Idaho Individual Medical Policy (Moda Select Idaho Silver 6400)
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This document is Moda Health Plan Inc.'s Idaho individual medical policy describing benefits, member resources, networks, prior authorization, and covered services for the Moda Select Idaho Silver 6400 plan; it governs plan terms and operations for members and provider interactions.
No material clinical or coverage changes in this revision.
Covered Services, Limits, and Exclusions
High-level covered services index
Table of contents indicates covered benefit categories and where benefit descriptions and criteria should appear.
ALL of the following
- Benefit Description — see Section 7 for detailed benefit descriptions and medical necessity criteria
- When Benefits Are Available — see Section 7.1 for eligibility and coverage effective rules
- Urgent & Emergency Care — see Section 7.2 for ambulance, ER and urgent care rules
- Preventive Services — see Section 7.3 for covered preventive services and frequencies
- Maternity Care — see Section 7.5 for maternity scope, length-of-stay protections and related pharmacy rules
- Pharmacy Prescription Benefit — see Section 7.6 for pharmacy tiers, supply limits and specialty rules
ALL of the following
- Rehabilitation & Habilitation — see Section 7.4.27 for PT/OT/ST limits and visit counting rules
- Durable Medical Equipment (DME), Supplies & Appliances — see Section 7.4.9 for DME medical necessity and prior authorization rules
- Transplants — see Section 7.4.33 for transplant coverage, COE rules and travel/housing limits
- Behavioral Health and ABA — see Sections 7.4.2 and 7.4.3 for ABA, intensive outpatient and residential program rules
This node maps table of contents entries to where criteria and benefit details are found in the handbook
High-level coverage notes
High-level coverage stance and special-case rules included in this part of the document.
Networks and Schedule of Benefits Summary
Coverage is limited to specified networks; cost sharing and limits summarized in the Schedule of Benefits. Members must read Benefit Description for details; some services may require prior authorization.
Selected Benefit Cost-Sharing and Limits
Selected coverage cost-sharing examples and limits from the Schedule of Benefits (Section 3).
Pharmacy coverage criteria
Coverage and member cost-sharing rules for prescription medications by pharmacy channel and tier:
Pharmacy schedule and rules
Pharmacy cost-sharing and mail order/specialty rules
Cost sharing rules
Deductible and out-of-pocket protections
Payment and extra-contractual
Payment mechanics and extra-contractual services
Network information
Network and service area provisions
Coverage Criteria and Rules
General coverage rules and services that require prior authorization.
Coverage criteria and rules
Coverage determinations and limits for the services described in this document include the following rules and examples.
Mental health services covered
The following services by a mental health provider are covered:
ALL of the following
- Office or home visits, including psychotherapy
- Intensive outpatient program
- Case management, skills training, wrap-around services and crisis intervention
- Assertive Community Treatment (ACT) and Strength through Active Recovery (STAR) programs
- Transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT)
- Partial hospitalization, inpatient and residential mental health care
Substance use disorder services covered
Services to assess and treat substance use disorder in an outpatient treatment program are covered, including:
ALL of the following
- State-licensed outpatient treatment programs providing organized outpatient course of treatment
- Room and treatment services for substance use detoxification by a state-licensed treatment program
Biofeedback coverage
Clinical trials coverage
Usual care costs in approved clinical trials are covered; some trial-related items/services are excluded.
ALL of the following
- Usual care costs (medically necessary conventional care) are covered when enrolled in an approved clinical trial
- The policy does not cover items/services not covered outside the trial, items required only to provide/monitor the investigational therapy, or items provided solely for data collection not used for direct medical care
- Participation in a clinical trial must be prior authorized; approved trials limited to specified funding/sponsor or FDA study types
Dental injury and DME exclusions
Dental services not covered except for accidental natural tooth injury meeting specific timing and necessity conditions; certain DME/appliances are excluded even if related to a covered condition.
