Moda Health

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. Sincerely, [redacted]

Dear Ms. [redacted]:
This is in response to the complaint number [redacted], dated February 26, 2016. In which you informedus of [redacted]’s issues regarding receiving conflicting information about the date premium paymentsare due and also the inadequate customer service Ms. [redacted] feels she has...

received from Moda Health.
Ms. [redacted]’s complaint states that when she was shopping around for health insurance at the end of2015 the Moda Health salesperson advised her that there was a 30 day grace period for members thatbought their policy directly from Moda Health and 20 days for customers that bought their plan throughthe Healthcare Marketplace. When she logged into the Moda Health ebill system on February 22, 2016to make February 2016’s premium payment, there was no longer a tab to make the payment. Shecontacted Moda Health medical customer service and was advised that it is over the 20 day grace periodfor payment, therefore there is no option to pay online. She was also informed the policy for her and herfamily may be cancelled due to non-payment. She felt that the customer service representative wascondescending and “snarky.” She would like to know if her medical coverage is still active and if it is notshe would like a receipt of her payment for February 2016 not being processed.
The Be Protected Preferred Provider Organization (PPO) Plan requires all premium payments due inadvance. Moda Health will allow a 20-day grace period after the premium due date. If payment is notreceived within the grace period, the policy will end after a 10-day advance notice. Coverage will end onthe last day of the coverage period for which premiums were paid. Please review the attached BeProtected PPO Plan handbook pages 47-51 that explain eligibility and premium payments.
On February 22, 2016, Ms. [redacted] contacted Moda Health medical customer service after not being ableto make February’s premium payment online and was advised that the due date for premium paymentis the 20th of each month. She gave the representative the payment information to process February2016’s premium payment. The representative told Ms. [redacted] that they would call her back to tell her whether or not Moda Health was able to accept the premium payment made for February 2016 as itwas past the 20 day grace period and also if we would be able to continue her family’s coverage.
On February 25, 2016, the premium payment in the amount of $898.00 was approved and processed forthe month of February 2016. The Moda Health medical customer service representative contacted Ms.[redacted] on February 25, 2016, and let her know that we did take the premium payment for February 2016and her and the [redacted] family currently have active medical coverage and will not be terminated for nonpayment.Ms. [redacted]’s next premium payment in the amount of $898.00 is due prior to March 20,2016.
We have reviewed your payment history with our billing and eligibility department. You are now ablemake payment for the month of March 2016 through the ebill system up until March 20, 2016 as theMarch 2016 bill is currently open.
We understand that the information Ms. [redacted] received when enrolling may have been conflicting, wealso appreciate the comments made in the complaint and look forward to providing her better customerservice in the future.
If we can be of additional assistance, please contact our office at, locally 503-243-3962 or,nationally 1-877-605-3229, and Telecommunications Relay Service at 711.
Sincerely,Peter C.Appeal CoordinatorModa Health Quality Programs

Complaint: [redacted]I am rejecting this response because: Moda health told ME, that they were in-network before I went to that appointment. However, they are now claiming they have no record of that call. They told me this can can occasionally happen, and the apologize if it did. However, I am still be held responsible for the bill, even though it was their error. This has turned into a he-said she-said battle, and they have chosen to take advantage of the situation. Sincerely,[redacted] ([redacted])

Moda Health reviewed and responded to the appeal in April 2016.  We advised the member that when the office called, they advised Moda Health that they were an in-network provider for the members plan.   There was no mis information provided by Moda Health.  Thank you.

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. As of Jan. 27 I have not received the refund and if indeed they repay the money I will be relieved. Sincerely, [redacted]

If Ms. [redacted] disagrees with the processing of her claim, she may appeal the decision with Moda Health.  Appeal rights are listed in her member handbook.  Thank you.

Case ID #: [redacted]This is in response to your letter dated January 19, 2016 in which you informed us of Mr. [redacted]’scomplaint regarding a refund on his individual policy. We apologize for the delay in our response and forMr.[redacted]’s inconvenience in this matter.
Mr. [redacted] stated in his complaint on...

