CurrentModa HealthPolicy N/A

Moda Health Medicare Supplement Plan N — Policy Document

Describes benefits, eligibility, definitions, and policyholder rights for Moda Health Medicare Supplement Plan N subscribers; governs coverage interactions with Medicare and administrative provisions for subscribers in Oregon (state references present).

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan N — Administrative/Operational Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare and provide Moda Health the Medicare Summary Notice before Moda Health will pay benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsclaim submission deadline

365additional inpatient days (lifetime)

$250foreign emergency deductible

$50,000foreign emergency lifetime max

30SNF admission window (days)

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minimum hospital stay for SNF

Coverage rules and limits for Plan N

Coverage and enrollment rules

ALL of the following

Coverage is limited to Medicare eligible expenses under Parts A and B; benefits are payable only when the expense is a Medicare eligible expense and Medicare has been billed and paid as required by the Plan.
For hospital stays: the stay must begin on or after the policy effective date, be covered under Medicare Part A during a benefit period, and when applicable, be beyond day 90 in the benefit period using lifetime reserve days or after Medicare hospital benefits are exhausted (Plan pays up to an additional 365 days).
For skilled nursing facility stays: the stay must be covered under Medicare Part A, begin within 30 days after an inpatient hospital stay of 3 or more consecutive days, be for the same condition if admitted more than once in a benefit period, and both the hospital and SNF stays must start while the subscriber is covered under the Plan.
For Medicare Part B medical care: Medicare Part B must have paid a portion of the expenses when required by the Plan; inpatient medical care must occur during a stay that began on or after the policy effective date; outpatient care must be received on or after the policy effective date.
Emergency foreign medical care: benefits apply only for emergency care while on a trip outside the U.S., where the care would have been covered by Medicare if provided in the U.S.; care must begin within the first 60 days of the trip, not be eligible for payment under any Medicare program, occur on or after the policy effective date, the $250 calendar-year foreign emergency deductible must be met, and the $50,000 lifetime limit must not have been reached. Benefits for foreign emergencies are payable only to the subscriber in U.S. currency based on the bank transfer exchange rate on the payment processing date.
Preventive services: only preventive services covered under Medicare Part B are eligible for benefits.
When Medicare is secondary due to other coverage, benefits under the Plan will be paid as if Medicare's normal Part A and Part B benefits had not been reduced.
Only one type of benefit is payable for a service; services are reimbursed under the single applicable benefit category (non-duplication of benefits).
If a subscriber changed to this Plan from another Moda Health supplement plan on the effective date, no benefits will be paid under this Plan for any stay or care to the extent benefits are payable under the prior plan.
Electronic claims: providers must file claims with Medicare first; Moda Health requires notification from the Medicare carrier of its payment before secondary payment. A subscriber-submitted claim to Moda Health must include the Medicare Summary Notice and be mailed within 12 months of the date the expense was incurred (except for absence of legal capacity).
Out-of-country claims for emergency/urgent care: subscribers must provide name, group/ID numbers, explanation of location and reason for care, medical records (translated if available), itemized bills, and proof of payment to Moda Health.
Payment of claim: benefits payable under the Plan will be paid to whoever received the Medicare benefits; foreign travel emergency care benefits are payable directly to the subscriber.
Effect of Medicaid: benefits and premiums will be suspended during entitlement to Medicaid for up to 24 months if requested within 90 days of becoming eligible; reinstatement rules apply if Medicaid entitlement ends and request made within 90 days.
Grace period: upon payment of the first premium, subscribers have 31 days after the premium due date to pay subsequent required premiums; coverage remains in force during the grace period but premiums must be paid; if the Plan is replaced, coverage stops on the new plan's effective date and the grace period does not apply.
Misstatement of age: if age was misstated and policy would not have been issued, the policy is void and Moda Health will refund all premiums paid.
Household premium discount: available when residing with at least one other Moda Health Medicare supplement member (max three eligible members); discount ends if the other adult no longer resides in the home and will be removed effective the first of the following month. Moda Health may request documentation to determine eligibility.

ANY of the following

No benefits are provided for short-term at-home assistance (home health aide, homemaker, personal care aide, or nurse) for activities of daily living (e.g., bathing, dressing, personal hygiene, transferring, eating, ambulating, assistance with normally self-administered drugs, changing dressings).
No benefits for stays, care, or visits provided without charge to the subscriber in the absence of insurance.
No benefits are available for the Medicare Part B deductible or for Medicare Part B excess charges.
No benefits for services, supplies or facilities provided by a government-owned or -operated hospital or institution unless payment is required by law.
No benefits for outpatient prescription drugs except outpatient drugs covered by Medicare Part A for hospice care.

