrasounds) may require prior authorization; inpatient hospital stay after delivery is protected by the Newborns' and Mothers' Health Protection Act (up to 48 hours vaginal, 96 hours cesarean) without prior authorization.
Take-home prescription drugs after hospitalization are limited to a 3-day supply at the hospitalization benefit level.
Maternity and pharmacy coverage criteria
Maternity and pharmacy coverage criteria and pharmacy program rules.
Hospital maternity benefits include hospital room, facility charges (including birthing center), nursery care with one in-nursery physician well-newborn visit at no cost sharing in-network, and other medically necessary hospital services; take-home prescriptions limited to 3-day supply.
No prior authorization is required to stay up to 48 hours after vaginal delivery or 96 hours after cesarean (Newborns' and Mothers' Health Protection Act).
Pharmacy coverage: covered medications include medically necessary prescriptions, certain compounded meds, ACA preventive meds, tobacco dependence meds with prescription, contraceptives with initial 3-month then up to 6-month supply, and certain immunizations with no cost sharing at in-network retail pharmacies.
Insulin and diabetic supplies are covered with a prescription using a preferred manufacturer; some medications and quantities require prior authorization and specialty medications must be obtained from designated specialty pharmacies.
Formulary exceptions require provider support and decisions are made within 72 hours (24 hours if urgent); members may obtain up to a 90-day retail supply at participating pharmacies for eligible meds.
Section 8 exclusions (partial list)
Section 8 — selected exclusions and exceptions.
Examples of exclusions
- Abortion is excluded except when mother's life is at risk or pregnancy results from rape or incest.
- Care outside the United States is not covered except for emergency medical conditions.
- Cosmetic procedures are not covered; reconstructive or gender-confirming surgery may be covered if medically necessary and not specifically excluded.
- Experimental or investigational procedures and related expenses are excluded.
- Dental examinations and treatment (except specified dental injury) are excluded.
Excluded services (partial)
Additional excluded services (partial list) with noted exceptions where applicable.
Excluded categories
- Illegal acts: services to treat conditions caused by your illegal act are excluded.
- Infertility: all services for diagnosis and treatment of infertility, including reversal of elective sterilization, are excluded.
- Inmates: services while in custody of law enforcement or jail/prison are excluded.
- Massage therapy and certain naturopathic supplies are excluded.
- Never events and hospital-acquired conditions are excluded.
- Obesity/weight reduction treatments are excluded except services necessary to treat established medical conditions caused or worsened by obesity; ACA-required exceptions apply.
- Orthognathic surgery, personal items, exercise programs, private nursing, professional athletic activities, recreation-related services and equipment, and reports/records are excluded as specified.
- Routine foot care is excluded except when required by a medical condition such as diabetes.
Excluded Services (continued)
Excluded Services — further examples of non-covered items unless an explicit exception is stated elsewhere.
Examples
- Reports and Records: charges for completing claim forms or treatment plans are excluded.
- Routine Foot Care: trimming/cutting benign lesions, trimming nails, removing dead tissue/foreign matter from nails except when required by a medical condition such as diabetes.
- Self-Administered Medications obtained outside the pharmacy benefit are excluded (see pharmacy sections).
- Services Provided or Ordered by a Family Member (except dental provider) and services provided by volunteer workers are excluded.
- Telehealth is excluded except telemedicine specifically described in Section 7.4.34 (virtual care visits).
- Treatment after coverage ends is excluded except covered hearing aids ordered before coverage ends if received within 90 days.
Exclusions and non-covered items
Examples of exclusions and non-covered services.
Treatment that is not medically necessary is excluded, including services prescribed for purposes other than treating disease, inappropriate for the diagnosis, not standard treatment, primarily for convenience, or not the least costly safe alternative.
Vision care and vision surgery are generally excluded except where specifically covered (see pediatric/adult vision sections and diabetes retinal exam coverage).
Vitamins and minerals are not covered unless required by law or medically necessary with prescription; work-related conditions are excluded except in specified owner/partner situations.
Appeals, External Review, Continuity of Care, Complaints, and COB criteria
Appeals, External Review, Continuity of Care, Complaints, and Coordination of Benefits criteria.
Members must exhaust internal appeals before seeking external review unless exhaustion is waived; external review available for final adverse determinations involving medical necessity, appropriateness, level of care, effectiveness, or investigational status.
Standard external review: file with Idaho Department of Insurance within four months of final denial; department assigns an IRO and IRO decision is due within 42 days.
Expedited external review: urgent care requests may qualify for expedited review with IRO decision within 72 hours and written confirmation within 48 hours; members may pursue internal urgent appeal and expedited external review simultaneously if eligible.
Binding effect: IRO decision is final and binding on the carrier for ERISA plans and final and binding on both parties for non-ERISA plans.
Continuity of care: members may request continuity of care if continuing care patient criteria met (serious/complex condition, scheduled nonelective surgery, pregnancy, terminal illness); continuity may continue up to specified periods (e.g., 90 days) with provider agreement to prior contract terms.
