Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon

Page created by Barbara Ward
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Northwest Oregon
2021 | Moda Health                  Columbia, Lincoln, Tillamook
Medicare Advantage enrollment kit   and Yamhill counties
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Get more                         Table of contents
    out of                           � Medical plans .  .  .  .  .  .  .  .  .  .  .  .  .  . 4

                                         Why choose Moda Health  .  .  .  .  .  .  .  .  .  .4
                                         Plan details  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7
                                         Summary of Benefits  .  .  .  .  .  .  .  .  .  .  .  .  . 7
                                            Medical benefits .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8
                                            Part D prescription drugs .  .  .  .  .  .  .  . 14
    Moda Health is here to help
    you be your best. Together,             Optional supplemental benefits
                                            (Extra Care) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  15
    we will find a Medicare
                                         Low income Subsidy premium  .  .  .  .  .  . 18
    Advantage plan that works for
    you — a plan that will inspire   � How to enroll  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
    you to actively participate          Pre-enrollment checklist .  .  .  .  .  .  .  .  .  . 19
    in your health and maximize          Enrollment instructions .  .  .  .  .  .  .  .  .  .  .  21
    your insurance dollars.
                                     � Additional resources
    Let’s explore your Medicare          Member care resources .  .  .  .  .  .  .  .  .  . 22
    Advantage plan options…

2                                                                                                                     3
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Why choose Moda Health

    Quality, choice                                                                              Vision                                  Fitbit® personalized

    and access
                                                                                                                                         wellness program
                                                                                         Get a routine vision exam and eyewear
                                                                                         through the VSP Advantage Elements       Stay fit, healthy and connected with a
                                                                                         plan, and in-network coverage through    FREE Fitbit Premium membership and
                                                                                         VSP’s Advantage provider network.        Fitbit Inspire 2™ (a heart-rate enabled
                                                                                         All routine vision exams and eyewear     device). From steps to sleep, you will
    Enjoy choosing from a large network of quality healthcare providers                  claims are administered by VSP. You      gain valuable insights into how your
    and hospital systems. You'll have access to over 10,000 doctors and                  can learn more about VSP at     behaviors affect your health. Plus, you’ll
    specialists in Oregon. Your Moda Health Medicare Advantage plan                      If you have questions, please call VSP   get the tools you need to make healthy
                                                                                         at 844-693-8863, TTY: 800-428-4833.      changes:
    also comes with access to our expert health coaches and caring
    customer service. We are a dedicated team, here to support you.                                                                 • Access to thousands of dynamic
                                                                                                                                      workouts that can be adapted to
                                                                                              Dental                                  create the ideal program for you
    Our plans                                        Nurse line
                                                                                         Two no-cost preventive dental visits       • Fitness challenges to complete
    We have preferred provider                                                           through the Delta Dental of Oregon           on your own or with others
    organization (PPO) plans with and        Need quick advice? The friendly nurses
                                             on our Registered Nurse Advice Line are
                                                                                         Medicare Advantage Network and up to       • Guided programs to help you move
    without pharmacy benefits. If you                                                    $500 of comprehensive dental benefits.       more, sleep better and eat well.
    choose a plan with pharmacy coverage,    available 24 hours a day.                                                                These programs are customizable,
                                                                                         (Total $500 allowance is combined for
    you won't have a co-pay for vaccines!    Call for guidance on:                       in and out of network services).             based on your goals and schedule.
    All of our PPO plans include:             • Basic health conditions                                                             • Personalized insights to help
      • $0 medical deductible                   and symptoms                                                                          improve your health, based on your
      • Both in-network and out-              • Treatment for minor                                                                   exercise, heart rate and sleep
        of-network care; in-network             injuries and burns                            Hearing                               • Advanced sleep tools to
        care saves you money                  • Home cold and flu remedies                                                            boost your energy
      • Specialist care without referrals     • When to visit your doctor                Receive a routine hearing aid
                                                                                         exam and hearing aid coverage
    Optional supplemental benefits                                                       through TruHearing. Hearing aids
    Moda Health Medicare Advantage                Text a doctor                          are costly. This benefit makes them
    members also have the option to enroll                                               much more affordable. You can
    in Extra Care. For an additional $5      Enjoy fast and private access to a          learn more at To
    monthly premium, you can have routine    dedicated doctor in under a minute          schedule an appointment, please
    chiropractic services, acupuncture       -- at no cost to you. With the CirrusMD     call 866-929-6749.
    and naturopathic services. We will       app, all you need is Internet access to:
    pay 50 percent of services up to a         • Connect with a doctor via text, 24/7,
    combined $500 annual maximum.                without appointments or time limits
    Added benefits                             • Ask urgent or general
                                                 health questions
    When you choose a Moda Health
    Medicare Advantage plan, you
                                               • Message, share photos
                                                 or video chat
    also receive additional benefits.          • Get peace of mind, even at 2 a.m.
    Among these benefits are gym
    membership and wellness resources.
                                               • Come back to conversations or
                                                 follow up as often as you'd like