ALL of the following
- Dental services generally not covered except to treat accidental injury to natural teeth when all conditions met (diagnosis within 6 months, treatment completed within 12 months, medically necessary to restore function)
- Implants and implant-related services are not covered
- Certain appliances/equipment used primarily for comfort, convenience or cosmetic purposes are excluded (see Section 7.4.9 and exclusions list)
Diabetes services and DME rules
Insulin and diabetic supplies covered under pharmacy benefit; insulin pumps may be DME; DME must be medically necessary and some items require prior authorization; rental covered up to purchase price.
ALL of the following
- Insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) covered under pharmacy benefit when obtained from a pharmacy with a prescription and preferred manufacturer
- Insulin pumps may be covered under DME benefit if not obtained from pharmacy
- DME must be medically necessary; some DME require prior authorization and replacement/repair covered if not abused and within specifications; rental covered up to purchase price
Gender affirming services
Expenses covered for members over age 18 when procedures are by qualified providers, surgical prior authorization obtained, and treatment meets medical necessity.
ALL of the following
- Gender affirming services covered for members over age 18 when performed by qualified professional providers
- Prior authorization is required for surgical procedures; treatment plan must meet medical necessity criteria
- Covered services may include mental health, hormone therapy and specified surgeries (breast/chest, gonadectomy, genital reconstruction, facial surgery)
Hearing and cochlear implant coverage
Hearing services covered for enrolled dependent children with certain impairments; hearing aids limited to one per ear every 3 years; cochlear implants covered when medically necessary and prior authorized.
ALL of the following
- Hearing services for enrolled dependent children with birth defect or acquired hearing loss that may impact development are covered, including evaluations and hearing aids
- One hearing aid per impaired ear every 3 years; bone conduction sound processors and fittings covered; outpatient speech therapy up to 45 visits/year when billed for hearing loss
- Cochlear implants covered for members of all ages when medically necessary and prior authorized
Home healthcare and hospice coverage
Home healthcare covered when homebound, medically necessary, ordered by a provider and provided by licensed clinicians; hospice covered for terminal illness with a hospice treatment plan and includes listed home care services.
ALL of the following
- Home healthcare covered when member is homebound, services ordered by treating practitioner and provided by licensed clinicians (RNs, therapists, licensed social workers); home health aides not covered under home health (except hospice context)
- Hospice care covered when terminally ill and not receiving curative treatment; services must be part of a written hospice treatment plan certified by treating provider; hospice home care includes RNs, therapists, home health aide, licensed social worker and short-term inpatient hospice covered
Coverage Criteria Summary
Covered services and conditions (summary of eligibility and included services):
ALL of the following
- Hospice: medically necessary or palliative hospice care covered per written plan when terminally ill
- Hospice home care services include licensed nurses, PT/OT/SLP, home health aide and licensed social worker (home health aide provides intermittent custodial care under supervision)
- Short term hospice inpatient services and supplies covered
- Respite care covered when continuous assistance required; must be prior authorized and arranged by attending provider
- Infusion therapy: medically necessary infusion services and supplies covered; provider must obtain prior authorization; may require preferred supplier or setting
- Hospital care: inpatient hospital care covered when medically necessary; take-home drugs limited to 3-day supply at hospitalization benefit level; dental procedures with general anesthesia covered if medically necessary and prior authorized
- Kidney dialysis coverage includes treatment planning and professional services
- Maxillofacial prosthetic services covered when needed to control infection/pain or restore function due to disease, trauma or congenital deformity
- Nonprescription elemental enteral formula for home use covered when medically necessary and sole/essential source of nutrition
- Rehabilitation & habilitation services (PT/OT/ST, cardiac/pulmonary) covered when medically necessary, part of written plan; outpatient limits separate; maintenance and recreational therapies not covered; one session per therapy type per day
- Skilled nursing facility: limited number of days covered; payment limited to daily semi-private hospital room rate
Skilled nursing facility care
Skilled nursing facility coverage and exclusions
ALL of the following
- SNF covered for a limited number of days; payment limited to daily semi-private hospital room rate
- SNF charges not covered if admitted before coverage, if care is mainly for cognitive decline/dementia, routine nursing care, non-medical self-help/training or personal hygiene/custodial care
Spinal manipulation
Spinal manipulation
ALL of the following
- A limited number of spinal manipulation visits are covered each year (see Section 7.4.29).