Complaints should be submitted in writing within 30 days; insurer will review within 30 days (with possible 15-day extension).
Coding, Billing, and Code-Grouped Notes
Billing/Coding (none present)mixed
| No specific billing/coding entries present in this fragment. |
(no codes)mixed
| No codes listed |
Benefit cost-sharing examplesmixed
| No codes listed |
Pharmacy cost-sharing tiersmixed
| Value Tier - Retail | $2 copay (up to 90-day supply per prescription) |
| Select Tier - Retail | $2 or $5 copay (one copay for a 30-day supply) |
| Preferred Tier - Retail | $5 copay (one copay for a 30-day supply) |
| Nonpreferred Tier - Retail | 30% or 50% coinsurance |
| Mail Order (Preferred) | One copay for a 30-day supply; up to 90-day supply via mail order or participating pharmacies |
| Specialty Pharmacy | 50% coinsurance; specialty medications subject to prior authorization and Moda-designated specialty pharmacy requirements |
Services potentially requiring prior authorizationmixed
| No codes listed |
Preventive screening groupsmixed
| No codes listed |
Advanced imagingmixed
| No codes listed |
Surgery/Transplant billing notesmixed
| No codes listed |
N/Amixed
| No explicit CPT/HCPCS/ICD-10 codes provided in this excerpt. |
Experimental or investigational proceduresmixedNot Covered
| No codes listed |
Cosmetic procedures (non-reconstructive)mixedNot Covered
| No codes listed |
Routine foot care exclusionsmixedNot Covered
| No codes listed |
No codes providedmixed
| No codes listed |
Required claim codingmixed
| ICD-10 | Diagnosis codes required on claims |
| CPT | Procedure codes required on itemized services |
| HCPCS | Procedure codes required on itemized services |
Appeals and determinations definitionsmixed
| Definitions of adverse benefit determinations, expedited appeals, pre/post-service appeals, and utilization review as used in Section 9.2 |
Prior Authorization, Billing, and Provider Requirements
Prior Authorization
Prior Authorization (Section 6)
Section 6 lists the Plan's prior authorization program, including services that require authorization, limits that may be applied to authorizations (time, scope, number/amount/frequency), and that authorizations are based on evidence‑based criteria and may require use of preferred centers or providers.
- When a service requires authorization, the provider should contact Moda Health before the member receives the service.
- Authorizations will be described in the authorization letter and may limit services by time, scope, frequency, or require treatment at a preferred center.
Prior Authorization
Prior authorization information location
Use the Member Dashboard for current prior authorization requirements and to see whether a specific service or supply must be prior authorized.
- Member Dashboard: www.modahealth.com/idaho
- Tools include Find Care, Prescription Price check, and an indicator whether a service/supply must be prior authorized.
Prior Authorization
Prior authorization note
Prior authorization may be required for some services; refer to Section 6 for full details and to confirm requirements before scheduling non‑emergency services.
Prior Authorization
Prior authorization general note
Many outpatient services and all non‑emergency inpatient and residential care must be prior authorized; failure to obtain required prior authorization may result in noncoverage or penalties.
Prior Authorization
Pharmacy prior authorization
Some pharmacy benefits require prior authorization: specialty medications generally must be obtained from Moda‑designated specialty pharmacies and non‑Moda specialty or mail‑order supply may require prior authorization.
- Most specialty medications must be prior authorized.
- Prior authorization required for purchases from non‑Moda designated specialty or mail order pharmacies.
Prior Authorization
Prior Authorization Requirements and Penalties
Providers must contact Moda Health for prior authorization when required; emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible). If required authorizations are not obtained for out‑of‑network services, a 50% penalty up to $2,500 per occurrence applies (penalty does not count toward deductible or OOP max).
- Emergency hospital admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).
- Out‑of‑network services without authorization may incur a penalty of 50% up to $2,500 per occurrence; penalty excludes deductible/OOP accumulation.
Documentation Required
Second Opinion
Moda may require an independent second opinion to confirm medical necessity for non‑emergency treatment; the second opinion visit is provided at no cost to the member.
- If Moda requests a second opinion, the member pays nothing for that second‑opinion visit.
- If the member chooses a second opinion voluntarily, it is paid under regular benefits and usual cost sharing applies.
Prior Authorization
Emergency care prior authorization
Prior authorization is not required for emergency medical screening exams or treatment to stabilize an emergency medical condition; notify the PCP as soon as possible after emergency care.
- Emergency services are paid at in‑network benefit level and do not require prior authorization for screening/stabilization.
- Member/attending provider should notify the PCP promptly after emergency care.
Prior Authorization
General prior authorization requirement
Many outpatient services and all non‑emergency inpatient and residential care require prior authorization; if a provider does not obtain required authorization charges may be denied or the member may face penalties.
