Moda Health Medicare Supplement Plan G Coverage | OpenPayer
CurrentModa HealthPolicy EC
Moda Health Medicare Supplement Plan (Plan G) with Vision and Hearing
Rules and eligibility for payment of covered hospital, medical, skilled nursing facility, and foreign emergency care under the Moda Health Medicare Supplement Plan, plus details of vision and hearing riders and member value‑added services; applies to plan subscribers.
Policy Summary
PayerModa Health
PolicyMedicare Supplement Plan (Plan G) 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 notification from the Medicare carrier of its payment before secondary payment.
No material clinical or coverage changes in this revision.
60foreign trip max days
$50,000foreign emergency lifetime
$250foreign emergency deductible
1/yrvision exam frequency
2/yrhearing aids covered
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Up to 365
additional inpatient days
Coverage Criteria and Limits
Hospital Care
Hospital care payment conditions
ALL of the following
Hospital stay begins on or after the effective date of the policy.
Hospital stay is covered under Part A of Medicare during a benefit period.
One of
If past day 90 in any one benefit period, the subscriber is utilizing lifetime reserve days.
If all Medicare hospital benefits are exhausted, the Plan will pay Medicare Part A eligible expenses for up to an additional 365 days of inpatient hospital care.
The service provider must accept the Plan's payment as payment in full and may not bill the subscriber for any balance.
Medical Care (Medicare Part B)
Medical care (Part B) payment conditions
ALL of the following
Medicare Part B has paid a portion of the expenses when required by the Plan.
Medical care received as an inpatient occurred during a stay which began on or after the effective date of the policy.
Medical care received as an outpatient must be received on or after the effective date of the policy.
Claims must be filed with Medicare prior to submission to the Plan.
Providers must file a claim with Medicare first; Moda Health must receive notification from the Medicare carrier of its payment before the Plan pays secondary benefits.
Skilled Nursing Facility Stays
Skilled nursing facility (SNF) payment conditions
ALL of the following
The skilled nursing facility stay is covered under Part A of Medicare during a benefit period.
The skilled nursing facility stay begins within 30 days after an inpatient hospital stay of 3 or more consecutive days.
If admitted to a skilled nursing facility more than once in a benefit period, the confinement is for the same condition as the first stay in the benefit period.
Both the hospital and the skilled nursing facility stay must start while the subscriber is covered under the Plan.
Foreign Emergency Medical Care
Emergency medical care in foreign countries criteria
ALL of the following
While on a trip outside the United States, the subscriber needs emergency care (care needed immediately because of an injury or an illness of sudden or unexpected onset).
The emergency hospital, physician or medical care received in the foreign country would have been covered by Medicare if provided in the United States.
The emergency medical care is not eligible for payment under any Medicare program.
The emergency medical care begins during the first 60 days of the trip.
The emergency medical care is received on or after the effective date of the policy.
Vision Services (VSP)
Vision services under Vision and Hearing Benefits Rider (VSP Advantage network)
ALL of the following
One complete eye exam annually, including refraction (Well-vision exam: one per year; $0 copayment).
One pair of frames from the Genesis Eyewear Collection every 2 years; $50 retail allowance for frames outside Genesis.
One pair of corrective lenses every 2 years (includes specified lens types) or elective contact lenses every 2 years in lieu of frames and lenses (up to $50).
Exclusions
Services or materials not indicated as covered plan benefits, plano lenses with refractive correction < ±50 diopter, two pairs of glasses instead of bifocals, and replacement of lenses/frames/contacts are not covered.
Hearing Services (TruHearing)
Hearing services under Vision and Hearing Benefits Rider (TruHearing network)
ALL of the following
One hearing exam and evaluation per year by a TruHearing provider ($0 copayment).
One TruHearing-branded Advanced or Premium hearing aid per ear per year (two aids per year, one per ear).
Cost sharing: $699 copayment per aid for TruHearing Advanced; $999 copayment per aid for TruHearing Premium.
Benefit features with purchase: first year follow-up visits, 60-day trial period, 3-year extended warranty, and 80 batteries per non-rechargeable aid.
Exclusions
Value-Added Services
Value-added services and discounts available to members
ALL of the following
Active&Fit Direct gym membership: one-time $25 enrollment fee and $28 monthly fee; access to >16,000 centers and digital resources (membership via Member Dashboard).