- Related services at a spinal manipulation visit (office visits, labs, x-rays, PT) are paid under standard benefits for those services; if copayments differ, member pays the highest copayment at that visit
Surgery
Surgery and reconstructive surgery
ALL of the following
- Surgery (operations and cutting procedures) is covered when medically necessary, including associated facility and professional services
- Cosmetic surgery is not covered; reconstructive surgery must be medically necessary and prior authorized or benefits will not be paid; partially cosmetic reconstructive surgery may be covered if medically necessary (including gender dysphoria)
- Treatment for complications of reconstructive surgery covered when medically necessary; complications of cosmetic surgery not covered except to stabilize emergencies
Therapeutic injections
Therapeutic injections coverage
ALL of the following
- Administrative services for therapeutic injections (e.g., allergy shots) are covered when provided in a professional provider's office
- When similar results can be achieved with self-administered medications at home, administrative services for provider-administered injections are not covered; vitamin/mineral injections not covered unless medically necessary
Therapeutic radiology and chemotherapy
Therapeutic radiology and chemotherapy
ALL of the following
- Coverage includes treatment planning and simulation, professional administration/supervision, and treatments including therapist, facility and equipment charges
Transplants
Transplants
ALL of the following
- Medically necessary transplants that follow standard practice and are not experimental are covered; prior authorization should be obtained as soon as possible for transplant candidates
- If transplant performed outside a Center of Excellence, deductible and coinsurance will not accumulate toward the out-of-pocket maximum; donor cost coverage varies by enrollment/relationship; travel and housing for recipient and one caregiver covered up to a per-transplant maximum
- Certain transplants (e.g., chemotherapy with bone marrow transplant for non-covered cancers) are excluded
Virtual care
Virtual care visits (telemedicine)
ALL of the following
- Virtual care visits covered when services can be safely and effectively provided virtually and technology meets privacy/security standards
- Preferred vendor virtual visits (CirrusMD) covered at no cost sharing in many plan configurations
Vision services
Vision services
ALL of the following
- Pediatric vision (under age 19): one complete well-vision exam and one pair of eyeglasses and frames or contact lenses once per year; contact lens supply minimums apply
- Adult vision (19+): one complete eye exam annually including refraction; VSP provides benefit authorization to in-network providers; members who get services without required authorization may be financially responsible
Maternity care
Maternity care
ALL of the following
- Pregnancy care, childbirth and related conditions covered when provided by a professional provider; midwives only if licensed/certified
- Breastfeeding support and counseling covered; breast pump purchase/rental covered (MPA applies) and hospital-grade pumps covered when medically necessary
- Circumcision within 3 months of birth covered without prior authorization; after 3 months requires medical necessity and prior authorization
- Diagnostic procedures related to maternity covered; some may require prior authorization
- Hospital maternity benefits include room, facility charges, nursery care with one in-nursery physician wellness visit covered at no cost sharing when in-network, and take-home prescriptions limited to a 3-day supply
- Newborns' & Mothers' Health Protection: hospital stay protections of at least 48 hours for vaginal and 96 hours for cesarean without prior authorization
Maternity and Pharmacy coverage criteria
Coverage and limits governed by medical necessity, prior authorization, step therapy, and specific exclusions.