Prior Authorization
Anticancer medication prior authorization and pharmacy requirement
Most anticancer medications require prior authorization; specialty anticancer medications must be obtained from Moda's designated specialty pharmacy or have prior authorization to use a non‑designated specialty pharmacy.
- Some anticancer medications may require enrollment in medication‑specific programs as a condition of coverage.
- See Member Dashboard or Customer Service for details.
Prior Authorization
Behavioral and ABA prior authorization
Applied Behavior Analysis (ABA) and certain intensive behavioral services must be prior authorized; ABA services are covered only when prior authorized and specified exclusions apply.
- ABA for autism spectrum disorder is covered but services must be prior authorized.
- Intensive outpatient mental health, ACT, STAR and TMS require prior authorization.
Prior Authorization
Behavioral health prior authorization
Intensive outpatient mental health treatment, ACT, STAR and TMS must be prior authorized prior to care.
Prior Authorization
Clinical trial participation prior authorization
Participation in an approved clinical trial must be prior authorized; only trials meeting specified federal funding or FDA criteria are eligible.
- Approved trials include those funded/supported by NIH, CDC, AHRQ, CMS, DoE, DoD or VA, or conducted under IND/IDE/BLA or exempt by federal law.
Prior Authorization
Advanced imaging prior authorization
Providers must obtain prior authorization for most advanced imaging (MRI/MRA, CT, PET, nuclear and cardiac imaging); a full list of diagnostic procedures requiring authorization is available on the Moda Health website or via Customer Service.
- Provider must get prior authorization for most advanced imaging services (see section 6.1).
- Full list of procedures that require prior authorization is on the Moda website or via Customer Service.
Prior Authorization
Gender-affirming surgery prior authorization
Surgical gender‑affirming procedures require prior authorization and must meet medical necessity criteria and be performed by a qualified provider.
- Prior authorization is required for surgical procedures related to gender‑affirming care.
- Covered gender‑affirming services may include mental health and hormone therapy; surgery requires prior authorization.
Prior Authorization
Prior authorization and provider/supplier requirements
Certain services (respite care, infusion therapy, some treatment center medications) require prior authorization and may require use of preferred suppliers, home infusion providers, or treatment centers for coverage.
- Infusion therapy requires prior authorization and may require use of a preferred medication supplier or home infusion provider.
- Respite care must be arranged by the attending provider and prior authorized.
Prior Authorization
Prior authorization for transplants and some maternity diagnostics
Providers should obtain prior authorization as soon as possible for transplant candidates; some diagnostic maternity procedures may also require prior authorization and a full list is available on the Moda Health website or via Customer Service.
- Seek prior authorization promptly after you know a member may be a transplant candidate.
- Some maternity diagnostic procedures may need prior authorization; refer to the full list on the Moda website.
Documentation Required
Vision prior authorization process
Some vision services may require prior authorization; in‑network vision benefit authorization is handled directly by VSP to in‑network providers—members who receive services without authorization may be responsible for payment and must submit a reimbursement claim.
- VSP provides benefit authorization directly to in‑network vision providers.
- If services are received without authorization from an in‑network provider, the member may be responsible for payment and must submit a reimbursement claim form to VSP.
Prior Authorization
Prior authorization, formulary exceptions, and step therapy
Certain prescription medications and most specialty medications require prior authorization; formulary exception requests must include supporting clinical information from the prescribing provider and are decided within 72 hours (24 hours if urgent). Step therapy requires trying Step 1 before Step 2 unless an exception is granted for ineffectiveness, intolerance, harm, or lack of equivalent effect.
- Formulary exception decisions: standard 72 hours, urgent 24 hours.
- Step therapy exceptions allowed if Step 1 is ineffective, harmful, or not equivalent to requested Step 2 medication.
Denial Risk
General exclusions statement
This Section 8 statement lists services, supplies and conditions that are not covered even if medically necessary; treatment of an emergency medical condition is always covered.
Denial Risk
Obesity exclusion with ACA exception
Obesity and weight‑reduction treatments (surgery, programs, medications) are excluded; services and supplies necessary to treat established medical conditions caused or worsened by obesity are covered, and direct obesity treatments are covered only as required under the Affordable Care Act.
Note
Exclusions overview
Section 8 enumerates numerous excluded items and services; reviewers and providers should consult the exclusions list for specific non‑covered categories before providing services.
Documentation Required
How to Send Claims
When billed directly by a hospital or professional provider, submit a copy of the bill with patient/subscriber name and ID, date of service, diagnosis (ICD codes), itemized services with CPT/HCPCS codes, provider tax ID, and proof of payment; some claim types require additional documentation (accident details, ambulance pickup/dropoff, vision reimbursement form, out‑of‑country documentation).
- Include diagnosis codes (ICD) and procedure codes (CPT/HCPCS) on itemized bills.
- Provide proof of payment (credit card/bank statement or cancelled check) when claiming reimbursement.