4                                                                                                                                                                              5
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Plan details

    Find the right
    Medicare plan for you
    Part of being your best is finding a Medicare Advantage plan that
    is right for you. We offer two PPO plans for you to choose from.

    Moda Health PPO H3813-001                 Moda Health NW PPORX
     • $0 medical deductible                  (PPO) H3813-011
     • No prescription drug benefit            • Includes a prescription drug benefit
     • You can get both in-network and         • $0 medical deductible
       out-of-network care; in‑network         • You can get both in-network
       care saves you money                      and out-of-network care; in-
     • No referral needed for                    network care saves you money
       specialist care                         • No referral needed for
    Moda Health PPO is available in Benton,      specialist care
    Clackamas, Columbia, Coos, Crook,         Moda Health NW PPORX
    Curry, Deschutes, Douglas, Hood River,    (PPO) is available in Columbia,
    Jackson, Jefferson, Josephine, Klamath,   Lincoln, Tillamook and Yamhill
    Lane, Lincoln, Linn, Marion, Multnomah,   counties in Oregon.
    Polk, Tillamook, Wasco, Washington,
                                              See page 9 for plan details.
    and Yamhill counties in Oregon.
    See page 8 for plan details.

                                                   Compare your plan
                                                   options side by side on
                                                   the following pages...
6                                                                                       7
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Medical benefits
Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

                                                              Moda Health PPO H3813-001
                                                    Benton, Clackamas, Columbia, Coos, Crook, Curry,         Moda Health NW PPORX (PPO) H3813-011
                                                   Deschutes, Douglas, Hood River, Jackson, Jefferson,
                                                                                                             Columbia, Lincoln, Tillamook and Yamhill
                                                     Josephine, Klamath, Lane, Lincoln, Linn, Marion,
                                                                                                                  counties counties in Oregon
                                                    Multnomah, Polk, Tillamook, Wasco, Washington,
                                                             and Yamhill counties in Oregon
                                                           In-network                       Out-of-network    In-network              Out-of-network
    Monthly premium                                                             $18                                            $105
    Medical deductible                                                          $0                                              $0
    Maximum out-of-pocket responsibility
                                                                              $3,500                           $6,700                      $9,500
    (Does not include prescription drugs)
    Inpatient hospital coverage
    (Copay per day for days 1-5)                              $250                              $350            $350                        50%
    (Authorization rules may apply)
    Outpatient hospital coverage
    (Observation)                                             $200                              $300            $300                        50%
    (Authorization rules may apply)
    Ambulatory surgical center
    (Authorization rules may apply)                           $200                              $300            $300                        50%

    Outpatient surgery
    (Authorization rules may apply)                           $200                              $300            $300                        50%

    Doctor visits Primary care provider (PCP)                  $15                               $15             $15                        50%
    Specialists                                               $35                                $35             $35                        50%
    Preventive care                                            $0                                30%             $0                         50%
    Emergency care                                                            $65                                             $90

