CurrentModa HealthPolicy EC

Moda Health Medicare Supplement Plan F (with Vision and Hearing)

This document describes coverage, definitions, benefits, member rights, and administrative provisions for Moda Health Medicare Supplement Plan F with optional vision and hearing rider; it governs subscribers to this Plan (Moda Health Plan, Inc.).

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan F (with Vision and Hearing)

Policy CodePolicy EC

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must file claims with Medicare first; Moda Health requires Medicare's payment notification before paying secondary benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysright to examine policy / free look period

365 daysadditional inpatient hospital days (lifetime)

$50,000foreign emergency lifetime max

80%foreign emergency coverage level

$250foreign emergency annual deductible

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claim submission period

Coverage criteria, benefits, exclusions and payment rules

Coverage criteria and conditions

Core Benefits and additional Plan F benefits are provided for Medicare-eligible expenses when conditions below are met.

Core Benefits: Part A hospital coinsurance days 61–90; Part A lifetime reserve days (60 non-renewable); 100% of Medicare Part A eligible hospital expenses after Medicare exhausted up to 365 lifetime days; first 3 pints of blood per calendar year and Part B blood coinsurance; Part B coinsurance/copayment after Part B deductible met; Part A hospice and respite coinsurance amounts.

Plan F Additional Benefits: Medicare Part A inpatient deductible; 100% of Medicare Part B deductible per calendar year; 100% of Medicare Part B excess charges; skilled nursing facility coinsurance for days 21–100 per benefit period; medically necessary emergency care in a foreign country at 80% after a $250 calendar year deductible up to a $50,000 lifetime maximum.

Medicare-eligible expenses: Benefits are payable only for Medicare-eligible expenses under Parts A and B and are subject to the same conditions and exclusions that apply under Medicare.

Hospital care payment conditions: Hospital stay must begin on or after the policy effective date, be covered under Medicare Part A during a benefit period; if past day 90 the subscriber must be using lifetime reserve days; if Medicare hospital benefits are exhausted the Plan will pay up to an additional 365 inpatient days. Service providers must accept the Plan's payment as payment in full and may not bill the subscriber for any balance.

Medical care payment conditions: Medicare Part B must have paid the required portion when the Plan requires it; inpatient medical care must occur during a stay that began on or after the policy effective date and outpatient care must be received on or after the policy effective date.

Benefit conditions and exclusions

Coverage conditions and notable exclusions described in this portion of the policy.

Hospital benefits payable if stay begins on or after policy effective date and is covered under Medicare Part A during a benefit period; lifetime reserve and additional 365 days provisions apply when Medicare benefits exhausted.

Medical (Part B) benefits payable when Medicare Part B has paid the required portion and services occur on or after the policy effective date.

Skilled nursing facility benefits payable if the stay is covered under Medicare Part A during a benefit period, admission begins within 30 days after an inpatient hospital stay of 3 or more consecutive days, subsequent confinements in a benefit period are for the same condition, and both hospital and SNF stays must start while subscriber is covered under the Plan.

Emergency foreign medical care payable if: care is emergency/urgent (sudden/unexpected onset), would have been covered by Medicare if provided in the U.S., is not eligible for payment under Medicare, begins during the first 60 days of a trip outside the U.S., the $50,000 lifetime maximum has not been reached, the $250 per-calendar-year deductible has been satisfied, and care is received on or after the policy effective date.

Exclusions and limits

Explicit coverage exclusions and limitations:

No coverage for stays, services, supplies, or facilities provided by hospitals or institutions owned or operated by a national or other government unless payment of the charge is required by law.

No benefits are provided for outpatient prescription drugs, except outpatient drugs covered by Medicare Part A for hospice care.

Only preventive services covered under Medicare Part B are eligible for benefits under this Plan.

No benefits are provided for charges that are not covered expenses under the subscriber's Medicare plan unless otherwise specifically stated in the handbook.

The Plan will not cover any injury or sickness for which the subscriber is entitled to benefits under workers' compensation or a similar law.

Payment and EOB

Payment, EOB and benefit continuation rules:

If the policy terminates while the subscriber is hospitalized, the Plan will continue to pay toward that hospitalization until discharge or benefits are exhausted; this is the only situation where the Plan pays for an expense incurred while not covered.

Benefits payable under the Plan will be paid to whoever received the Medicare benefits; foreign travel emergency care benefits will be paid directly to the subscriber.