Documentation Required
Member appeal submission and representation
Members may review the claim file, submit written comments and designate a representative with a signed PHI authorization; appeals must be submitted in writing and will be reviewed by someone not involved in the original decision.
- Representative must sign authorization to disclose PHI.
- Appeal decisions: pre‑service within 15 days, post‑service within 30 days.
Prior Authorization
Expedited appeal timeline and information requests
Expedited (urgent) appeals will be completed no later than 72 hours after receipt. If additional information is requested, Moda will ask for it within 24 hours and will issue a decision no more than 48 hours after receiving the information or the end of the response period.
- If requested information is not provided promptly, timelines may be extended subject to notice.
- Providers/members must return requested information as soon as possible to avoid delay.
Billing Rule
Continuity of benefits during appeals for ongoing treatment
If an appeal concerns ending or reducing an ongoing course of treatment, Moda will continue to provide benefits during the review; if the appeal is denied, the member may be required to repay benefits received during the review period.
- Benefits continue while appeal of ongoing treatment is under review.
- If appeal is upheld (denial affirmed), benefits paid during review may be recoverable.
Key Definitions and Terms
Policy Return Period
Return windowSubscriber may return this policy within 10 days of delivery for a full premium refund and cancellation from the effective date.
Effect of returnIf returned within 10 days, the policy is canceled from the beginning as if no policy had been issued.
How initiatedReturn is effected by subscriber sending the policy back to Moda Health within the 10-day period.
Plan Name / Deductible
Plan nameModa Select Idaho Gold 2200 Plan
Deductible (in-network, per member)$2,200
Deductible (out-of-network, per member)$4,400
Child-only coverage
Child-only policy ruleIf this is a child-only policy, references to dependents (including spouse or domestic partner) are deleted.
Eligible relativesSiblings of the subscriber remain eligible under a child-only policy.
ApplicabilityChild-only status modifies policy language and eligibility references as stated in policy terms.
Medicare supplement status
Medicare supplement statusThis policy is not a Medicare Supplement policy.
Guidance for Medicare-eligible personsMedicare-eligible individuals should review the Guide to Health Insurance for People with Medicare on medicare.gov.
ImplicationMedicare beneficiaries should not rely on this policy as Medigap coverage.
Member ID card
ID card issuanceMember ID cards are sent after enrollment and show member ID number and provider network.
Use of ID cardMembers should show the ID card each time services are received so providers know the member is covered by Moda Health.
ReplacementIf you lose your ID card, request a replacement via the Member Dashboard or Customer Service.
Medical Network
Primary medical networkModa Select (Idaho counties listed in policy).
Pharmacy networkNavitus.
Vision networkVSP.
Maximum Plan Allowance (MPA)
DefinitionMaximum Plan Allowance (MPA) is the basis Moda Health uses to pay covered expenses.
Provider billingProviders may balance-bill members for amounts above the MPA when permitted by law.
In-network implicationIn-network providers agree to look solely to Moda Health for compensation (except cost sharing and benefit limits).
Extra-contractual service
DefinitionExtra-contractual (extracontractual) service is coverage provided outside the standard policy contract when Moda Health, the member and the provider agree after case evaluation.
Effect on future paymentsPayment of extra-contractual services does not obligate Moda Health to make similar payments in the future.
Inclusion in benefitsExtra-contractual benefits paid will be included when calculating benefits, limitations or cost sharing under the policy.
Primary Care Provider (PCP)
PCP rolePrimary Care Provider (PCP) is an in-network provider (family/general practice, general internist, pediatrician, obstetrician/gynecologist or other designated provider) who coordinates care.
Member choiceMembers are encouraged to choose an in-network PCP and may change PCP at any time; each family member may choose a different PCP.
How to find a PCPUse Find Care on the Member Dashboard or contact Customer Service to locate in-network PCPs.
Prior authorization penalty
Penalty amount50% penalty up to $2,500 per occurrence applies when services that require prior authorization are provided without authorization by an out-of-network provider.
Timing and applicabilityPenalty applied before regular plan benefits begin; does not count toward deductible or out-of-pocket maximum.
Emergency admissionsPrior authorization is not required for emergency admissions and the penalty does not apply to emergency admissions.
urgent care facility
DefinitionAn urgent care facility is an office or clinic distinct from a hospital emergency room that diagnoses and treats patients without an appointment for immediate medical attention.
Coverage conditionUrgent care visits are covered when the member is actually examined by a professional provider and the facility bills as an urgent care facility.
Billing noteMany walk-in/same-day clinics bill as office visits and will be paid under the office visit benefit rather than urgent care unless billed as urgent care.
emergency services
Scope of emergency servicesEmergency services include medical screening exams and treatment to stabilize an emergency medical condition and are covered at the in-network benefit level worldwide.
Prior authorizationPrior authorization is not required for emergency medical screening exams or stabilization treatment; notify your PCP as soon as possible after emergency care.