8                                                                                                                                                       9
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Medical benefits (continued)
                                                         Moda Health PPO H3813-001
                                               Benton, Clackamas, Columbia, Coos, Crook, Curry,      Moda Health NW PPORX (PPO) H3813-011
                                              Deschutes, Douglas, Hood River, Jackson, Jefferson,
                                                                                                     Columbia, Lincoln, Tillamook and Yamhill
                                                Josephine, Klamath, Lane, Lincoln, Linn, Marion,
                                                                                                          counties counties in Oregon
                                               Multnomah, Polk, Tillamook, Wasco, Washington,
                                                        and Yamhill counties in Oregon
                                                    In-network                Out-of-network           In-network             Out-of-network
 Urgently needed services                                            $35                                              $40

 Diagnostic services/labs/imaging (Authorization rules may apply)
 Diagnostic services/labs/imaging (e.g.                20%                         30%                $15-$295                     50%
 MRIs, CT scans)
 Lab services                                           $0                          $0                   $15                       50%
 Outpatient x-rays                                     20%                         30%                   $15                       50%

 Hearing services

     Exam to diagnose and treat hearing
     and balance issues                                $25                         $25                   $35                       50%

 Routine hearing exam for hearing aids                  $0                     Not covered               $0                     Not covered
 Hearing aids (Copay per each aid)                 $699 - $999                 Not covered           $699 - $999                Not covered

 Dental services

 (Authorization rules may apply)                       $35                        $35                    $35                       50%

 Preventive and comprehensive dental
                                                   $0 preventive                                     $0 preventive
 (Total $500 allowance is combined for in                                    $500 allowance                                   $500 allowance
 and out of network services)                     $500 allowance                                    $500 allowance

 Vision services

 Medical vision services (Medicare covered)             $0                         $0                    $35                       50%
 Routine vision services
 (Annual exam every year & glasses every 2              $0                     Not covered               $0                     Not covered

10                                                                                                                                              11
Moda Health Medicare Advantage enrollment kit - Y0115_1097H381301121A_M Northwest Oregon
Medical benefits (continued)

                                                        Moda Health PPO H3813-001
                                              Benton, Clackamas, Columbia, Coos, Crook, Curry,     Moda Health NW PPORX (PPO) H3813-011
                                             Deschutes, Douglas, Hood River, Jackson, Jefferson,
                                                                                                   Columbia, Lincoln, Tillamook and Yamhill
                                               Josephine, Klamath, Lane, Lincoln, Linn, Marion,
                                                                                                        counties counties in Oregon
                                              Multnomah, Polk, Tillamook, Wasco, Washington,
                                                       and Yamhill counties in Oregon
                                                   In-network                 Out-of-network        In-network                 Out-of-network

 Additional services

     Mental health services                           $20                         $35                  $35                          50%

 Skilled nursing facility (SNF)
 (Copay per day 21-100)                               $150                        $150                $150                          30%
 (Authorization rules may apply)

 Physical therapy
                                                      $35                         $35                  $35                          50%
 (Authorization rules may apply)

 Ambulance (Authorization rules may apply)                          $100                                            $300

 Transportation                                                 Not covered                                      Not covered

 Medicare Part B Drugs
                                                      20%                         25%                  20%                          50%
 (Authorization rules may apply)

 Durable medical equipment
                                                      20%                         25%                  20%                          50%
 (Authorization rules may apply)

 Diabetes monitoring supplies
                                                    $0 - 20%                    $0 - 25%             $0 - 20%                       50%
 (Authorization rules may apply)