Moda Health will issue an Explanation of Benefits (EOB) after receiving a claim stating payment, denial, or accumulation toward a deductible; subscribers are encouraged to access EOBs electronically and an EOB will state reasons for denial if applicable. Failure to receive an EOB or notice may indicate Moda Health has not received the claim.

Foreign care and claim prerequisites

Out-of-country emergency coverage and claim documentation:

Out-of-country care is covered only for emergency or urgent care situations. For such claims, the subscriber must provide: patient and subscriber name, group and ID numbers; a statement explaining where and why care was sought; a copy of the medical record (translated if available); an itemized bill for each date of service; and proof of payment (credit card/bank statement or cancelled check).

Providers must file claims with Medicare first; Moda Health must receive notification from Medicare of its payment before the Plan will pay secondary benefits. Electronic filing is available. Member‑submitted claims to Moda Health must include the Medicare Summary Notice and be mailed to the Moda Health claims address. Claims must be submitted within 12 months of the date the expense was incurred except for lack of legal capacity.

Third-party recovery and subrogation

Third-party recovery, subrogation, and subscriber obligations:

Moda Health does not cover benefits for which a third party may be legally liable (except certain motor vehicle accident provisions) and may seek reimbursement for benefits it paid that are recoverable from a third party.

Upon payment, Moda Health has the right to pursue the third party in its own name or in the subscriber's name and is entitled to all subrogation rights and remedies under common and statutory law.

Subscriber holds recovery rights in trust for Moda Health to the extent of benefits paid; Moda Health is entitled to receive the amount it paid out of any settlement or judgment regardless of characterization, whether or not the subscriber is made whole, and recovery rights will not be reduced due to the subscriber's negligence.

Motor vehicle accidents: Moda Health may advance benefits if motor vehicle insurance has not yet paid, but retains the right to repayment from any settlement, judgment, or other payment received by the subscriber that exceeds full compensation for injuries; attorney fees may be apportioned if Moda Health requires protection of its rights.

Coverage effects and administrative rules

Policy-level coverage and benefit effects described in these provisions include exclusivity of benefit types, effect of plan changes, Medicaid suspension, recovery rights, and household discount applicability.

Non‑duplication of benefits: Services are eligible for only one type of benefit under the Plan (e.g., a service defined as skilled nursing facility care is reimbursed under that benefit only).

Effect of change of plan: If the subscriber changed to this Plan from another Moda Health supplement plan on the effective date, no Plan benefits will be paid to the extent benefits are paid under the prior plan for the same stay or care.

Medicaid suspension: Benefits and premiums will be suspended during a subscriber's entitlement to Medicaid for up to 24 months if requested within 90 days of eligibility; coverage may be reinstated within 90 days of losing Medicaid entitlement and may be retroactive if premiums for that period are paid. Reinstated coverage will be the same plan (if available) or substantially equivalent coverage.

Recovery of payments: Moda Health may recover payments made that were not required according to the Plan from any person, insurance companies, or other organizations or persons.

Coding, limits and key numeric limits

mixed

Coverage exclusionsmixedNot Covered

No codes listed

Foreign emergency deductible / lifetime limit

Deductible$250 per calendar year

Coverage levelPays 80% of medically necessary emergency care after deductible

Lifetime maximum$50,000

foreign emergency lifetime max

Lifetime maximum (foreign emergency care)$50,000

Applies toMedically necessary emergency care received in a foreign country

Eligibility window

Provider requirements, claims filing and documentation

Note

Medicare-eligible expenses and provider payment acceptance

Benefits are payable only for Medicare-eligible expenses under Parts A and B and are subject to the same conditions and exclusions that apply under Medicare. Providers and facilities must follow Medicare rules for coverage and payment when submitting claims to the Plan.

Medicare Part A covers hospital and skilled nursing facility stays; Part B covers medical care services and supplies.
Only charges determined by Medicare to be Medicare-eligible expenses will be covered under the Plan.

Billing Rule

Hospital payment conditions and balance-billing prohibition

For hospital stays the Plan will pay the amounts shown in Section 3 only when the stay begins on or after the policy effective date, is covered under Medicare Part A during a benefit period, and meets Medicare rules for lifetime reserve days or extended inpatient coverage when applicable. The service provider must accept the Plan's payment as payment in full and may not balance-bill the subscriber for any remaining amount.

Defined terms used in this policy

Subscriber

DefinitionSubscriber is the person in whose name the policy is issued following acceptance by Moda Health of that person's health statement application.