Balance billing protectionOut-of-network emergency providers may not balance bill you beyond applicable cost sharing when prohibited by law.
Applied Behavior Analysis (ABA)
DefinitionApplied Behavior Analysis (ABA) is a set of psychosocial interventions for autism spectrum disorder involving direct observation, measurement and functional analysis to change behavior.
Coverage noteABA for autism spectrum disorder is covered but services must be prior authorized.
Non-covered examplesServices by family members, custodial/respite care, certain therapies provided under IDEA or by Department of Health and Welfare are not covered.
Intensive outpatient
DefinitionIntensive outpatient services are more intensive than routine outpatient and less intensive than a partial hospital program; mental health intensive outpatient is 3+ hours/week; substance use disorder intensive outpatient is 9-19 hours/week for adults or 6-19 hours/week for adolescents.
Prior authorizationIntensive outpatient services must be prior authorized.
Coverage contextCovered when provided by appropriate professional/licensed providers and as described in behavioral health section.
Partial hospital program
DefinitionA partial hospital program is a licensed behavioral health facility providing no less than 4 hours of direct, structured treatment services per day and 20+ hours/week; it does not provide overnight care.
Coverage requirementPrograms must be appropriately licensed to be covered.
Position vs residentialPartial hospital is more intensive than intensive outpatient but does not include overnight 24-hour care like residential programs.
Residential program
DefinitionA residential program provides organized full- or part-day treatment with overnight 24-hour care and must be state-licensed to be covered.
Coverage requirementResidential programs must be state-licensed for services to be covered.
DistinctionResidential program includes overnight care whereas partial hospital programs do not.
Substance use disorder
DefinitionSubstance use disorder is an addictive physical and/or psychological relationship with drugs or alcohol that interferes with major life areas; it does not include addiction to foods or tobacco.
Covered servicesOutpatient treatment programs and room/treatment services for detoxification by state-licensed programs are covered.
Program typeCovered outpatient programs are state-licensed courses of treatment provided by appointment.
Hospice
DefinitionHospice is a private or public hospice agency approved by Medicare and accredited by a nationally recognized entity (e.g., The Joint Commission).
Coverage conditionsMedically necessary or palliative hospice care covered when member is terminally ill and not seeking curative treatment; services must be part of a written hospice treatment plan.
Covered hospice home careCovered services include RN/LPN, PT/OT/SLP, home health aide, and licensed social worker; home health aide must be employee of approved hospice and provide intermittent custodial care under supervision.
Hospital
DefinitionHospital is a licensed facility providing surgical, medical and psychiatric care with 24-hour nursing service by registered nurses and physician supervision.
Covered inpatient itemsCovered hospital expenses include room, ICU, isolation, facility charges for outpatient surgery and other medically necessary services; take-home prescriptions limited to a 3-day supply at hospital benefit level.
Licensing noteCare in facilities operated by the federal government that are not considered hospitals is covered when payment is required by law.
Skilled Nursing Facility
DefinitionA skilled nursing facility is licensed to provide inpatient rehabilitative care under medical supervision and 24-hour nursing by registered nurses.
Coverage limitA limited number of days are covered; covered expenses are limited to the daily service rate for a semi-private hospital room.
ExclusionsCare mainly for cognitive decline/dementia, routine nursing care, non-medical self-help or custodial care is not covered in skilled nursing benefit.
Home health aide
DefinitionA home health aide is an employee of an approved hospice who provides intermittent custodial care under the supervision of an RN, PT, OT or speech therapist.
ScopeHome health aide services covered as part of hospice home care when provided by approved hospice employer and supervised appropriately.
LimitationHome health aides are not covered outside hospice except as specified elsewhere in the policy.
virtual care visit
DefinitionA virtual care visit is a live, interactive audio-video visit with a provider for diagnosis and treatment of chronic or minor medical conditions.
Coverage conditionsCovered when services can be safely/effectively provided virtually and technology meets state/federal privacy and security standards.
Cost sharingVirtual care visits using the preferred vendor are covered at no cost sharing (see Schedule of Benefits).
transplant
DefinitionTransplant includes transfer of tissue/organs between persons and autologous re-implantation.
Prior authorizationProviders should obtain prior authorization as soon as possible for transplant candidates.
Limits and benefitsIf performed outside a Center of Excellence, deductible/coinsurance may not accumulate toward OOP max; travel/housing for recipient and one caregiver covered up to a per-transplant maximum; donor costs covered per policy rules.
Brand Medications
Brand medicationsMedications sold under a trademark and protected name; brand substitution rules apply when generic available.
Generic medicationsMedications FDA-found to be therapeutically equivalent to brand options; must match active ingredient, strength and dosage form.
FormularyList of prescription medications and coverage details available on the Member Dashboard prescription medication list.
Generic Medications
DefinitionGeneric Medications are FDA-approved therapeutically equivalent versions of brand drugs.
Cost implicationGeneric options generally cost less and may be placed in preferred tiers; brand substitution may require paying the cost difference.