Third-Party Recovery and Subrogation

Moda Health does not cover benefits for which a third party may be legally liable (except certain motor vehicle accident provisions) and is entitled to reimbursement for benefits it paid that are recoverable from a third party or other source.
Upon payment, Moda Health has subrogation rights and may pursue the third party in its own name or in the subscriber's name; the subscriber must cooperate and shall not prejudice those rights.
Moda Health may require the subscriber and their attorney to protect its recovery rights; subscriber holds recovery rights in trust for Moda Health to the extent of benefits paid.
Moda Health is entitled to recover the amount of benefits paid out of any settlement or judgment regardless of how the recovery is characterized, whether or not the subscriber is made whole, and Moda Health's recovery rights are not reduced by the subscriber's negligence.
If requested to protect reimbursement rights, the subscriber may deduct a proportionate share of reasonable attorney fees from the amount repaid to Moda Health as an expense of collection.

Claim Filing and Timeliness

Providers must file claims with Medicare first; Moda Health requires notification of Medicare payment before paying secondary benefits. Electronic claims forwarded to secondary payor will indicate that status.
Subscribers submitting claims to Moda Health must include the Medicare Summary Notice and mail claims to Moda Health PO Box 40384, Portland, OR 97240. Claims must be submitted within 12 months from the date the expense was incurred except in cases of absence of legal capacity.

Payment Rules

Benefits are payable only for charges determined by Medicare to be Medicare eligible expenses and will be paid to whoever received the Medicare benefits unless otherwise specified (foreign travel emergency benefits payable directly to the subscriber).
When Medicare becomes secondary, the Plan pays 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; no duplication of benefits is allowed.

Coverage Transfers, Suspensions and Reinstatements

If coverage is suspended due to Medicaid entitlement (requested within 90 days of eligibility), benefits and premiums are suspended for up to 24 months; reinstatement must be requested within 90 days of losing Medicaid entitlement and may be retroactive if premiums for the period are paid.
If the Plan is replaced by another health plan, coverage under this Plan stops on the effective date of the new plan and the 31-day grace period will not apply.

Administrative and Eligibility Rules

Core benefits and Plan N additional benefits (e.g., Part A deductible, SNF days 21–100 coinsurance, foreign emergency benefits at 80% after deductible with lifetime limit) are subject to the coverage conditions and limits described in this section and elsewhere in the handbook.
No benefit will duplicate Medicare payments; benefits are limited to stated lifetime or per-period maxima (e.g., 365 additional inpatient days lifetime, $50,000 lifetime foreign emergency maximum) and applicable deductibles and cost-sharing as described in the Plan.

Operational Notes

Benefits for emergency foreign care are conditioned on meeting the $250 calendar-year deductible and the $50,000 lifetime maximum; payment is made in U.S. currency based on the exchange rate on the payment processing date.
Providers must accept the Plan's payment as payment in full for covered hospital stays and may not balance-bill the subscriber for amounts covered by the Plan when the provider has accepted Plan payment as full payment.

Coding notes, limits, and key financial values

No explicit codesmixed

No codes listed

Outpatient prescription drugsmixedNot Covered

Outpatient prescription drugs not covered except outpatient drugs covered by Medicare Part A for hospice care.

Medicare Part B cost-sharing exclusionsmixedNot Covered

	Medicare Part B deductible not covered.
	Medicare Part B excess charges not covered.

Medicare-determined eligible charges onlymixedCovered

No codes listed

inv-11: Foreign emergency deductible — $250 calendar year

Foreign emergency deductible$250 calendar year

Applies to medically necessary emergency care abroadDeductible must be satisfied for foreign emergency benefits to pay

Coordination with lifetime maxDeductible is applied before Plan pays up to $50,000 lifetime maximum

inv-12: Emergency foreign care lifetime max — $50,000

Emergency foreign care lifetime maximum$50,000

Benefit applies to emergency medical care received outside the United States

Provider responsibilities, billing, and recovery actions

Billing Rule

Provider payment and coverage prerequisites

For hospital, SNF, and medical services the provider must ensure the service is covered under the applicable Medicare part and occurs on or after the Plan's effective date. The provider must accept Moda Health's payment as payment in full and may not balance-bill the subscriber when the Plan covers the service.

Hospital stays must be covered under Medicare Part A and begin on or after the policy effective date.
Skilled nursing facility (SNF) stays must be covered under Medicare Part A, begin within 30 days of a 3+ day inpatient hospital stay, and — for multiple SNF admissions in a benefit period — be for the same condition as the first stay.
Medical care payable under Medicare Part B requires that Medicare Part B has paid its portion when required by the Plan; inpatient stays must begin on or after the policy effective date and outpatient care must be on or after the policy effective date.