ChooseHealthy discounts on health and wellness products/services, specialty practitioner savings, and no‑cost online classes (access via Member Dashboard).
Assist America travel assistance services automatically available for travel >100 miles from home or outside U.S., up to trips of 90 days; services include medical consultation, emergency evacuation, foreign hospital admission assistance, transport home/repatriation, lost luggage/document assistance, interpreter/legal referral; activation by calling Assist America.
24‑hour Nurse Advice Line available toll‑free at no additional cost for non-critical medical advice.
General Exclusions and Limits
Exclusions and limitations
ALL of the following
No benefits for short‑term at‑home assistance for activities of daily living (home health aide, homemaker, personal care aide, or nurse).
No benefits for stays, care, or visits provided without charge to the subscriber.
No benefits are available for the Medicare Part B deductible.
In no event will medical payment under the Plan duplicate any amounts payable under Medicare (duplicate benefits limitation).
No coverage for stays, services, supplies, or facilities provided by hospitals or institutions owned or operated by a national government or any other government unless payment of the charge is required by law.
Coverage exclusions and conditions
Coverage is contingent on Medicare eligibility and excludes specific providers, services, and conditions.
ALL of the following
Plan will not duplicate amounts payable under Medicare (non‑duplication of Medicare payments).
Services provided by government‑owned or ‑operated hospitals/institutions are not covered unless payment 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.
No benefits are provided for charges that are not covered expenses under the subscriber's Medicare plan, unless specifically stated.
Payment and EOB procedures
Payment and post‑termination rules.
ALL of the following
If the policy terminates while the subscriber is hospitalized, the Plan will continue to pay toward that hospitalization until discharge or benefits are exhausted (the only circumstance the Plan pays toward 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.
Soon after receiving a claim, Moda Health will provide an Explanation of Benefits (EOB) stating actions taken; lack of an EOB within a few weeks may indicate Moda Health has not received the claim.
Claims and legal limits
Claims submission, timelines, inquiries, and legal action limits.
ALL of the following
Providers must file claims with Medicare first; Moda Health must receive notification from the Medicare carrier of its payment before the Plan pays secondary benefits.
Claims must be submitted to Moda Health no later than 12 months from the date the expense was incurred, except in cases of lack of legal capacity.
Out‑of‑country care is covered only for emergency or urgent care; the subscriber must provide specified documentation (patient/subscriber/group IDs, statement of circumstances, medical records—translated if available, itemized bills, and proof of payment).
Customer Service can answer questions about filing claims or claim status (contact numbers in section 1.4).
Third‑party recovery, subrogation and obligations
Third‑party liability, subrogation, recovery rights and subscriber obligations.
ALL of the following
The Plan does not cover benefits for which a third party may be legally liable, except certain motor vehicle accident situations; Moda Health may advance benefits but reserves recovery rights.
Upon payment by the Plan, Moda Health has the right to pursue the third party in its own name or in the name of the subscriber and is entitled to subrogation rights under common and statutory law and under the Plan.
Subscriber holds recovery rights in trust for Moda Health for amounts paid; Moda Health is entitled to receive amounts it paid out of any settlement or judgment regardless of characterization or whether the subscriber is made whole.
If Moda Health requires protection of its reimbursement rights, the subscriber may subtract a proportionate share of reasonable attorney fees when repaying Moda Health.
Coverage coordination and suspension rules
Coverage interactions and limits
ALL of the following
When Medicare is secondary, Plan benefits will be paid as if Medicare's normal Part A and Part B benefits had not been reduced.
Services are eligible for only one type of benefit under the Plan (non‑duplication).
No benefits will be paid under this Plan for any stay or care to the extent benefits are paid under a prior Moda Health supplement plan upon change of plan.
Benefits and premiums may be suspended during a subscriber's entitlement to Medicaid for up to 24 months if suspension is requested within 90 days of becoming eligible for Medicaid; reinstatement requires request within 90 days of losing Medicaid eligibility and may require payment of premiums owed for the period.
Third-party recovery enforcement
Recovery and repayment
ALL of the following
Moda Health may recover payments made that were not required according to Plan terms from any person, insurers, or other organizations.
If the subscriber or their representatives fail to comply with recovery‑cooperation requirements, Moda Health may refuse to advance, may suspend, or may recover benefits advanced (except for motor vehicle accident protections referenced separately).