Formulary placementGeneric availability and tiering may change; check Member Dashboard for current tier and coverage.
Formulary
Formulary definitionFormulary is the list of prescription medications and how they are covered under the pharmacy benefit; the Moda Health Prescription Medication List is on the Member Dashboard.
UpdatesFormulary and tier placement may change over time; use prescription price check for latest info.
ExceptionsFormulary exception requests require provider-supplied clinical info and decisions are made in defined timeframes.
Specialty Medications
Specialty medicationsOften used for complex chronic conditions; require special handling and ordering; most require prior authorization.
Supply limitsSome specialty medications may be limited to a 2-week supply.
Prior authorization and pharmacySpecialty medications typically require prior authorization and may need to be obtained from designated specialty pharmacies.
Self-Administered Medications
DefinitionSelf-administered medications are FDA-labeled for self-administration (oral or self-injectable) and intended to be taken outside medical settings.
Coverage exclusion noteSelf-administered medications obtained directly from a physician's office, facility or clinic instead of through the pharmacy benefit are excluded unless covered under another benefit (see sections 7.6 and 7.4.1).
Pharmacy processingSelf-administered prescription meds are generally covered through the pharmacy prescription benefit subject to formulary/prior authorization rules.
Formulary tiers
Formulary tiersPreferred/Select/Value/Nonpreferred (and Specialty) tiers determine cost sharing and coverage rules.
Tier changesA medication's tier may change over time; check the Member Dashboard for current tiering.
Cost impactTier placement affects copay/coinsurance, prior authorization and potential step therapy requirements.
Exclusion (general)
General exclusion definitionExcluded services are services, supplies and conditions not covered by the policy even if medically necessary, with exceptions noted where applicable.
ExamplesIncludes cosmetic procedures, experimental/investigational procedures, care outside the U.S. (except emergency), custodial care, infertility, and others listed in Section 8.
EffectTreatment of a complication arising from an exclusion is also not covered.
Custodial care
DefinitionCustodial care is routine care and assistance with activities of daily living (bathing, dressing, feeding, etc.) that can be provided by non-medical personnel.
Coverage statusCustodial care is excluded from coverage except where specifically provided under another benefit (e.g., hospice with specified conditions).
ExamplesIncludes assistance with medication that can be self-administered and non-medical supervision tasks.
Experimental or investigational
DefinitionExperimental or investigational procedures are those considered experimental/investigational and related expenses are excluded.
ReferenceSee the definition in Section 11 for additional detail on what constitutes experimental/investigational.
Effect on coverageSuch procedures and related expenses are excluded even if they would otherwise be covered.
Never Events
DefinitionNever events are serious, preventable events that should never happen (e.g., wrong surgery, surgery on wrong body part or patient) and include hospital-acquired conditions per CMS definitions.
Coverage statusServices and supplies related to never events are excluded from coverage.
ExamplesWrong-site surgery, surgery on wrong patient, and other CMS-defined serious preventable events.
Nuclear Radiation exclusion
DefinitionNuclear Radiation exclusion applies to medical conditions arising from ionizing radiation, radioactive contamination, or nuclear-related hazards.
Coverage exceptionExcluded unless otherwise required by law.
ScopeIncludes conditions from combustion of nuclear fuel, radioactive waste contamination and hazardous properties of nuclear assemblies.
Routine Foot Care
DefinitionRoutine foot care includes trimming/cutting of benign overgrown or thickened lesions (corns/calluses), trimming of nails, and removing dead tissue or foreign matter from nails.
Coverage exceptionRoutine foot care is excluded unless medically required due to a condition such as diabetes.
ExamplesTrimming nails regardless of condition and removing corns/calluses are not covered unless indicated by a medical condition.
Self-Administered Medications (definition)
DefinitionSelf-administered medications are oral and self-injectable medications labeled for self-administration and intended to be taken outside medical settings.
Exclusion noteSelf-administered medications obtained directly from a physician's office, facility or clinic instead of through the pharmacy benefit are excluded (see sections 7.6.6 and 7.4.1).
Pharmacy coverageSelf-administered medications are covered when obtained and processed through the pharmacy prescription benefit subject to formulary and prior authorization rules.
Adverse Benefit Determination (definition)
DefinitionAdverse Benefit Determination is a letter or Explanation of Benefits (EOB) notifying a member that they are not eligible for benefits or that benefits have not been fully paid for specified reasons (rescission, eligibility, network exclusion, utilization review, investigational/non-medical necessity, etc.).
Examples of reasonsRescission, eligibility, network exclusion, annual benefit limit, utilization review findings, or determination that a service is investigational or not medically necessary.
Relation to appealsAn adverse benefit determination may be appealed via the internal appeal process and can become a Final Internal Adverse Benefit Determination if upheld after appeals.