December 1, 2015 Moda Health withdrew two insurance premiumsfrom his checking account and he had only authorized one. He called and was told that he would receivea refund for the second withdrawal in 2-4 weeks. After 6 weeks, he had not received a check and calledagain to Moda Health. He was told that if he gave Moda Health his checking account information that adirect deposit would be made into the account from which it was removed. That was over a week agoand the member has still no refund.
We reviewed Mr. [redacted]’s complaint and verified on January 22, 2016 the full amount of $1,098.00 wasdeposited into Mr. [redacted]’s account via Automated Clearing House (ACH). We contacted Mr. [redacted] onJanuary 22, 2015 and informed him that the amount was refunded. This issue has been resolved withModa Health.
If we can be of additional assistance, please contact our office at, locally 503-243-3962 or,nationally 1-877-605-3229, and Telecommunications Relay Service at 711.Sincerely,Lowanna N.Appeal Coordinator IIQuality Programs

This matter was reviewed again by the Customer Service Manager.  Due to the situation, Moda Health will be adjusting the claim.  Please see the attached letter being sent today.
 
[redacted]SUPPORTING DOCUMENTS REDACTED BY Revdex.com[redacted]

We received the initial concern.  This member also filed an insurance division concern.  We have 21 days to respond to the insurance division and once we do this, we will forward a copy to your office.

We apprecaitge the comments and we will share them with the privacy/fraud unit.

This is in response to your letter dated December 3, 2016 in which you informed us of Mr. [redacted]‘complaint regarding his individual policy.
Mr. [redacted] states in his complaint with tax credits his family’s out-of-pocket premium for 2016 was$239.00. Around April, his wife, who receives disability had...

pretty much run through her deductibleand annual total out-of-pocket with doctors, procedures, and medication and she started to monthlyjustify her being qualified to be covered by making calls to the Marketplace and Moda Health. ModaHealth soon thereafter, stopped sending monthly bills but would sent a letter with a “random”amount due. His wife could make no progress with her phone call and whatever is said the phone callusually ends up with his wife being responsible for calling the Marketplace to verify her eligibility.
Moda Health has made various claims of balances due; from over $6,000.00 dollars to $2,100.00 to amonthly increase of $277.00. None are in any indicative of what he owes or provide any reasoning.Despite accepting a premium payment of $1,900.00 in early November and confirming coverage byphone, his wife was forced to come up with out-of-pocket funds of around $175.00 for medicationsas she was not showing eligible at the time she picked up her medication. Currently, Moda Health isseeking $400.00 but has not accounted for a $550.00 credit from the November premium of nearly$2,000.00. The Marketplace has assured my wife repeatedly that there is nothing that indicates anyineligibility of coverage.
Mr. [redacted] and family has been eligible with Moda Health as of May 1, 2014. Effective January 1,2016 Mr. [redacted] and family have been eligible on the Alaska Individual Be Vigorous Silver Planpurchased through the Health Insurance Marketplace. Eligibility and enrollment, including premiumtax credit and allocations are administered by the Health Insurance Marketplace. Premium paymentsare due monthly for continued coverage. Payments can be made by check, cashier’s check, moneyorder or prepaid debit card with a billing statement, or by electronic fund transfer (EFT). If a subscriber no longer wishes to pay by EFT, Moda Health must be notified in writing 15 days beforethe next deduction date. For other changes in billing options, Moda Health must receive 30 days priorwritten notice from the subscriber. Electronic billing (eBill) is also available, allowing subscribers topay the monthly premium on myModa. All premium payments are due in advance. If payment is notreceived within the grace period, this policy will end. Coverage will end on the last day of the coverageperiod for which premiums were paid. Unless within 30 days before the premium due date ModaHealth has delivered to the subscriber or mailed to the last address, as shown by its records, writtennotice of its intention not to renew this policy beyond the period for which the premium has beenaccepted, Moda Health will allow a 20-day grace period for payment after the premium due date,during which grace period the policy shall continue in force. Members who are eligible for tax creditsand taking any portion as a prepaid subsidy will be allowed a 3 month grace period. Enclosed arepages 46-48 from Mr. [redacted]’ member handbook with information regarding eligibility.
On Mr. [redacted]’ Alaska Individual Be Vigorous Silver Plan there is a family aggregate in-networkdeductible of $5,000.00 and an out-of-network deductible of $10,000.00. Once the deductible issatisfied the maximum annual aggregate out-of-pocket per family for in-network providers is$10,900.00 and out-of-network is $26,600.00. After the annual out-of-pocket maximum is met, thePlan will pay 100 percent of covered services for the remainder of the year. If coverage is for morethan one member, the per member maximum applies only until the total family out-of-pocketmaximum is reached. In-network and out-of-network out-of-pocket maximums accumulateseparately and are not combined. Enclosed are pages 3 and 7-8 of the member handbook with thisinformation.
When we received Mr. [redacted]’ complaint we contacted our membership accounting department tounderstand his eligibility. Mr. [redacted] enrolled through the Health Insurance Marketplace onNovember 13, 2015 for a January 1, 2016 effective date. The monthly premium on the policy is$2,051.00. The following are the changes received by the Health Insurance Marketplace that causedmultiple changes in the member’s premiums:
• A Plan change effective January 1, 2016 and an updated subsidy amount from the HealthInsurance Marketplace was received at Moda Health on January 19, 2016. The subsidychanged to $1,812.00, changing the premium to $239.00 a month.
• A subsidy loss notification was received from the Health Insurance Marketplace on June 10,2016 effective July 1, 2016. The subsidy changed to $893.00, changing the premium amountto $1,158.00.
• A subsidy update was received at Moda Health from the Health Insurance Marketplace onAugust 24, 2016 effective September 1, 2016. The subsidy amount changed to $1,812.00,changing the premium to $239.00
• End of year force terminations were entered October 12, 2016. Force terminations areentered for all Health Insurance Marketplace members at the end of the year in order for the Health Insurance Marketplace to renew coverage starting the new plan year. This is requiredby the Health Insurance Marketplace.
• Mr. [redacted]’ policy terminated effective August 31, 2016 for non-pay by on November 1, 2016.
• Mr. [redacted]’ policy was reinstated effective September 1, 2016 on November 14, 2016 per theHealth Insurance Marketplace case [redacted].
• Mr. [redacted]’ policy was terminated effective September 30, 2016 for non-pay on December 1,2016.
• Mr. [redacted]’ policy was reinstated effective October 1, 2016 on December 2, 2016 onDecember 1, 2016.
The amount of payments received from Mr. [redacted] for his 2016 premiums is $4,304.00 in total. Theamount due for the year with all the subsidy changes is $4,706.00. At this time our records indicatethat Mr. [redacted] and family is currently active; however he owes $402.00 in order for his premium andplan to be paid through the end of 2016. This amount needs to be received at Moda Health byDecember 31, 2016. The changes in the subsidy amounts come directly from the Health InsuranceMarketplace. If Mr. [redacted] does not agree with the subsidy amounts applied between July and Augusthe must appeal directly with the Health Insurance Marketplace.
In addition, Mr. [redacted]’ comments about out-of-pocket expenses his wife for paid for prescriptionswhen the policy showed terminated. Moda Health does show that prescriptions were denied as thepolicy was not showing active. As the policy is now active, Mr. [redacted] may send in the receipts ofpayment along with a completed prescription drug claim form (enclosed) for reimbursement.This issue has been resolved with Moda Health and Mr. [redacted] owes $402.00 for the remaining period,and we would like to apologize to Mr. [redacted] for any inconvenience this may have caused.If we can be of additional assistance, please contact our office at, locally 503-243-3962 or,nationally 1-877-605-3229, and Telecommunications Relay Service at 711.Sincerely,
Lowanna N.Appeal Coordinator IIQuality ProgramsEnclosure
 