ALL of the following
- Hospital maternity services covered including hospital room, facility charges and nursery care; take-home prescriptions limited to a 3-day supply
- Newborn & mothers length-of-stay protections: up to 48 hours after vaginal delivery and 96 hours after cesarean without prior authorization
- Pharmacy supplies: covered prescriptions, compounded meds with covered main ingredient, certain ACA preventive meds, tobacco dependence treatments; contraceptive meds initial 3-month then up to 6-month supplies
- Specialty medications: most require prior authorization and must be obtained from Moda-designated specialty pharmacy; some limited to <30 days or eligible for 90-day supply; enrollment programs may be required
- Step therapy applies where specified; exceptions allowed if initial step is ineffective, harmful or not equivalent
- Formulary exception process: provider documentation required; decision within 72 hours (24 hours if urgent)
Listed exclusions (section excerpt)
The following items are explicitly excluded from coverage under this policy excerpt, unless an exception is noted.
ALL of the following
- Abortion is excluded except when mother's life is at risk or pregnancy results from rape/incest
- Cosmetic procedures are excluded when main purpose is appearance change without significant functional improvement; reconstructive/gender-confirming surgery covered if medically necessary
- Dental examinations and treatment (including orthodontia) excluded except as described for accidental dental injury and section 7.4.6
- Hearing services excluded except as described in section 7.4.12
- Infertility treatments and services (including reversal of elective sterilization) are excluded
Exclusions List
The following services and supplies are not covered under this policy:
Exclusions
Services and supplies excluded from coverage include, but are not limited to, the following categories and conditions. Exceptions are specified where applicable.
ALL of the following
- Reports and Records: charges for completing claim forms or treatment plans are excluded
ALL of the following
- Routine Foot Care: trimming/cutting benign lesions, trimming nails, removing dead tissue or foreign matter from nails excluded unless medically required (e.g., diabetes)
ALL of the following
- School Services: educational or correctional services or sheltered living provided by a school or halfway house excluded
ALL of the following
- Self-Administered Medications obtained directly from physician office/facility instead of through the pharmacy prescription or anticancer benefits are excluded
ALL of the following
- Self-Improvement Programs: psychological/lifestyle improvement programs excluded unless medically necessary for a covered condition
ALL of the following
- Service Related Conditions: treatment of conditions caused by armed forces service or insurrection/war excluded unless not covered by military/veterans coverage
ALL of the following
- Services for Administrative or Qualification Purposes (employment/licensing/sports/insurance/legal) excluded
ALL of the following
- Services Otherwise Available: services someone else should be responsible for are excluded, with exceptions for certain state hospitals/community mental health and VA when care is not service related
ALL of the following
- Services Provided or Ordered by a Family Member excluded (other than dental providers)
ALL of the following
- Sexual Disorders and Paraphilic Disorders: services for sexual dysfunction/paraphilia and court-ordered sex offender treatment excluded
ALL of the following
- Support Education: level 0.5 education-only programs, certain court-mandated classes and family education/support groups excluded except as required by ACA
ALL of the following
- Taxes, Fees and Interest excluded except as required by law
ALL of the following
- Telehealth excluded except telemedicine services specifically described in Section 7.4.34
ALL of the following
- Temporomandibular Joint Syndrome (TMJ) services and supplies excluded
ALL of the following
- Therapies: animal therapy and maintenance therapy/programs excluded
ALL of the following
- Third Party Liability Claims: services to treat conditions for which a third party may be responsible are excluded to the extent of recovery from that third party
ALL of the following
- Transportation excluded except medically necessary ambulance transport
ALL of the following
- Treatment After Coverage Ends excluded except limited exception for hearing aids ordered before coverage ends and obtained within 90 days
Codes, Limits, and Key Benefit Metrics
| Prescribed anticancer medications, including oral, intravenous (IV) or injected medications; most require prior authorization and specialty pharmacy sourcing or prior authorization to use a non-designated specialty pharmacy. |
| Dental examinations and treatment; orthodontia excluded except as described in section 7.4.6 |
| Cosmetic procedures excluded unless reconstructive or gender-confirming and medically necessary |
| Routine foot care services such as nail trimming/cutting, trimming of benign overgrown lesions, and removal of dead tissue or foreign matter from nails are excluded unless medically required (e.g., diabetes). |
Prior Authorization, Documentation, and Provider Responsibilities
Prior Authorization requirements overview
Prior Authorization is covered in a dedicated Section 6 with subsections including 'Services Requiring Prior Authorization', 'Prior Authorization Limitations', and 'Second Opinion'.