Medicare Linkage and Coding Notes
Medicare Part A/B linkagemixed
No codes listed
Medicare eligibility requirementmixed
Only charges determined by Medicare to be Medicare eligible expenses will be covered.
Non-duplication rulemixed
Services are eligible for only one type of benefit under the Plan (non-duplication).
Foreign emergency lifetime maximum
Foreign emergency lifetime maximum$50,000 lifetime maximum for emergency medical care in a foreign country.
ApplicabilityApplies only if emergency care begins during the first 60 days of a trip outside the United States.
PreconditionCare must be emergency (sudden or unexpected onset) and would have been covered by Medicare if provided in the U.S.
Foreign emergency annual deductible
Annual deductible amount$250 per calendar year for emergency medical care in a foreign country.
When assessed
Provider Filing, Documentation and Recovery Actions
Prior Authorization
Vision provider network authorization
Routine vision services must be received from Vision Service Plan (VSP) Advantage network providers. Members can visit www.vsp.com or call 800-877-7195 to choose a VSP Advantage network vision care provider and arrange for vision services. For members eligible for vision benefits, VSP will provide benefit authorization directly to the Advantage network doctor. When contacting an Advantage network doctor, members must identify themselves as VSP members so the doctor will obtain benefit authorization from VSP.
One complete eye exam annually, including refraction
One pair of frames from the Genesis Eyewear Collection every 2 years (or $50 retail allowance for frames outside the Genesis collection)
One pair of corrective lenses every 2 years (includes single vision, lined bifocal, lined trifocal, lenticular, standard progressive, UV and scratch-resistant coatings)
Prescription contact lenses and fitting/evaluation every 2 years in lieu of frames & lenses (up to $50 maximum)
DefinitionEmergency care means care needed immediately because of an injury or an illness of sudden or unexpected onset.
ContextApplies to emergency medical care received while on a trip outside the United States for foreign emergency benefit eligibility.
Related conditionEmergency care must not be eligible for payment under any Medicare program to qualify for foreign emergency benefits.
Skilled nursing facility stay requirements
Medicare Part A coverage requirementSNF stay must be covered under Medicare Part A during a benefit period.
Timing after hospital staySNF stay must begin within 30 days after an inpatient hospital stay of 3 or more consecutive days.
Policy Summary
PayerModa Health
PolicyMedicare Supplement Plan (Plan G) 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 notification from the Medicare carrier of its payment before secondary payment.
Lifetime maximum for emergency medical care in a foreign country: $50,000.
Emergency medical care deductible: $250 per calendar year.
Payment details for foreign emergency care.
Benefits for foreign emergency care are payable only to the subscriber in U.S. currency based on the bank transfer exchange rate in effect on the day the claim payment is processed.
Orthoptics, vision training, supplemental testing, insurance policies for contact lens coverage, artistically painted/non‑prescription contacts, additional contact office visits, refitting after initial 90 days, and contact lens modification/polishing/cleaning are not covered.
Ear molds, hearing aid accessories, additional provider visits, extra batteries, hearing aids not obtained through TruHearing, and costs associated with loss/damage warranty claims are not covered.
Individual Assistance Program (IAP) providing confidential counseling, limited in‑person/telephone sessions, legal consultations, financial coaching, and identity theft consultation (contact info provided).
ArrayRx discount card available at no additional cost to members living in Oregon for prescription savings (signup via provided contact).
The Plan will not cover any injury or sickness for which the subscriber is entitled to benefits under workers' compensation or similar law.
Subscribers may not bring legal action until 60 days after filing a claim and may not bring action more than 3 years after the date the claim was required to be filed.
Subscriber obligations: notify Moda Health in advance of any third‑party claim or lawsuit, cooperate to protect recovery rights, sign and deliver required documents (e.g., Third Party Recovery Questionnaire and Agreement), and provide medical and settlement information and records.
Moda Health may seek recovery by appropriate procedures and has discretion in interpreting and enforcing recovery/subrogation provisions.
Deductible must be satisfied for foreign emergency care benefits to be payable.
Applies toApplies to emergency medical care that begins during the first 60 days of a trip outside the United States.
Foreign travel emergency payment recipient
Payment recipient for foreign travel emergency careBenefits for foreign travel emergency care will be payable directly to the subscriber in U.S. currency.