Expedited appeal (definition)
DefinitionAn expedited appeal is a pre-service appeal that requires faster review because using the regular time period could seriously risk life/health/ability to regain function or cause severe unmanaged pain; urgency is determined by a physician familiar with the member's condition.
When usedUsed for pre-service matters where delay would cause serious harm or severe unmanaged pain.
Timing implicationExpedited appeals have accelerated internal timelines (see appeals section for specifics).
Representative (definition)
DefinitionRepresentative is a person chosen by the member to act on their behalf for appeals and other processes; a signed authorization to disclose PHI is required.
How to appointMember must sign an authorization form allowing the representative to access PHI and act on their behalf.
RoleRepresentatives may review claim files, submit written comments and supporting information for appeals.
Adverse Benefit Determination (duplicate definition)
Adverse Benefit Determination (duplicate)An adverse benefit determination is an EOB or letter notifying a member that benefits are denied or not fully paid for specified reasons (see definitions).
Common reasonsRescission, eligibility, network exclusions, utilization review, investigational or not medically necessary findings.
AppealabilitySuch determinations may be appealed via the internal appeal process described in Section 9.2.
Expedited appeal (duplicate definition)
Expedited appeal (duplicate)Pre-service appeal requiring faster review because delay risks life/health/function or severe unmanaged pain; determined by a physician familiar with the member's condition.
Use caseApplies when regular appeal timelines are inadequate to prevent harm.
Process noteExpedited internal appeals are completed no later than 72 hours after receipt (see appeals section).
External review (IRO) definition
DefinitionExternal review is a review by an independent review organization (IRO) appointed by the Idaho Department of Insurance for certain final adverse benefit determinations involving medical necessity or investigational status.
Filing deadline (standard)File written external review with the Idaho Department of Insurance within four months of the final denial; the IRO decision is due within 42 days.
Expedited external reviewAn urgent/expedited external review decision timeline is 72 hours for IRO decision with written confirmation within 48 hours; eligibility and process details are handled by the department.
Quick Facts, Limits, and Plan Metrics
Deductible (summary value)
In-network deductible (summary)$2,200 per member (annual).
In-network out-of-pocket maximum (summary)$7,600 per member (annual).
Out-of-network deductible (summary)$4,400 per member (annual).
Essential health benefits exclusions (pediatric dental note)
Essential health benefits coveragePolicy covers essential health benefits as defined by HHS except pediatric dental.
Pediatric dental availabilityPediatric dental care is not included and can be purchased as a stand-alone product in the market.
LimitsAnnual and lifetime dollar maximums are not applied to essential health benefits.
Colonoscopy frequency
Colonoscopy frequencyColonoscopy, including polyp removal and pre-surgical exam or consultation, every 10 years for average-risk members age 45 and over.
Other screening optionsFOBT/FIT annually; fecal DNA every 3 years; CT colonography or flexible sigmoidoscopy every 5 years; flexible sigmoidoscopy with annual FIT as alternative.
Follow-up colonoscopyA follow-up colonoscopy after a positive non-colonoscopy screening is covered as preventive for one follow-up.
Rehabilitation/Habilitation visit limit
Outpatient rehabilitation/habilitation limitUp to 20 outpatient sessions per year; limits apply separately to rehabilitation and habilitation services (does not apply to mental health/substance use disorder).
Inpatient rehabInpatient rehabilitation covered at in-network coinsurance per schedule; see policy for day limits and settings.
Session limit applicationOnly one session of each therapy type (PT/OT/SLP) is covered per day.
Biofeedback limit
Biofeedback lifetime limitBiofeedback therapy services have a lifetime visit limit (10 visit lifetime maximum noted in Schedule of Benefits).
IndicationCovered only to treat tension or migraine headaches.
Cost sharingCovered benefit and cost sharing as listed in the Schedule of Benefits (e.g., $30 per visit in-network per schedule excerpt).
Authorization validity and limits
Authorization validityAuthorizations are valid for a set period of time; authorized services received outside that time may not be covered.
Authorization limitsAuthorizations may limit treatment type, number, amount, frequency, or require use of preferred treatment centers or providers.
NoticeAny limits or requirements applicable to authorized services will be described in the authorization letter sent to member and provider.
Colorectal screening age threshold
Colorectal screening age thresholdBegin screening at age 45 for average-risk members.
High-risk noteHigh-risk individuals may be screened earlier/more often per treating provider's recommendation.
Screening optionsMultiple screening modalities accepted (FOBT/FIT, fecal DNA, CT colonography, flexible sigmoidoscopy, colonoscopy, etc.).
Biofeedback indication limit
Biofeedback indication limitBiofeedback is covered only for treatment of tension or migraine headaches; lifetime visit limit applies.
Benefit capLifetime cap referenced in Schedule of Benefits (10 visits lifetime maximum).
Prior authorizationCoverage subject to standard prior authorization rules when applicable.
Wheelchair/scooter replacement frequency
Wheelchair/scooter replacement frequencyMay be limited to one per year for members under age 19 and one every 3 years for members age 19 and over (based on utilization review).