12                                                                                                                                              13
Part D prescription drugs
                                                                                                You begin in the deductible stage when you fill your first prescription of
                       Moda Health PPO H3813-001                                                the year. During this stage, you pay the full cost of your drugs until you
                      Benton, Clackamas, Columbia,                                              have paid $275 (waived or drugs on Tier 1, Tier 2 and Tier 6) .
                      Coos, Crook, Curry, Deschutes,                                            Cost sharing amounts are the same when received from network retail, mail-
                       Douglas, Hood River, Jackson,       Moda Health NW PPORX                 order, and home infusion pharmacies as well as if you reside in a long-term care
                                                              (PPO) H3813-011                   facility. You may get up to a 31-day supply of drugs from an out-of-network
                      Jefferson, Josephine, Klamath,                                            pharmacy, but you will pay more than you pay at a network pharmacy.
                                                         Columbia, Lincoln, Tillamook
                        Lane, Lincoln, Linn, Marion,    and Yamhill counties in Oregon          Cost sharing changes when you enter another stage of the Part D benefit.
                        Multnomah, Polk, Tillamook,                                             During the coverage gap phase, you pay 25% of the
                         Wasco, Washington, and                                                 cost for generic or brand name drugs.
                        Yamhill counties in Oregon                                              During the catastrophic coverage stage, you pay the greater of 5% or
                                                                                                $3.70 copay for generic drugs and $9.20 copay for all other drugs.
                                                                      $275                      For more information on the different stages, please access your Evidence
 Deductible*                        N/A
                                                        *(waived on Tier 1, Tier 2, & Tier 6)   of Coverage online at or contact Pharmacy
                                                                                                Customer Service at 888-786-7509, 7 am to 8 pm Pacific Time, seven days a
 Initial                                                  30-day                  90-day        week from October 1 through March 31. (After March 31, your call will be handled
 coverage stage                                           supply                  supply        by our automated phone systems Saturdays, Sundays, and holidays.)

     Tier 1
     (Preferred                                              $5                      $15
                                                                                                Optional supplemental benefits
     Tier 2                                                                                     You must pay an extra premium each month for these benefits
                                                            $15                      $45

     Tier 3                                                                                                                                               Moda Health Extra Care
     (Preferred         This plan does not cover Part       $47                     $141
     brand)                 D prescription drugs.                                                                                       Additional $5 per month. You must keep paying your Medicare
                                                                                                 How much is the
                                                                                                                                          Part B premium and your monthly plan premium. You can
                                                                                                 monthly premium?
     Tier 4                                                                                                                               find your monthly plan premium on pages eight and nine.
     (Non-preferred                                        $100                     $300
     brand)                                                                                                                                         Benefits include naturopathic services,
                                                                                                 What benefits are included?
                                                                                                                                                    chiropractic services and acupuncture.
     Tier 5
     (Specialty                                             28%                      N/A         How much is the deductible?                       This benefit does not have a deductible.
                                                                                                                                                      Our plan pays up to $500 every year.
     Tier 6                                                                                      Is there a limit on how                      You pay 50% of the allowed cost for these services
                                                            $0                       N/A         much the plan will pay?
     (Vaccine)                                                                                                                                 until the plan maximum of $500 for all services
                                                                                                                                               combined is met, then you pay 100% of the cost.

14                                                                                                                                                                                                    15
Additional information

     This information is not a complete       Service area and eligibility                  How to obtain additional materials
     description of benefits. Call Customer   requirements:                                 You can search our online provider and
     Service at 1-877-299-9062 for more                                                     pharmacy directory by clicking on the
     information or visit us at               Moda Health Medicare Advantage
                                              plans are PPO plans with a Medicare           “Find Care” link on our website,                 contract. To join Moda Health Medicare Or, call
     If you are not a member of this plan,    Advantage plan you must be entitled to        us and we will send you a copy of the
     call toll-free 1-888-217-2375.           Medicare Part A, be enrolled in Medicare      provider and pharmacy directories.
     TTY users, call 711.                     Part B, and live in our service area.         To view the drugs covered by Moda
     From October 1 to March 31, you          The Moda Health PPO plan service              Health Medicare Advantage plans, you
     can call us 7 days a week from 7:00      area includes the following counties in       can find our formulary on our website
                                              Oregon: Benton, Clackamas, Columbia,          at
     a.m. to 8:00 p.m. Pacific Time.                                                        Or call us and we will send you a copy
                                              Coos, Crook, Curry, Deschutes, Douglas,
     From April 1 to September 30, you can    Hood River, Jackson, Jefferson,               of the formulary.
     call us Monday through Friday from       Josephine, Klamath, Lane, Lincoln, Linn,      This booklet gives you a summary
     7:00 a.m. to 8:00 p.m. Pacific Time.     Marion, Multnomah, Polk, Tillamook,           of what we cover and what you pay.
                                              Wasco, Washington, and Yamhill.               It doesn’t list every service that we
                                              Moda Health NW PPORX plan                     cover or list every limitation or exclusion.
                                              service area includes the following           To get a complete list of services
                                              counties in Oregon: Columbia,                 we cover, visit our website at
                                              Lincoln, Tillamook and Yamhill.     
                                                                                            or call us and ask for the “Evidence
                                              Out-of-network/non-contracted                 of Coverage.”
                                              Medicare providers are under no
                                              obligation to treat Moda Health               If you want to know more about
                                              Medicare Advantage members, except            the coverage and costs of Original
                                              in emergency situations. Please call          Medicare, look in your current
                                              our Customer Service number or see            “Medicare & You” handbook. View it
                                              your Evidence of Coverage for more            online at or
                                              information, including the cost sharing       get a copy by calling 1-800-MEDICARE
                                              that applies to out-of-network services.      (1-800-633-4227), 24 hours a day,
                                                                                            7 days a week. TTY users should call