AlaskaIndividual PolicyInside Exchange($2,500 Deductible Plan)The subscriber may return this policy to Moda Health within 10 daysof its delivery and have the premium paid refunded. In such a case,this policy shall then be voided from the beginning and ModaHealth will hold the position as if no policy has been issued. b. Services will be paid at the in-network benefit level if provided within a 50-mile radius ofthe childís residence or at the closest appropriate facilityc. Services will be paid at the out-of-network benefit level if such services are providedoutside the 50-mile radius of the childís residenced. Out-of-network providers may bill members for charges in excess of the maximum planallowance2.2 SCHEDULE OF BENEFITSCovered expenses for American Indians and Alaska Natives are at no cost sharing whenprovided directly through the Indian Health Service, Tribal Clinic, Urban Indian Clinic, or throughreferral under Contract Health Services.All ìannualî or ìper yearî benefits accrue on a calendar year basis unless otherwise specified.In-NetworkBenefitsOut-ofNetworkBenefitsAnnual deductible per member $ 2,500 $ 5,000Maximum annual family aggregate deductible $ 5,000 $10,000Annual out-of-pocket maximum per member $ 5,450 $13,300Maximum annual aggregate out-of-pocket maximum perfamily$10,900 $26,600Services Cost Sharing(Deductible appliesunless noted differently)Section in Handbook& DetailsIn-Network Out-of-NetworkÜEmergency CareEmergency Room Facility 35% 35% Section 6.3In-network deductible andout-of-pocket maximumapply to all servicesHospital and Residential Facility CareInpatient Acute Care 35% 50% Section 6.4.3Inpatient Rehabilitation 35% 50% Section 6.4.430 days per yearSkilled Nursing Facility Care 35% 50% Section 6.4.560 days per yearResidential Mental Health &Chemical DependencyTreatment Programs35% 50% Section 6.4.6Chemical DependencyDetoxification35% 50% Section 6.4.7Services Cost Sharing(Deductible appliesunless noted differently)Section in Handbook& DetailsIn-Network Out-of-NetworkÜMedicationsInjectable Medication 35% 50% Section 6.8.1Prescription Medication Section 6.9Up to 90-day supply forretail and mail orderOne copay for each 30 daysupplyDeductible waivedValue $2 $2Select $15 $15Preferred 35% 35%Brand and Specialty 45% 45% Up to 30-day supply perprescription for specialtypharmacyAll professional services provided in Alaska will be paid at the in-network benefit level, subjectto the deductible, and accrue toward the in-network out-of-pocket maximum. In Alaska, allhospital services except those provided by out-of-network hospitals located within 50 miles ofan in-network hospital will be reimbursed at the in-network benefit level, subject to thedeductible, and accrue toward the in-network out-of-pocket maximum.2.3 DEDUCTIBLESThe Plan has an annual deductible. The deductible amounts are shown in section 2.2, and arethe amount of covered expenses that are paid by members before benefits are payable by thePlan. In-network and out-of-network amounts accumulate separately. After the deductible hasbeen satisfied, benefits will be paid according to section 2.2.Covered expenses accrue toward the deductibleIn Alaska Outside of AlaskaIn-network providersIn-Network deductible In-network hospitalOut-of-network providers In-Network deductible Out-of-Network deductibleOut-of-network hospitals In-Network deductible(if located more than 50 miles Out-of-Network deductiblefrom an in-network hospital)Providence hospitals locatedwithin 50 miles of an AlaskaRegional hospitalOut-of-Network deductibleWhen a per member deductible is met, benefits for that member will be paid according tosection 2.2. If coverage is for more than one member, the per member deductible applies onlyuntil the total family deductible is reached. Copayments and disallowed charges do not apply to the deductible.2.4 ANNUAL MAXIMUM OUT-OF-POCKETAfter the annual out-of-pocket maximum is met, the Plan will pay 100% of covered services forthe remainder of the year. If coverage is for more than one member, the per membermaximum applies only until the total family out-of-pocket maximum is reached. In-networkand out-of-network out-of-pocket maximums accumulate separately and are not combined.Expenses accumulate toward the annual out-of-pocket maximum as shown:Out-of-pocket covered expenses accrue towardIn Alaska Outside of AlaskaIn-network providersIn-network out-of-pocket maximumIn-network hospitalOut-of-network providers In-network out-of-pocketmaximumOut-of-networkout-of-pocketmaximumOut-of-network hospitals In-network out-of-pocketmaximum Out-of-networkout-of-pocketmaximum (if located more than 50 milesfrom an in-network hospital)Providence hospitals locatedwithin 50 miles of an AlaskaRegional hospitalOut-of-Network out-of-pocket maximumMembers are responsible for the following costs (they do not accrue toward the out-of-pocketmaximum and members must pay