Rental vs purchaseRental charges for DME covered up to purchase price for most DME; consult policy and preferred providers.
Preferred supplierUse of preferred DME provider is encouraged and may save money; Find Care lists preferred providers.
Hearing aid frequency (dependents)
Hearing aid frequency for dependentsOne hearing aid per hearing-impaired ear every 3 years for enrolled dependent children with qualifying hearing loss.
Covered componentsCoverage includes hearing evaluations, ear molds and replacement molds, bone conduction processors and fittings as specified.
Therapy limitOutpatient speech therapy up to 45 visits per year when billed for hearing loss.
Take-home prescription limit
Take-home prescription limitTake-home prescription drugs after hospitalization are limited to a 3-day supply at the hospitalization benefit level.
ApplicabilityApplies to hospital stays including maternity hospitalization take-home prescriptions.
Pharmacy vs medicalSome inpatient medications (e.g., immunosuppressives during hospital stay) are paid as a medical supply; outpatient transplant meds billed via pharmacy benefit.
Skilled nursing facility day limit
SNF day limitSkilled nursing facility coverage is limited to a specified (limited) number of days per year (policy references limits; Schedule of Benefits notes 30 days per year for certain contexts).
Daily rateCovered expenses are limited to the daily service rate for a semi-private hospital room.
ExclusionsAdmissions before coverage, care mainly for dementia/cognitive decline, routine nursing and custodial care are not covered under SNF benefit.
travel and housing maximum (transplant)
Travel and housing maximum (transplant)Travel and housing expenses for the transplant recipient and one caregiver are covered up to a maximum per transplant (amount specified in transplant benefit details).
Donor costsDonor costs covered for recipient or self-donor; coverage limited if donor/recipient not enrolled per policy rules.
Prior authorizationProviders should obtain prior authorization as soon as possible for transplant candidates.
day supply limits
Day-supply limits (retail/mail)Eligible medications may be available for up to a 90-day retail supply at participating pharmacies; some specialty medications limited to a 2-week or <30-day supply.
Dosing interval impactMedications with dosing intervals greater than the plan's maximum day supply may have increased copayments to match the day supply.
Early refill/travelEarly refills for travel allowed once every 6 months but cannot extend supply beyond the policy year.
Medical necessity exception for reconstructive or gender-confirming surgery
Medical necessity exception (reconstructive/gender-confirming)Reconstructive or gender-confirming surgery is covered if medically necessary and not specifically excluded; prior authorization and referenced policy sections apply.
Cosmetic exclusionCosmetic procedures intended primarily to change appearance without functional improvement are not covered.
Referenced sectionsSee sections 7.4.30 and 7.4.11 for reconstructive/gender-confirming surgery coverage criteria and prior authorization requirements.
Coverage exception condition (obesity-related)
Coverage exception condition (obesity-related)Services and supplies necessary to treat established medical conditions caused or worsened by obesity are covered; direct obesity/weight-reduction treatments are excluded except as required under the Affordable Care Act.
Excluded obesity servicesGastric restrictive procedures, weight management programs, medications/formulas for weight loss and related services are excluded.
ACA exceptionDirect obesity treatment may be covered when required under the Affordable Care Act.
hearing aid fill window
Hearing aid fill window after coverage endsCovered hearing aids ordered before coverage ends must be received no more than 90 days after the policy ends to remain covered.
ExtensionExtensions of benefits may apply under specified sections (10.11.1 or 10.11.2) as noted in the policy.
ApplicabilityThis provision applies to hearing aids ordered prior to coverage termination.
Claim submission deadline
Claim submission deadlineClaims must be received no more than 12 months after the date of service; exceptions for legal incapacity allow up to one year beyond that.
Failure to fileClaims not received on time will not be paid except in absence of legal capacity.
Proof of loss timingWritten proof for periodic payments must be sent within 90 days after termination of the period for which insurer is liable; other proof within 90 days after date of loss unless not reasonably possible.
External review filing deadlines and timelines
Standard external review filing deadlineFile a written external review request with the Idaho Department of Insurance within 4 months of the date of the final denial.
Standard IRO timelineThe independent review organization must provide written notice of its decision within 42 days after receipt of an external review request.
Expedited external review timelineFor expedited/urgent requests, the IRO must decide within 72 hours and provide written confirmation within 48 hours.
Revision History and Review Timeline
2026-01-01effective_date
Policy effective date for the Idaho Individual Medical Policy (Moda Select Idaho Gold 2200 Plan).
2026-01-26revisionLatest
Document revision recorded (Rev 1/26) indicating an updated version of the 2026 Idaho Individual Medical Policy.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy — Moda Select Idaho Gold 2200 Plan
Policy CodePolicy Policy 2026
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionProviders must contact Moda Health for prior authorization when a service requires it and authorize emergency admissions within 48 hours.
SourceLink
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