RoleNamed insured under the policy contract

IncludesPolicy, health statement application, declaration pages, addendums, endorsements, or amendments define the contractual relationship

Approved Amount

DefinitionApproved Amount means the amount Medicare determines to be reasonable for a service covered under Medicare Part B.

ImplicationApproved Amount may be less than actual charge and is used to calculate Medicare payment and beneficiary responsibility

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan F (with Vision and Hearing)

Policy CodePolicy EC

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must file claims with Medicare first; Moda Health requires Medicare's payment notification before paying secondary benefits.

SourceLink

On This Page

Vision rider conditions: routine vision services must be received from VSP Advantage network providers; covered services include one complete eye exam annually, one pair of frames every 2 years (Genesis collection or $50 allowance otherwise), one pair of lenses every 2 years, or contact lenses every 2 years in lieu of frames/lenses; $0 copay for listed services.

Hearing rider conditions: hearing services must be received from TruHearing providers; covered services include one hearing exam per year, one TruHearing Advanced or Premium hearing aid per ear per year, trial period, warranty and batteries as specified; cost-sharing as listed.

Notable exclusions

Outpatient prescription drugs are not covered except outpatient drugs covered by Medicare Part A for hospice care.
No benefits for at‑home short‑term assistance for activities of daily living provided by aides or homemakers.
No benefits for care provided without charge.
Plan will not duplicate Medicare payments; charges not covered by the subscriber's Medicare plan are not covered unless specifically stated.
No coverage for hospitals/institutions owned or operated by a government unless payment is required by law.

Only preventive services covered under Medicare Part B are eligible under the Plan.

Subscriber obligations: the subscriber must notify Moda Health in advance of any third‑party claim or lawsuit, cooperate with Moda Health, sign and deliver required documents (including a Third Party Recovery Questionnaire and Agreement), provide medical and settlement information, and take actions requested to protect Moda Health's recovery rights.

Consequences of non‑cooperation: If the subscriber or their representatives fail to comply with these obligations, Moda Health may refuse to advance payment, suspend payment, or recover benefits it advanced (except for certain motor vehicle accident rules) and may notify providers that payments have been suspended.

Household premium discount: Members residing with at least one other Moda Health Medicare supplement member may be eligible for a household premium discount applied to at most three eligible members; the discount ends if the other adult no longer resides in the home and will be removed effective the first of the following month.

Care must begin within first 60 days of a trip outside the United States

foreign emergency deductible

Amount$250 per calendar year

When appliesMust be satisfied before Plan pays foreign emergency benefits

Applies toEmergency medical care in foreign countries that would have been covered by Medicare if provided in the U.S.

Claim submission time limit

Time limitClaims must be submitted within 12 months from the date the expense was incurred

ExceptionAbsence of legal capacity extends the filing period

Submission methodsProviders file with Medicare first; member claims mailed with Medicare Summary Notice to Moda Health PO Box 40384, Portland, OR 97240

Hospital stay must begin on or after the policy effective date.
Hospital stay must be covered under Medicare Part A during a benefit period.
Providers must accept Moda Health payment as payment in full and may not bill the subscriber for any balance.

Billing Rule

Medicare Part B prerequisite and effective date requirement

For Medicare Part B–eligible medical care, Medicare Part B must have paid the required portion when the Plan requires it. Medical care received as an inpatient must occur during a stay that began on or after the policy effective date; outpatient medical care must be received on or after the policy effective date.

Medicare Part B payment is a prerequisite when required by the Plan.
Care must occur on or after the policy effective date.

Documentation Required

Skilled nursing facility admission conditions

Skilled nursing facility (SNF) stays are payable only when the SNF stay is covered under Medicare Part A, begins within 30 days after an inpatient hospital stay of three or more days in a row, and meets Medicare’s conditions for subsequent admissions in the same benefit period. Both the hospital and SNF stays must begin while the subscriber is covered under the Plan.

SNF stay must be covered under Medicare Part A during a benefit period.
SNF stay must begin within 30 days after an inpatient hospital stay of 3 or more consecutive days.
If admitted to an SNF more than once in a benefit period, subsequent confinements must be for the same condition as the first stay in that benefit period.
Both the hospital and SNF stays must start while the subscriber is covered under the Plan.

Prior Authorization

Network provider requirement for vision and hearing riders

Routine vision and hearing rider benefits require use of the specified in-network vendors. Vision services must be provided by VSP Advantage network providers and hearing services must be provided by TruHearing providers in order for the rider benefits to apply.