for them even after the out-of-pocket maximum is met):a. Cost containment penaltiesb. Disallowed charges2.5 PAYMENTExpenses allowed by Moda Health are based upon the maximum plan allowance, which is acontracted fee for in-network providers and for out-of-network providers is an amountestablished, reviewed, and updated by a national database. Depending upon the planprovisions, cost sharing may apply.Except for cost sharing and policy benefit limitations, in-network providers agree to look solelyto Moda Health, if it is the paying insurer, for compensation of covered services provided tomembers. SECTION 8. ELIGIBILITY & ENROLLMENTA person cannot be covered by more than one Moda Health individual medical policy at anytime.To become a subscriber, a person must apply for individual or family coverage with the HealthInsurance Marketplace during the open enrollment period or a special enrollment period. Asubscriber must meet state and federal residency requirements.Eligibility and enrollment, including premium tax credit and allocations or American Indian andAlaskan Native eligibility status, are administered by the Health Insurance Marketplace. Contactthe Health Insurance Marketplace for information.The subscriber must notify the Health Insurance Marketplace if family members are added ordropped from coverage, even if it does not affect premiums. Moda Health must be notifiedwhenever there is a change of address.A subscriberís child who has sustained a disability rendering him or her physically or mentallyincapable of self-support at even a sedentary level may be eligible for coverage even though heor she is over 26 years old. To be eligible, the child must be unmarried and principallydependent on the subscriber or the subscriberís parent for support and have had continuousmedical coverage. The incapacity must have arisen, and the information below must bereceived, before the child's 26th birthday. Social Security Disability status does not guaranteecoverage under this provision. Moda Health will determine eligibility based on commonlyaccepted guidelines. To avoid a break in coverage, it is recommended that the followinginformation be submitted to Moda Health at least 45 days before the childís 26th birthday:a. Recent medical or psychiatric progress notes and evaluations, referrals or consult notesb. Relevant test results (e.g., lab, imaging, neuro-psychiatric testing, etc.)c. Relevant recent hospitalization records (e.g., history and physical, discharge summary)d. Disability information from prior carrierModa Health will make an eligibility determination based on documentation of the childísmedical condition. Periodic review by Moda Health will be required on an ongoing basis exceptin cases where the disability is certified to be permanent.8.1 ENROLLING NEW DEPENDENTSA subscriber may obtain coverage for newly acquired or newly eligible dependents bysubmitting an application (along with placement or adoption paperwork, if applicable) within60 days of their eligibility.8.2 OPEN ENROLLMENT PERIODSPersons can apply for coverage during the open enrollment period. For 2016, open enrollmentis from November 1, 2015 to January 31, 2016. These dates may be different for future years.American Indians and Alaskan Natives, Medicaid participants and CHIP participants can applyfor coverage in monthly enrollment periods.8.3 SPECIAL ENROLLMENT PERIODSPersons can apply for coverage or enroll in another individual plan within 60 days of thefollowing qualifying events:a. Loss of minimum essential coverage through an employer but not as a result of nonpaymentof premium or rescissionb. Loss of coverage under Medicaid or a state child health planc. Obtaining new dependents through marriage, domestic partner registration, birth,adoption or placement for adoption or foster care, or a court orderd. Becoming a citizen, national or lawfully present individuale. Becoming enrolled or disenrolled as a result of the error, misrepresentation or inactionof the Health Insurance Marketplace and its agents, or of the U.S. Department of Healthand Human Services (HHS), or of a non-Health Insurance Marketplace entity providingenrollment assistance or conducting enrollment activitiesf. Having adequate evidence that there is a violation of a material provision made by theQualified Health Plan in which he or she is enrolledg. Becoming eligible for advanced payments of the premium tax credith. Having a change in eligibility for cost sharing reductionsi. Moving permanently to a new locationj. Having other exceptional circumstances in accordance with guidelines issued by HHSand accepted by the Health Insurance Marketplace8.4 WHEN COVERAGE BEGINSCoverage begins for new applicants and their eligible dependents on the 1st day of the monthfollowing plan selection if loss of previous coverage was in the past. If loss of previous coverageis in the future, coverage begins