Prior authorization lookup via Member Dashboard
Use the Member Dashboard (www.modahealth.com/idaho) to check whether a service or supply must be prior authorized before providing it.
Prior authorization may be required (see Section 6)
Some services may require prior authorization; providers and members should refer to Section 6 for the full prior authorization requirements.
Prior authorization and specialty pharmacy limits
Prior authorization may be required for some services; certain medications may be limited to specific providers or settings and some medications are covered under the specialty pharmacy benefit.
- Infusion and some specialty medications may be limited to preferred suppliers or settings.
- Check specialty pharmacy and infusion rules in Sections 7.4.18 and 7.6.5.
Prior authorization for non‑Moda mail‑order and specialty items
Prior authorization is required for non‑Moda‑designated mail‑order fills and for certain specialty pharmacy items; members must use Moda‑designated mail order pharmacies or pharmacies that agree to Moda's terms for mail‑order fills.
- Up to 90‑day supply per prescription allowed via Moda‑designated mail order.
- Non‑Moda‑designated mail‑order or specialty fills require prior authorization.
Prior authorization for non‑Moda‑designated specialty pharmacies
Prior authorization is required when specialty medications are obtained from non‑Moda‑designated specialty pharmacies or for non‑Moda‑designated preferred specialty pharmacies.
- Most specialty medications must be prior authorized.
- Preferred specialty fills at non‑Moda pharmacies require prior authorization.
Obtain prior authorization and note penalties for unauthorized out‑of‑network services
Providers must obtain prior authorization for services listed in Section 6.1.1; emergency hospital admissions must be authorized within 48 hours after admission; failing to obtain prior authorization for out‑of‑network services may trigger a penalty of 50% up to $2,500 per occurrence (penalty does not count toward deductible or OOP max).
- Authorizations may be limited in time, scope, frequency, or require specific providers/centers and will be described in the authorization letter.
Second opinion may be required or requested
The plan may require an independent second opinion for non‑emergency medical necessity determinations; if the plan requests the second opinion, the visit is free to the member; if the member elects a second opinion it is paid under regular benefits with applicable cost sharing.
Which services require prior authorization
Prior authorization is not required for emergency medical screening exams or for treatment to stabilize an emergency medical condition; many outpatient services and all non‑emergency inpatient and residential care must be prior authorized.
- Most anticancer medications and certain behavioral health services (ABA, intensive outpatient, ACT, STAR, TMS) require prior authorization.
Consequence of failing to obtain required prior authorization
If prior authorization is not obtained for services that require it, charges may be denied and the member may be responsible for the full cost or a penalty per the utilization review rules in Section 6.1.
Prior authorization required for select behavioral health services
Certain behavioral health services — intensive outpatient mental health treatment, ACT, STAR, and TMS — must be prior authorized before they are covered.
- Intensive outpatient mental health: 3+ hours/week.
- Substance use disorder intensive outpatient: 9–19 hours/week (adults).
Prior authorization required for clinical trial participation
Participation in an approved clinical trial must be prior authorized; approved trials are limited to specified federally funded or FDA‑related categories.
- Approved trials include NIH/CDC/AHRQ/DoD/VA funded groups, FDA investigational new drug/device exemption trials, or trials exempt by federal law.
Prior authorization for advanced imaging and certain DME
Providers must obtain prior authorization for most advanced imaging (MRI/MRA, CT, PET, nuclear medicine, cardiac imaging) and some DME; a full list of diagnostic procedures requiring authorization is on the Moda Health website.
- Provider must get prior authorization for most advanced imaging services.
- Some DME may also require prior authorization and documentation.
Prior authorization required for gender‑affirming surgery
Surgical procedures related to gender‑affirming treatment require prior authorization and must meet medical necessity criteria and be performed by qualified providers.
- Covered services may include mental health, hormone therapy, and surgical procedures such as chest surgery, gonadectomy, genital reconstruction, and facial surgery.