Vision services: members must use VSP Advantage network providers. Members can visit www.vsp.com or call 800-877-7195 for provider selection and benefit authorization.
Hearing services: members must see a TruHearing provider. Members can call 844-516-1478 to choose an in-network audiologist or hearing instrument specialist and arrange services.
Benefits (exams, lenses/frames, hearing aids, etc.) are available only when obtained through the specified networks.

Documentation Required

Out-of-country emergency claim documentation

When care is received outside the United States for an emergency or urgent condition, the subscriber must provide Moda Health with full documentation to support the claim before the Plan can process payment.

Patient's name, subscriber's name, and group and identification numbers.
A statement explaining where the subscriber was and why they sought care (circumstances of the emergency/urgent care).
Copy of the medical record for the out-of-country treatment (translated copies preferred if available).
Itemized bill for each date of service.
Proof of payment such as a credit card or bank statement or a cancelled check.

Denial Risk

Consequences of non-cooperation

Failure of the subscriber or their representatives to notify Moda Health of potential third-party claims, to cooperate in protecting Moda Health’s recovery rights, or to execute and deliver requested documents may cause Moda Health to withhold, suspend, or recover benefits. Moda Health may also notify providers that payments have been suspended.

Subscriber must notify Moda Health in advance of any claim or lawsuit against a third party seeking recovery of damages.
Subscriber must cooperate with Moda Health, including signing and delivering documents (e.g., Third Party Recovery Questionnaire and Agreement) and providing medical records, settlement correspondence, pleadings, releases, or judgments as requested.
If the subscriber or their representatives fail to comply, Moda Health may refuse to advance payment, suspend payment of benefits, or recover any benefits already advanced (except as specified for motor vehicle accidents).
Moda Health may notify providers that payment authorizations have been suspended and that payments may not be made.

SourceDetermined by Medicare fee schedules or limiting charge rules

Rider

DefinitionRider means the optional vision and hearing benefits that are supplemental to the Plan.

ScopeProvides vision and/or hearing benefits in addition to core Plan F coverage

RenewabilityRider is optional and is not guaranteed renewable with the Plan in all circumstances

Emergency care

DefinitionEmergency care means care needed immediately because of an injury or an illness of sudden and unexpected onset (medical emergency).

Foreign care conditionFor foreign emergency coverage, care must begin within the first 60 days of a trip outside the United States

Medicare equivalenceCare must be of the kind that would have been covered by Medicare if provided in the U.S.

Value-added services

DefinitionValue-added services are non-insurance supplemental services that end when Plan coverage ends and may be discontinued by Moda Health with 30 days' notice.

AccessMembers can learn more via the Member Dashboard at www.modahealth.com

NatureThese services complement the Medicare supplement plan but are not insurance

Benefits

DefinitionBenefits means any amount paid by Moda Health, or submitted to Moda Health for payment to or on behalf of the subscriber.

IncludesBills, statements, or invoices submitted by a provider are considered requests for payment of benefits by the subscriber

ApplicabilityUsed in third-party recovery and subrogation provisions (section 7.4)

Third Party

DefinitionThird Party means any person or entity responsible for the medical condition or aggravation of the subscriber, including various forms of liability and other insurance (e.g., uninsured/underinsured motorist, med-pay, PIP, workers' compensation).

ScopeIncludes insurers of such persons or entities and other forms of coverage that may pay money to or on behalf of the subscriber

UseRelevant to Moda Health's subrogation and recovery rights

Third Party Claim

DefinitionThird Party Claim means any claim, lawsuit, settlement, award, judgment, arbitration decision or other action against a third party or any right to assert such action.

IncludesSettlements, judgments, awards, and arbitration decisions involving third parties

RelationTriggers subscriber obligations to notify and cooperate with Moda Health under recovery provisions

Coordination of Benefits

RuleCoordination of benefits (coverage under more than one plan) is not considered a third-party claim.

ImplicationCoordination of benefits does not activate third-party recovery/subrogation procedures described for third-party claims

ReferenceSee Additional Third Party Liability Provisions

Medicare Secondary Payer

DefinitionWhen Medicare is secondary due to benefits from other plans, Plan benefits will be paid as if Medicare Part A and Part B benefits had not been reduced.

EffectModa Health pays Plan benefits without regard to Medicare reductions caused by other primary payers

ContextApplies when Medicare becomes a secondary payer because of other coverage