                                              This document is available in large print.
                                              Moda Health Plan, Inc. is a PPO and PDP with a Medicare contract.
                                              Enrollment in Moda Health Plan, Inc. depends on contract renewal.

16                                                                                                                                         17
Low Income Subsidy premium

     Moda Health NW PPORX (PPO) H3813-011                                                          Pre-enrollment checklist
     Monthly plan premium for people who get Extra Help from Medicare
     to help pay for their prescription drug costs.
     If you get Extra Help from Medicare to help pay for your Medicare prescription                Moda Health Medicare Advantage plans
     drug plan costs, your monthly plan premium will be lower than what it would
                                                                                                   Before making an enrollment decision, it is important that you fully
     be if you did not get Extra Help from Medicare. The amount of Extra Help you
                                                                                                   understand our benefits and rules. If you have any questions, you can
     get will determine your total monthly plan premium as a member of our Plan.
                                                                                                   call and speak to a member services representative at 1-877-299-9062.
     This table shows you what your monthly plan premium will be if you get Extra Help.
                                                                                                   Understanding the benefits
      Your level             Monthly Premium for Moda Health                                       � 
                                                                                                     Review the full list of benefits found in the Evidence of
      of extra help            NW PPORX (PPO) H3813-011*                                             Coverage (EOC), especially for those services for which
                                                                                                     you routinely see a doctor. Visit
      100%                                  $69.00                                                   or call 1-877-299-9062 to view a copy of the EOC.
      75%                                   $78.00                                                 � R
                                                                                                      eview the provider directory (or ask your doctor) to make
                                                                                                     sure the doctors you see now are in the network. If they are not
      50%                                   $87.00                                                   listed, it means you will likely have to select a new doctor.
      25%                                   $96.00                                                 � 
                                                                                                     Review the pharmacy directory to make sure the
                                                                                                     pharmacy you use for any prescription medicines is in the
     *This does not include any Medicare Part B premium you may have to pay.                        network. If the pharmacy is not listed, you will likely have
                                                                                                     to select a new pharmacy for your prescriptions.
     Moda Health NW PPORX (PPO) premium includes coverage for                                      Understanding important rules
     both medical services and prescription drug coverage.
                                                                                                     In addition to your monthly plan premium, you must continue
     If you aren’t getting Extra Help, you can see if you qualify by calling:                        to pay your Medicare Part B premium. This premium is normally
        • 1-800-MEDICARE (1-800-633-4227), TTY users should call                                     taken out of your Social Security check each month.
          1-877-486-2048 (24 hours a day/7 days a week),                                           � 
                                                                                                     B enefits, premiums and/or copayments/
        • Your State Medicaid Office, or                                                             coinsurance may change on January 1, 2022.
        • The Social Security Administration at 1-800-772-1213. TTY users should                   � 
                                                                                                     Our plan allows you to see providers outside of our network (non-
          call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.                      contracted providers). However, while we will pay for covered
     If you have any questions, please call Customer Service at 1-888-786-                           services provided by a non-contracted provider, the provider must
     7509 from 7 a.m. to 8 p.m., Pacific Time, seven days a week from Oct. 1 to                      agree to treat you. Except in an emergency or urgent situations, non-
     March 31. After March 31, your call will be handled by our automated phone                      contracted providers may deny care. In addition, you will pay a higher
     systems Saturdays, Sundays, and holidays. TTY users, please call 711.                           copayment for services received by non-contracted providers.