on the 1st day of the month following the qualifying event.Coverage for a newborn is effective on the date of the newbornís birth. Coverage for a child newlyadopted or placed for adoption or as a foster child is effective on the date of adoption orplacement. For new spouses or domestic partners and persons who qualified due to the loss ofminimum essential coverage, coverage begins on the 1st of the month following plan selection.The required premium or any applicable premium credit must be processed by the Health InsuranceMarketplace for coverage to become effective.8.5 ELIGIBILITY AUDITModa Health reserves the right to conduct audits to verify a memberís eligibility, and mayrequest documentation including but not limited to medical and certain financial records andbirth certificates, adoption paperwork, marriage certificates, domestic partner registration,proof of residency and any other evidence necessary to document eligibility on the Plan.8.6 PREMIUMSThe current premium amount is shown either on the declaration page that comes with thispolicy, or any subsequent premium change notice. Members may contact the Health InsuranceMarketplace regarding premium tax credits. Premium payments are due monthly for continued coverage. Payments can be made by check,cashierís check, money order or prepaid debit card with a billing statement, or by electronicfund transfer (EFT). If a subscriber no longer wishes to pay by EFT, Moda Health must benotified in writing 15 days before the next deduction date. For other changes in billing option,Moda Health must receive 30 days prior written notice from the subscriber. Electronic billing(eBill) is also available, allowing subscribers to pay the monthly premium on myModa.Premium payments by third parties are not accepted, except when required by law.8.6.1 When Payments are DueAll premium payments are due in advance. If payment is not received within the grace period(section 8.6.2), this policy will end. Coverage will end on the last day of the coverage period forwhich premiums were paid.This policy is renewed each time a subscriber makes a timely premium payment.8.6.2 Grace PeriodUnless within 30 days before the premium due date Moda Health has delivered to thesubscriber or mailed to the last address, as shown by its records, written notice of its intentionnot to renew this policy beyond the period for which the premium has been accepted, ModaHealth will allow a 20-day grace period for payment after the premium due date, during whichgrace period the policy shall continue in force. Members who are eligible for tax credits andtaking any portion as a prepaid subsidy will be allowed a 3 month grace period.8.6.3 ReinstatementIf any renewal premiums are not paid within the time allowed for payment, a subsequentacceptance of premiums by Moda Health or by any agent authorized by Moda Health to acceptsuch premiums shall be subject to an application for reinstatement and a conditional receiptwill be issued for the premiums received. The policy will be reinstated upon approval of suchapplication by Moda Health or, lacking such approval, upon the 45th day following the date ofthe conditional receipt unless Moda Health has previously notified the subscriber in writing ofits disapproval of the application. The reinstatement policy only covers claims resulting from anaccidental injury sustained after the date of reinstatement and claims due to sickness beginningmore than 10 days after the reinstatement date. In all other respects the subscriber and ModaHealth shall have the same rights as they had under the policy immediately before the due dateof the defaulted premium, subject to any provisions added in connection with thereinstatement. Any premiums accepted in connection with a reinstatement shall be applied to aperiod for which premiums have not been previously paid, but not to any period more than 60days prior to the date of reinstatement. Premium payments must be through electronic fundtransfer (EFT) upon reinstatement.8.6.4 Changes in Amount of PremiumsModa Health can change the premium amount without notice when there is a change in thefamily composition or eligibility status. The premium change will take effect the first of themonth following the event. When the subscriber moves into the next age bracket of the ratetable, premiums will change on the renewal date. 45 days written notice will be providedbefore Moda Health renews this individual plan and makes changes to the premiums. When thenew premium is paid, the payment confirms the subscriberís acceptance of the change.8.6.5 Segregation of Premium for Abortion ServicesThe first full dollar of any member-paid monthly premium is allocated to abortion services forwhich public funding is prohibited. Federal regulations require that the premium for theseservices be at least $1.00 per member per month, regardless of age or gender. Although this