Billing Rule

Medicare Part B coordination

Key defined terms used in this policy

inv-22: Key defined terms for Plan N — Accident, Approved Amount, Assignment, etc.

AccidentAccidental bodily injury sustained by the subscriber that is the direct result of an accident, independent of disease or other cause

Approved AmountThe amount Medicare determines to be reasonable for a Medicare Part B covered service (may be less than actual charge)

AssignmentArrangement where a physician or medical supplier accepts the Medicare-approved amount as full payment for Part B services

Benefit PeriodBegins day subscriber is hospitalized and ends after 60 consecutive days out of hospital or skilled facility; restarts if hospitalized after 60 days

inv-23: Emergency care definition — care needed immediately because of sudden injury or illness

Emergency care (definition)

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan N — Administrative/Operational Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare and provide Moda Health the Medicare Summary Notice before Moda Health will pay benefits.

SourceLink

On This Page

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

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

For motor vehicle accidents where Moda Health advances benefits, Moda Health retains the right to repayment from any proceeds that exceed full compensation to the subscriber; similar attorney-fee offset rules apply when Moda Health requires protection of recovery rights.

Subscribers must notify Moda Health in advance of any claim or lawsuit against a third party, cooperate fully, provide requested documentation (including medical records, settlement correspondence, pleadings, releases), sign required recovery agreements, and take actions reasonably requested to protect Moda Health's recovery rights.

Moda Health may intervene in lawsuits or arbitrate, may notify third parties or insurers of its recovery rights, and may exchange information with insurers or others to enforce recovery rights even without subscriber authorization.

Failure by the subscriber or their representatives to comply may result in Moda Health suspending or not advancing payments, or recovering benefits advanced (except certain motor vehicle accident rules); Moda Health may notify providers that payments have been suspended.

Coverage limited to emergencies that would have been covered by Medicare if provided in U.S.

Payments made to subscriber in U.S. currencyAmount based on bank transfer exchange rate on day claim payment is processed

inv-13: Emergency foreign care deductible — $250 per calendar year

Emergency foreign care deductible$250 per calendar year

Must be satisfied before Plan pays 80% of medically necessary emergency care abroadDeductible applies per calendar year and coordinates with lifetime max

Benefit payment percentage after deductiblePlan pays 80% of eligible charges after deductible is met

inv-14: Claim submission deadline — 12 months from date expense incurred

Claim submission deadline12 months from date expense incurred

Exception for absence of legal capacityClaims may be accepted after 12 months if subscriber lacks legal capacity

Required documentation when filing to Moda HealthInclude Medicare Summary Notice when submitting claim to Moda Health

When Medicare is the primary payer, the provider must file the claim with Medicare first. Moda Health requires notification from the Medicare carrier of Medicare's payment (or forwarding of the claim to Moda as the secondary payer) before Moda will pay its portion. Electronic claim forwarding will indicate: "This claim has been forwarded to your secondary Medicare payor."

Providers must file claims with Medicare prior to submitting to Moda Health.
Moda Health must receive notification from the Medicare carrier of its payment before Moda will pay.
Electronic claims filing is available and will indicate when the claim has been forwarded to the secondary payer.

Billing Rule

SNF admission requirements

SNF admission and coverage conditions must be documented and met for Plan payment. The SNF confinement must be covered under Medicare Part A, begin within 30 days of a qualifying inpatient hospital stay of 3 or more consecutive days, and, for repeated SNF admissions in the same benefit period, be for the same condition as the initial stay.

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 days in a row.
If admitted to an SNF more than once in a benefit period, the confinement must be for the same condition as the first stay.

Billing Rule

Emergency foreign care conditions

For emergency medical care received while traveling outside the U.S., providers must document that the care met the Plan's emergency foreign care conditions: care began during the first 60 days of the trip, would have been covered by Medicare if provided in the U.S., is not eligible for Medicare payment, the lifetime emergency foreign care maximum and deductible conditions are met, and services occurred on or after the policy effective date.

Emergency care must begin during the first 60 days of the trip outside the United States.
Care must be of a type that would have been covered by Medicare if provided in the U.S., but is not eligible for Medicare payment in the foreign country.
Emergency foreign care lifetime maximum ($50,000) and annual deductible ($250) requirements apply.
Services must be received on or after the policy effective date.

Billing Rule

Claim filing and notification

Providers must file claims with Medicare first and supply Medicare's determination or Medicare Summary Notice to Moda Health when submitting a claim for secondary payment. Moda Health will issue an Explanation of Benefits (EOB) after receiving and processing the claim. Claims must be submitted within the Plan's claim submission period (typically within 12 months of the date the expense was incurred) to be eligible for reimbursement.