     Moda Health Plan, Inc. is a PPO and PDP plan with Medicare contracts.
     Enrollment in Moda Health Plan, Inc. depends on contract renewal.

18                                                                                        Y0115_1099APEC21A_C                                                                 19
How to enroll

     Ready to enroll?
     Read on to find out how. And, remember, we are here to help!
     Please contact us if you would like assistance.

            Choose and                   Scan your completed          I f you would like
            complete the                 application, and              help, we can work
            application for the          then fax or mail it to:       with you to find
            plan you would like.         Fax: 503-224-1975             a Moda Health-
            Application forms                                          contracted agent
                                         Moda Health Plan, Inc.        or broker near you.
            are enclosed.                Attn: Medicare
                                         P.O. Box 40384
                                         Portland, OR

               You can also enroll at
               Please keep a copy of your application for your records.

     What happens after you enroll?
     1 You will receive a letter in the mail acknowledging
        that you are enrolled in our plan.
     2 You will receive your member ID card.
     3 You will receive your welcome packet.

20                                                                                           21
Member care resources

     Tools for
     your health
                                            Prescription price check                Health coaching
     All of our plans come with programs,   See prescription medication costs and   Need a hand with your health?
                                            how much you would pay by medication    Our health coaches use evidence-
     care teams, tools and resources                                                based practices to help you set
                                            tier at an in-network pharmacy.
     designed to help you manage your                                               goals and feel your best.
                                            This tool makes it easy. Simply
     well-being. Using your personal        log in to your Member Dashboard         Our care programs include:
     Member Dashboard, you can find         at to            • Cardiac Care
     dentists or pharmacies, get medical    find medication cost estimates           • Dental Care
                                            and generic options.
     advice from health professionals,                                               • Depression Care
     work with health coaches, compare                                               • Diabetes Care
     medication prices,                                                              • Kidney Care
     view your explanation of benefits                                               • Lifestyle Coaching
     and more.                                                                       • Women’s Health & Maternity Care
     Once you are an active member,                                                  • Respiratory Care
     use these care resources to help                                                • Spine & Joint Care
     you be your healthy best! Simply                                                • Weight Care
     log in to our Member Dashboard         Cost Estimator
     at             You shouldn’t learn the cost of
     to get started.                        care when the bill arrives. The
                                            Healthcare Cost Estimator offers
                                            you a simple way to understand:
                                              • Procedure costs
                                              • Cost comparisons across providers
                                              • Your specific out-of-pocket costs
                                            Use this tool to shop for cost-
                                            effective alternatives and make
                                            better, well- informed decisions.

22                                                                                                                       23
Care coordination                        Quitting tobacco
     and case management                      We cover two smoking or chewing
     When you’re sick, need hospitalization   tobacco counseling quit attempts
     or surgery, or are seriously             within a 12-month period. Each
     injured, we’ll give you support —        counseling attempt includes up
     so you can focus on healing.             to four face-to-face visits.
     We can help you:                         If you use tobacco, but do not
      • Understand and utilize                have signs or symptoms of
        all of your benefits                  tobacco-related disease, there
                                              is no coinsurance, copayment,
      • Navigate the healthcare system        or deductible for the Medicare-
      • Communicate with your providers       covered smoking and tobacco use
      • Arrange care ordered                  cessation preventive benefits.
        by your provider                      If you use tobacco and have been
      • Find community resources              diagnosed with a tobacco-related
                                              disease or are taking medicine that
                                              may be affected by tobacco, you
                                              will pay the applicable inpatient
                                              or outpatient cost-sharing.