Prior authorization required for cochlear implants
Cochlear implants are covered when medically necessary and require prior authorization.
Prior authorization required for infusion therapy
Prior authorization is required for infusion therapy and associated services and supplies; providers must obtain authorization and may be required to use preferred suppliers or settings for coverage.
- Covered infusion components include solutions, compounding, DME, supplies, nursing, and lab monitoring.
- Authorization may be limited to a preferred medication supplier or home infusion provider.
Arrange respite care and treatment programs with prior authorization
Respite care must be arranged by the attending professional provider and prior authorized; some treatment programs and medications also require prior authorization per Section 6.1.
- Non‑professional provider respite services may be covered with prior approval.
Obtain prior authorization for reconstructive surgery, transplants, and certain maternity diagnostics
Reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid; providers should obtain prior authorization early for transplant candidates and some maternity diagnostic procedures may require authorization.
- All reconstructive procedures require prior authorization to be covered.
- Transplant candidates should have prior authorization requested as soon as possible.
Prior authorization/benefit authorization for vision services (VSP)
Some vision services may require prior authorization; VSP will provide benefit authorization directly to in‑network vision providers — providers should ensure VSP authorization to avoid member financial responsibility.
- If an in‑network vision provider does not obtain VSP authorization, the member may be liable for payment in full and must seek reimbursement.
Maternity stay protections and specialty medication prior authorization rules
No prior authorization is required to remain in the hospital up to 48 hours after vaginal delivery or 96 hours after cesarean; however, many specialty medications and certain medications require prior authorization and take‑home hospital drugs are limited to a 3‑day supply.
- Take‑home prescription drugs after hospitalization are limited to a 3‑day supply at the hospitalization benefit level.
- Most specialty medications require prior authorization and must be obtained from a Moda‑designated specialty pharmacy.
Step therapy enforcement and exception criteria
Step therapy applies where a Step 1 medication must be tried before a Step 2 medication will be covered; exceptions will be made if Step 1 is ineffective, harmful, or not equivalent to the requested therapy.
- When a prescription is submitted out of order, it will not be covered and the provider must prescribe the Step 1 medication unless an exception is granted.
Formulary exception process and timelines
Formulary exception requests must include provider documentation of medical necessity (e.g., prior trials, intolerance, harm, or non‑equivalence) and the plan will decide within 72 hours or within 24 hours for urgent requests.
- Exceptions require prescriber contact information and supporting documentation of prior medication trials and outcomes.
General exclusions — services not covered
These services, supplies and conditions listed in the exclusions are not covered even if medically necessary, recommended or provided by an in‑network provider; treatment of complications that arise because of an exclusion is also not covered (except emergency care).
Obesity and weight reduction services excluded (with ACA exceptions)
Services and supplies that directly treat obesity (e.g., bariatric procedures, weight‑loss medications, weight management programs) are excluded except as required under the Affordable Care Act; treatments for medical conditions caused or worsened by obesity may be covered.
Infertility services and reversal of sterilization are excluded
All services and supplies for diagnosis and treatment of infertility, including surgery to reverse elective sterilization (vasectomy or tubal ligation), are excluded from coverage.
Never events and hospital‑acquired conditions excluded
Services and supplies related to 'never events' and hospital‑acquired conditions (as defined by CMS) are excluded from coverage.
Nuclear radiation–related conditions excluded unless required by law
Medical conditions arising from ionizing radiation or radioactive contamination are excluded unless coverage is otherwise required by law.
Routine foot care excluded unless medically required
Routine foot care services (e.g., trimming/cutting benign lesions or nails, removing dead tissue or foreign matter from nails) are excluded unless required by a medical condition such as diabetes.
Post‑coverage treatment generally excluded; hearing aid exception
Post‑coverage services are generally excluded; limited exception: covered hearing aids ordered before coverage ends are payable if obtained within 90 days after the policy ends or extension provisions apply.
Key Terms and Plan Identifiers
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