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. I believe that the Revdex.com's intervention in this matter speeded it's resolution, as I received a call from MODA after they had received the complaint and they immediately instigated the refund. This after nearly 2 months of non-productive phone calls and non-action by MODA. Thank you for your efforts.Sincerely, [redacted]

Moda Health received an appeal from Mr. [redacted] on September 6, 2017.  We will be reviewing his concerns and providing a response to him about this concern October 6, 2017.  Thank you.

Revdex.com Complaint ID: [redacted]
Dear Ms. [redacted]:
Thank you for sharing Mr. [redacted]’s concerns with Moda Health. We reviewed Mr. [redacted]’scomplaint and our records. Mr. [redacted] was on the 2014 Moda Health Individual Be Smart – Silvermedical plan and then the 2015 Individual Be...

Smart Plan through the Health Insurance Marketplaceand he elected automatic premium payments. On the 2015 plan, premiums payments are duemonthly and in advance. Automatic payments are set up by subscribers online and can only becancelled by the subscriber. If a subscriber no longer wishes to pay by automatic payments, ModaHealth must be notified in writing 15 days prior to the next deductible date. On both plans,payment for many covered services is only made by Moda Health after the member has met theannual deductible. Preventive healthcare services are covered as required under the AffordableCare Act.Mr. [redacted] stated that many of the servics he received were not covered by Moda Health. Uponreview of his claims, we confirmed that all services Mr. [redacted] received were covered by hismedical plan; however, the allowed amounts for many of the services were applied towards Mr.[redacted]’s annual deductible.
We received notification from the Health Insurance Marketplace to terminate Mr. [redacted]’sindividual plan effective December 31, 2015, which was processed on January 19, 2016. We did notreceive a request from Mr. [redacted] to cancel his automatic premium payments so the January2016 was drafted from his account. Mr. [redacted] indicated that he emailed Moda Health on January6, 2016; however, we do not have receipt of that email. We did receive an email on January 11,2016 requesting a refund of the premium. The request was granted and our customer servicerepresentative informed Mr. [redacted] on January 15, 2016 that he can expect to receive a checkwithin two to four weeks. Mr. [redacted]’s claims, premium and refund were handled in accordancewith his plan policies.
We hope this information has been helpful in resolving Mr. [redacted]’s complaint. If we can be offurther assistance, please contact our customer service department at 1-877-605-3229.
Sincerely,Kristin L.Appeal Coordinator IIModa Health Quality Programs