24                                                                                  25
ATENCIÓN: Si habla español, hay
 Nondiscrimination notice                                                                             disponibles servicios de ayuda con el
                                                                                                                                                                               અગત્યનું: જો તમે (ભાષાંતર કરેલ ભાષા
                                                                                                                                                                               અહીં દરાર્વો) બોલો છો તો તે ભાષામાં તમારે
                                                                                                      idioma sin costo alguno para usted.                                      માટે વવના મૂલ્યે સહાય ઉપલબ્ધ છે. 1-877-
                                                                                                      Llame al 1-877-605-3229 (TTY: 711).                                      605-3229 (TTY: 711) પર કૉલ કરો
 We follow federal civil rights laws. We do not discriminate                                          CHÚ Ý: Nếu bạn nói tiếng Việt, có dịch                                   ໂປດຊາບ: ຖ້າທ່ານເວົ້າພາສາລາວ, ການຊ່ວ
 based on race, color, national origin, age, gender identity,                                         vụ hổ trợ ngôn ngữ miễn phí cho bạn.                                     ຍເຫຼືອດ້ານພາສາແມ່ນມີໃຫ້ທ່ານໂດຍບໍ່ເສັຍ
 sex or sexual orientation.                                                                           Gọi 1-877-605-3229 (TTY:711)                                             ຄ່າ. ໂທ 1-877-605-3229 (TTY: 711)
 We provide free services to people with disabilities so that they can communicate with               注意:如果您說中文,可得到免費語言幫助服務。                                                   УВАГА! Якщо ви говорите українською,
 us. These include sign language interpreters and other forms of communication.                       請致電1-877-605-3229(聾啞人專用:711)                                             для вас доступні безкоштовні консультації
 If your first language is not English, we will give you free interpretation                                                                                                   рідною мовою. Зателефонуйте
                                                                                                      주의: 한국어로 무료 언어 지원 서비스를
 services and/or materials in other languages.                                                                                                                                 1-877-605-3229 (TTY: 711)
                                                                                                      이용하시려면 다음 연락처로 연락해주시기
                                                                                                      바랍니다. 전화 1-877-605-3229 (TTY: 711)                                       ATENȚIE: Dacă vorbiți limba română, vă punem
                                                                                                                                                                               la dispoziție serviciul de asistență lingvistică în
                                                                                                      PAUNAWA: Kung nagsasalita ka ng Tagalog,
 If you need any of the above,                        If you need help filing a complaint,            ang mga serbisyong tulong sa wika, ay
                                                                                                                                                                               mod gratuit. Sunați la 1-877-605-3229 (TTY 711)
 call Customer Service at:                            please call Customer Service.                   walang bayad, at magagamit mo. Tumawag                                   THOV CEEB TOOM: Yog hais tias koj hais lus
 877-299-9062 (TDD/TTY 711)                           You can also file a civil rights complaint      sa numerong 1-877-605-3229 (TTY: 711)                                    Hmoob, muaj cov kev pab cuam txhais lus, pub
                                                      with the U.S. Department of Health and                                                                                   dawb rau koj. Hu rau 1-877-605-3229 (TTY: 711)
 If you think we did not offer these                  Human Services Office for Civil Rights at                              ‫ فهناك خدمات‬،‫ إذا كنت تتحدث العربية‬:‫تنبيه‬
 services or discriminated, you             ,                                 ‫ اتصل برقم‬.‫مساعدة لغوية متاحة لك مجانًا‬          ត្រូវចងចាំ៖ ប�ើអ្នកនិយាយភាសាខ្មែរ ប�ើយត្រូវ
 can file a written complaint.                        or by mail or phone:                                                  )711 :‫ (الهاتف النصي‬1-877-605-3229
                                                                                                                   ‫( وتہج ی‬URDU) ‫وبےتل ہ ی� ن وت اسلین‬
 Please mail or fax it to:                                                                            ‫ارگ آپ اردو‬
                                                                                                               ‫ ت‬:�‫د‬
                                                      U.S. Department of Health                                                                                                គឺមាន្្ដល់ជូនបោកអ្នក។ េូមទូរេ័ព្ទបៅកាន់បល្
                                                      and Human Services                                                               ‫ت‬
 Moda Partners, Inc.                                                                                  ‫دساب ےہ۔‬‫ل الب اعموہض ی‬‫ااع� آپ ےک ی‬                                       1-877-605-3229 (TTY: 711)