Currency and exchangePayment amount is based on the bank transfer exchange rate in effect on the day the claim payment is processed in the United States.
ConditionBenefits payable only if emergency care conditions are met (e.g., care begins within first 60 days of trip and Medicare-equivalency criteria).
Medicaid suspension request window
Request window for suspensionSuspension of benefits and premiums during Medicaid entitlement must be requested within 90 days of becoming eligible for Medicaid.
Maximum suspension durationBenefits and premiums may be suspended for up to 24 months while entitled to Medicaid.
ReinstatementCoverage may be reinstated if subscriber requests reinstatement within 90 days of losing Medicaid entitlement and any required premiums for the period are paid.
Members must see a TruHearing provider to receive hearing benefits. Members can call 844-516-1478 to choose an in‑network audiologist or hearing instrument specialist and arrange for a hearing exam. The TruHearing provider will assist members with choices of hearing aids and will coordinate benefit authorization and fit/selection.
One hearing exam and evaluation per year by a TruHearing provider
One TruHearing-branded Advanced or Premium hearing aid per ear per year (two aids per year — one per ear)
First year of follow-up provider visits with purchase; 60-day trial period; 3-year extended warranty; 80 batteries per hearing aid for non-rechargeable models
Hearing aids cost sharing: $699 copayment per aid for TruHearing Advanced; $999 copayment per aid for TruHearing Premium
Documentation Required
Out‑of‑country emergency claim documentation
Out-of-country care is covered only for emergency or urgent care situations. When care is received outside the United States, the subscriber must provide Moda Health with the required documentation to process the claim.
Patient's name, subscriber's name, group and identification numbers
Statement explaining where the subscriber was and why they sought care
Copy of the medical record (translated preferred if available)
Itemized bill for each date of service
Proof of payment (credit card/bank statement or cancelled check)
Repeat admissionsIf admitted more than once in a benefit period, the confinement must be for the same condition as the first stay in that benefit period.
Enrollment statusBoth the hospital and SNF stays must start while the subscriber is covered under the Plan.
Benefits (definition)
Definition of BenefitsAny amount paid by Moda Health, or submitted to Moda Health for payment to or on behalf of the subscriber; provider bills are considered requests for payment by the subscriber.
ScopeIncludes amounts paid directly and requests for payment submitted by providers of services, supplies or facilities.
Contextual useThis definition applies for purposes of third‑party recovery and related provisions in section 7.4.
Third Party (definition)
Definition of Third PartyAny person or entity responsible for the medical condition or its aggravation, including insurers (liability, uninsured/underinsured motorist, med‑pay, PIP) and workers' compensation.
IncludesDifferent forms of liability insurance and any other form of insurance that may pay money to or on behalf of the subscriber.
UseDefinition used to determine Moda Health's subrogation and recovery rights against responsible parties.
Third Party Claim (definition)
Definition of Third Party ClaimAny claim, lawsuit, settlement, award, verdict, judgment, arbitration decision or other action against a third party (or any right to assert the foregoing) by or on behalf of a subscriber.
ExamplesIncludes settlements, judgments, arbitration decisions and legal actions seeking recovery from a third party.
Relation to recoveryTriggers subscriber obligations to notify and cooperate with Moda Health under third‑party recovery provisions.
Coordination of benefits (COB) exclusion
Coordination of benefits exclusionCoordination of benefits (where the subscriber has healthcare coverage under more than one plan) is not considered a third party claim under these provisions.
ImplicationCOB situations do not trigger third‑party claim notification or recovery procedures described for other third‑party claims.
ReferenceApplies to the additional third party liability provisions within the Plan's recovery rules.
Third party recovery rights and enforcement
Moda Health recovery rightModa Health may recover payments from proceeds of any settlement, judgment or other payment received by the subscriber that exceed full compensation for motor vehicle accident‑related injuries when Moda advanced benefits.
Attorney fee offsetIf Moda Health requires protection of its recovery rights and the subscriber is represented, the subscriber may subtract a proportionate share of reasonable attorney fees from amounts repaid to Moda Health.
Subscriber cooperationSubscriber must do whatever is proper to secure Moda Health's rights and may not prejudice those rights; failure to cooperate can affect Moda Health's recovery or advancement of benefits.