This is in response to your letter dated August 2, 2016 in which you informed us of Ms. [redacted] complaint regarding a refund on his individual policy. Ms. [redacted] states in her complaint that during the month of July she received a bill from Moda Health and was told that she had a premium credit. When...

she went to fill a prescription on July 23, 2016, she was informed that she did not have insurance. She called Moda Health and was informed that she needed to pay $817.00. Ms. [redacted] explains that she did not understand why she was being billed the $817.00 but sent in a payment. She received another letter stating that her coverage was terminated as of June 1, 2016. When she called Moda Health again she was informed that her payment was not posted and her policy was terminated June 30, 2016 for non-payment of July’s premium. She states when she made phone calls on July 24 and 26, 2016 she was informed that she could make the payment for July. Ms. [redacted] was eligible with Moda Health as of March 1, 2015. Moda Health did not receive Ms. [redacted] July premium; therefore, Moda Health sent a delinquent notice to Ms. [redacted] on July 9, 2016 (enclosed), stating that her premium in the amount of $534.00 must be received in our office no later than July 20, 2016 to ensure continuous coverage. Ms. [redacted] policy terminated on July 26, 2016 with a termination date of June 30, 2016 as her July premium was not received by the payment due date. On July 27, 2016, Ms. [redacted] called Moda Health’s customer service stating that she received a bill for $534.00. Moda Health’s customer service representative explained that her premium due was $534.00 because she had an overpayment on her policy from the payment posted for February 2016. Ms. [redacted] hung up on the customer service representative before she was informed that Moda Health would need to see if the account could be reinstated as the premium was due on July 20, 2016. Ms. [redacted] premium payment was received on July 28, 2016. Ms. [redacted] called Moda Health on August 2, 2016 and was informed that her policy was terminated as her July premium was not received in time, and the recent payment made on July 28, 2016 was being refunded and she would receive a refund check within 2-4 weeks. We reviewed Ms. [redacted] complaint and verified on August 8, 2016 the premium refund request is in process for the amount $1,100.00 and a refund checkwill be mailed to Ms. [redacted] in 2-4 weeks. This issue has been resolved with Moda Health, and we would like to apologize to Ms. [redacted] for any inconvenience this may have caused. If we can be of additional assistance, please contact our office at, locally 503-243-3962 or, nationally 1-877-605-3229, and Telecommunications Relay Service at 711. Sincerely,

This concern was reviewed by the dental claims and fraud unit.  It is our position that no privacy violation occurred.  When Ms. [redacted] contacted the customer service unit, the customer service representative followed the normal caller authentication process. Ms. [redacted]'s...

authorization is not needed for her dental office to send us a dental claim for processing or for us to send a denial back to the office.  Our records indicate that the dental provider sent the claim to [redacted] electronically.  There was no group number, group name on the claim form, but the office did provide her name, address and date of birth.  As Ms. [redacted] had coverage with [redacted] previously, the claim was processed under the previous coverage since this is the only record that we have for the member.  The claim was processed correctly and an explanation of benefits was sent to the address on file and what was provided by the office.  The claim denied due to eligibility.  While we appreciate and understand the concerns that Ms. [redacted] expressed in her complaint,[redacted] followed correct procedures in regards to this complaint.

Revdex.com:I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. Sincerely, [redacted]

This is in response to the complaint number [redacted], dated March 30, 2016, in which you informed usthat [redacted] is having issues regarding her dental policy being terminated for non-payment ofher premium.Ms. [redacted] stated in the appeal that she has used Moda Health in the past for health...