 Attention: Appeal Unit                               200 Independence Ave. SW, Room 509F                                        ‫رپ اکل ی‬
                                                                                                      1-877-605-3229 (TTY: 711) �‫رک‬
 601 SW Second Ave.                                   HHH Building, Washington, DC 20201                                                                                       HUBACHIISA: Yoo afaan Kshtik kan
 Portland, OR 97204                                   800-368-1019, 800-537-7697 (TDD)                ВНИМАНИЕ! Если Вы говорите по-русски,                                    dubbattan ta’e tajaajiloonni
 Fax: 503-412-4003                                    You can get Office for Civil Rights complaint   воспользуйтесь бесплатной языковой                                       gargaarsaa isiniif jira 1-877-605-3229
                                                      forms at    поддержкой. Позвоните по тел.                                            (TTY:711) tiin bilbilaa.
                                                                                                      1-877-605-3229 (текстовый телефон: 711).
                                                                                                                                                                               โปรดทราบ: หากคุณพูดภาษาไทย คุณ
                                                                                                      ATTENTION : si vous êtes locuteurs                                       สามารถใช้บริการช่วยเหลือด้านภาษา
                                                                                                      francophones, le service d’assistance                                    ได้ฟรี โทร 1-877-605-3229 (TTY: 711)
 Dave Nesseler-Cass coordinates                                                                       linguistique gratuit est disponible. Appelez
 our nondiscrimination work:                                                                          au 1-877-605-3229 (TTY : 711)                                            FA’AUTAGIA: Afai e te tautala i le gagana
 Dave Nesseler-Cass,                                                                                                                                                           Samoa, o loo avanoa fesoasoani tau
 Chief Compliance Officer                                                                                     ‫ خدمات‬،‫ در صورتی که به فارسی صحبت می کنيد‬:‫توجه‬                   gagana mo oe e le totogia. Vala’au
 601 SW Second Ave.                                                                                               ‫ با‬.‫ترجمه به صورت رايگان برای شما موجود است‬                  i le 1-877-605-3229 (TTY: 711)
 Portland, OR 97204                                                                                                  .‫( تماس بگيريد‬TTY: 711) 1-877-605-3229
 855-232-9111                                                                                                                                                                  IPANGAG: Nu agsasaoka iti Ilocano, sidadaan                                                                            ध्यान दें: यदद आप दिदं ी बोलते िैं, तो आपको भयाषयाई सियायतया बबनया कोई   ti tulong iti lengguahe para kenka nga awan
                                                                                                      पैसया ददए उपलब्ध िै। 1-877-605-3229 पर कॉल करें (TTY: 711)               bayadna. Umawag iti 1-877-605-3229 (TTY: 711)
                                                                                                      Achtung: Falls Sie Deutsch sprechen, stehen                              UWAGA: Dla osób mówiących po polsku
                                                                                                      Ihnen kostenlos Sprachassistenzdienste zur                               dostępna jest bezpłatna pomoc językowa.
                                                                                                      Verfügung. Rufen sie 1-877-605-3229 (TTY: 711)                           Zadzwoń: 1-877-605-3229 (obsługa TTY: 711)
                                                                                                      注意:日本語をご希望の方には、       日本語
 Moda Health Plan, Inc. is a PPO, HMO
                                                                                                      をご利用の方は711)    までお電話ください。
 and a PDP plan with Medicare contracts.
 Moda  Health
 Enrollment in Plan,
               ModaInc. is a PPO
                     Health  Plan,and
                                   Inc.PDP with a Medicare contract.
 on contract renewal. 57311161 (9/19)                                                       
26                                                                                                    57311161 (9/19)                                                                                                                27
Individual & family


                                                                  Small group
                                                                  Large group

Questions? We’re here to help.
Contact a Moda Health agent or call us at 877-299-
9062 (TTY users, please call 711). Our customer
service team is available from 7 a.m. to 8 p.m., Pacific
Time, seven days a week from Oct. 1 to March 31. After
March 31, your call will be handled by our automated
phone systems on weekends and holidays.

Important plan information

601 S.W. Second Ave.
Portland, OR 97204-3154

Health plans in Oregon provided by Moda Health Plan, Inc.
0775 (9/20)
You can also read