Electronic claims filing is available; forwarded electronic claims will indicate secondary payor forwarding.
If a subscriber submits a claim to Moda, include the Medicare Summary Notice and mail to Moda Health PO Box 40384, Portland, OR 97240.
Claims must be submitted within 12 months from the date the expense was incurred except in cases of legal incapacity.
Only charges determined by Medicare to be Medicare eligible expenses will be covered under the Plan.
Moda Health will send an EOB notifying the subscriber of payment, denial, or accumulation toward deductible.

Denial Risk

Third-party cooperation required

Subscribers and providers must cooperate with Moda Health's third-party recovery efforts. Failure of the subscriber or their representatives to notify Moda Health of potential third-party claims, to assist in recovery, or to permit Moda Health to pursue recovery actions may result in Moda suspending advance payments, refusing to advance payment, or recovering benefits already paid. Moda Health may also notify providers that payments have been suspended.

Subscriber must notify Moda Health of any potential third-party claim, even if the provider initially bills Moda.
Subscriber and providers must take actions reasonably requested by Moda Health to enforce third-party recovery rights and allow Moda to intervene in lawsuits or arbitrations.
Moda Health may, without written authorization, exchange information with third parties or insurers as needed to enforce recovery rights.
If the subscriber or representatives fail to cooperate, Moda Health may suspend or refuse to advance payments, recover advanced payments, and notify providers that payments are suspended.
Exceptions and special rules may apply for motor vehicle accident claims as described elsewhere in the policy.

Billing Rule

Recovery of improper payments

If Moda Health pays benefits that are not required under the Plan, Moda Health has the right to recover such payments from the subscriber, any insurance companies, or any other organization or person.

Moda Health may recover improper payments from the person to/for whom payments were made.
Moda Health may recover from other insurance companies or any other organizations or persons responsible.

Care needed immediately because of an injury or an illness of sudden or unexpected onset

Timing requirementEmergency care must begin during the first 60 days of a trip outside the United States to qualify for foreign emergency benefit

Medicare eligibility conditionCovered if the care would have been covered by Medicare if provided in the U.S.

inv-24: Activities of daily living — bathing, dressing, hygiene, transferring, eating, ambulating, med assistance, dressing changes

Activities of daily living (ADLs)Includes bathing, dressing, personal hygiene, transferring, eating, ambulating

Medication and wound careIncludes assistance with normally self-administered drugs and changing bandages or other dressings

Coverage noteShort-term at-home assistance for ADLs is not covered under the Plan

inv-25: Benefits — definition of benefits as amounts paid by or submitted to Moda Health

Benefits (definition)Any 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

Who may receive paymentBenefits payable under the Plan will be paid to whoever received the Medicare benefits (foreign emergency benefits payable to subscriber)

DocumentationBills, statements or invoices submitted by providers are treated as requests for payment of benefits by the subscriber

inv-26: Third Party — definition including entities responsible for condition, insurers, motor carriers, etc.

Third Party (definition)Any person or entity responsible for the medical condition or the aggravation thereof, including insurers and motor vehicle coverages and workers' compensation

Included coveragesExamples include liability insurers, uninsured/under-insured motorist, premises med-pay, PIP, and workers' compensation

RelevanceThird Party responsibilities can trigger Moda Health's subrogation and recovery rights

inv-27: Third Party Claim — definition covering claims, lawsuits, settlements, judgments, arbitration, etc.

Third Party Claim (definition)Any claim, lawsuit, settlement, award, verdict, judgment, arbitration decision or other action against a third party or any right to assert the foregoing

ScopeIncludes legal and equitable remedies pursued by or on behalf of a subscriber against third parties

Trigger for recoveryPayment by the Plan gives Moda Health rights to pursue subrogation or recovery related to such claims

inv-28: Non-duplication of benefits — services eligible for only one type of benefit under the Plan

Non-duplication of benefitsServices are eligible for only one type of benefit under the Plan (e.g., if a service is defined as skilled nursing facility care, it is reimbursed under that benefit only)

ApplicationPlan will not duplicate amounts payable under Medicare

ExampleSkilled nursing facility care reimbursed only under SNF benefit, not under other benefits

inv-29: Medicare secondary payer handling — Moda pays as if Medicare Part A and B benefits had not been reduced when Medicare is secondary

Medicare secondary payer handlingWhen Medicare is secondary, Moda Health pays as if Medicare Part A and Part B benefits had not been reduced

EffectPlan treats payments as though Medicare's normal Part A and Part B benefits remained intact for determination of Plan liability

Coordination implicationUsed when other plans or coverages make Medicare secondary payer