insurance and hasnever once missed a payment. This year she enrolled in dental insurance for her and her husband andwas six days late in making a payment and then the policy was terminated. Ms. [redacted] understandsthat she was late because she forgot to make the payment; however, this was the first time she everforgot. Ms. [redacted] stated that she did not get a payment reminder in the mail or via email. She feelsthat because she has a history of being a good customer and always having paid her bill on time that it isridiculous that we refuse to reinstate her policy. Ms. [redacted] guarantees that if we allow her to make apayment and reinstate the policy that she will never be late making a payment again and would also liketo set up auto-pay. Ms. [redacted] would like to make a payment in the amount of $56.00 to be reinstatedwithout a lapse in coverage.On the Delta Dental Preferred Provider Organization (PPO) Plan, all premium payments are due inadvance. Delta Dental will allow a 20-day grace period after the premium due date. Members who areeligible for tax credits and taking any portion as a prepaid subsidy will be allowed a three month graceperiod. If payment is not received within the grace period, this policy will end after a 10-day notice.Coverage will end on the last day of the coverage period for which premiums were paid. Whencoverage is lost, there is no reinstatement. If the subscriber chooses to terminate coverage, or coverageis terminated due to non-payment or late payment of premiums, members will not be eligible to reapplyfor either an Individual Delta Dental Premier or an Individual Delta Dental PPO policy for 2 years, unlessthey qualify for special enrollment. Please review the attached Delta Dental PPO Plan memberhandbook pages 17 through 20 that explain premium payments and eligibility.
We have thoroughly reviewed Ms. [redacted] complaint, calls received by Delta Dental of Oregoncustomer service, and her billing history. We are unable to reinstate Ms. [redacted]’ dental policy as herplan was correctly terminated on March 24, 2016 effective March 1, 2016. We received two paymentsduring the 2016 plan year. Payments in the amount of $56.00 were received on January 21, 2016 andFebruary 9, 2016. There was no payment received for March 2016. On March 14, 2016, there was adelinquency notification mailed to Ms. [redacted] (enclosed). The letter advised that to ensure continuouscoverage, Ms. [redacted] total premium in the amount of $56.00 must be received in our office no laterthan March 24, 2016.We appreciate the comments made in Ms. [redacted]’ letter; however, we are required to administerbenefits in accordance with the Delta Dental PPO Plan.If we can be of additional assistance, please contact our office at, locally 503-243-3962 or,nationally 1-877-605-3229, and Telecommunications Relay Service at 711.
Sincerely,Peter C.Appeal CoordinatorModa Health Quality Programs

Complaint: [redacted]I am rejecting this response because: I do not agree at all with the way they have chose to handle this and I do not wish to try any further. I will now NEVER use MODA For anything and I will be sure to tell my friends and family how they are and not to use them either. Sincerely,[redacted]

September 25, 2015
 
Revdex.com
Attention: [redacted]
PO Box 1000
DuPont, WA 98327
 
 
Member: [redacted]...

[redacted]                                   ...⇄                 ID#: [redacted]
Subscriber: [redacted]                                   ...⇄ Group#: [redacted]
Complaint ID #: [redacted]
 
Dear Ms. [redacted]:
 
This is in response to the Revdex.com (Revdex.com) complaint ID #: [redacted] received at Moda Health on September 21, 2015 regarding a premium refund for Ms. [redacted]’s previous individual medical policy with Moda Health.
 
We reviewed the complaint filed by Ms. [redacted]. We will provide you with details regarding the termination.
 
On August 24, 2015, Ms. [redacted] contacted Moda Health customer service to remove her son, [redacted], from her Oregon Individual Standard Bronze Plan effective August 31, 2015.
 
On August 25, 2015, Ms. [redacted] contacted Moda Health customer service to remove herself from her Oregon Individual Standard Bronze Plan. She also indicated, during this call, that her spouse should be the only one left on the account. A request was sent by the customer service representative to our billing and eligibility department to terminate the policy for an August 31, 2015 term date and to create a new policy for her husband.
 
On September 1, 2015, Ms. [redacted] contacted Moda Health customer service about the termination of her plan and she was advised to cancel the payment for her policy on her eBill account. She was told that her spouse will be going on his own policy and a new account would need to be created for him. On September 1, 2015, the full premium for Ms. [redacted]s account was drafted, however did not post until September 2, 2015.
 
On September 4, 2015, Ms. [redacted] contacted Moda Health customer service stating that the premium amount of $438.00 was drafted. According to the Moda Health billing and eligibility department, since a termination was entered previously for Ms. [redacted]’s son [redacted] on the same account our database would not allow to terminate the policy before September 1, 2015. Based on the call, the policy was terminated correctly with a termination date of August 31, 2015. Ms. [redacted] was informed that she would receive a refund in the amount of $438.00 however it will take a couple of weeks for the refund to be processed and a check issued.
 
On September 18, 2015, Ms. [redacted] emailed Moda Health stating that she had not received her refund check and inquired when the check was mailed. Moda Health contacted Ms. [redacted] and stated that the check was not issued and it could take two to three weeks.
 
Ms. [redacted]’s refund was processed and issued on September 24, 2015. Ms. [redacted] should receive her check in the mail with 7 business days.
 
If we can be of additional assistance, please contact our office at, locally [redacted] or, nationally [redacted], and Telecommunications Relay Service at [redacted].
 
Sincerely,
 
 
 
Lowanna N.
Appeal Coordinator II
Quality Programs