CurrentModa HealthPolicy N/A

Moda Health Medicare Supplement Plan N — policy handbook (part 1)

Describes coverage, benefits, member resources, exclusions, claim filing, third-party recovery, eligibility and value-added services for Moda Health Medicare Supplement Plan N for subscribers (primarily Oregon residents). Intended for members, providers and billing/clinical operations interacting with Moda Health for Medicare Supplement claims.

Policy Summary

PayerModa Health

PolicyModa Health Medicare Supplement Plan N — policy handbook (part 1)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare first and submit Moda Health claims (with Medicare payment notification) within 12 months of the date the expense was incurred.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Plan NMedicare Supplement plan identifier described

365Max additional inpatient days after Medicare exhaustion

$50,000Foreign emergency lifetime maximum

$250Foreign emergency calendar-year deductible

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Compliance Officer listed

2Customer service numbers provided

When the Plan Pays

Hospital care — conditions for Plan payment

Conditions that must be met for the Plan to pay hospital benefits.

ALL of the following

Hospital stay begins on or after the effective date of the policy.
Hospital stay is covered under Medicare Part A during a benefit period.
If past 90 days in a benefit period, subscriber is utilizing lifetime reserve days (when applicable).
If all Medicare hospital benefits are exhausted, Plan pays up to additional 365 days of inpatient care.
Service provider must accept Plan payment as payment in full and not bill subscriber for any balance.

Medical care (Medicare Part B) — conditions for Plan payment

Conditions that must be met for Plan to pay Part B eligible medical care.

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 must occur during a stay that began on or after policy effective date; outpatient care must be on or after effective date.

Skilled nursing facility (SNF) stays — conditions for Plan payment

Conditions for Plan payment of SNF benefits.

ALL of the following

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

Emergency medical care in foreign countries — payment conditions

Requirements for foreign emergency benefits.

ALL of the following

Subscriber needs emergency care while on a trip outside the United States (sudden/unexpected onset).
Care would have been covered by Medicare if provided in the U.S.
Care is not eligible for payment under any Medicare program.
Care begins during the first 60 days of the trip.
Lifetime foreign emergency maximum of $50,000 has not been reached.

Numeric Limits and Deductibles

Policy thresholds

Foreign emergency lifetime maximum$50,000

Foreign emergency calendar-year deductible$250

Maximum additional inpatient days after Medicare exhaustion365 days

Lifetime reserve days for Part A inpatient60 days (lifetime reserve)

What Providers Must Do

Billing Rule

Claims must be filed to Medicare first

Provider must file claims with Medicare before Moda Health will pay; Moda requires notification from the Medicare carrier of its payment. Electronic claims filing is available. Claims must be submitted to Moda Health within 12 months of the date the expense was incurred, except where the claimant lacked legal capacity.

Moda must receive notification from the Medicare carrier of its payment.
Electronic claims filing is available and, if filed electronically, it will indicate the claim was forwarded to the secondary Medicare payor.
Claims are not valid if submitted later than 12 months from the date the expense was incurred, except for absence of legal capacity.

Documentation Required

Out-of-country claim documentation requirements

Key Terms

Definitions

Approved AmountAmount Medicare determines reasonable for a Part B covered service; may be less than the actual charge and often comes from a Medicare fee schedule.

AssignmentArrangement where a physician or medical supplier agrees to accept the Medicare-approved amount as full payment for Part B services.

Benefit PeriodMeasurement for use of Medicare Part A services that begins with hospital admission and ends after 60 consecutive days out of inpatient care; no limit on number of benefit periods.

CoinsurancePortion or percentage of the Medicare-approved amount the subscriber is responsible for paying.

Lifetime Reserve Days60 lifetime reserve days for Medicare Part A inpatient hospital care used after 90 days in a benefit period.

Limiting ChargeMaximum a non-participating physician may charge a Medicare beneficiary for a covered physician service — up to 15% above the fee schedule.

Policy Scope & Purpose

This document describes coverage, claims processes, exclusions, member resources, and related operational rules for Moda Health Medicare Supplement Plan N for subscribers, primarily Oregon residents. It is intended for members, providers, and billing/clinical operations teams who interact with Moda Health regarding Medicare supplement claims and benefits. The handbook summarizes the Plan's core benefits (including Part A coinsurance for days 61–90, lifetime reserve days, up to 365 additional inpatient days after Medicare exhaustion, first 3 pints of blood, Part B office/ER visit copay limits, and hospice/respite coinsurance) and the Plan N additional benefits such as the Part A inpatient deductible, SNF coinsurance for days 21–100, and foreign emergency coverage at 80% after a $250 calendar-year deductible with a $50,000 lifetime maximum

Operationally, providers must file claims with Medicare first; Moda Health requires notification from the Medicare carrier of its payment before secondary benefits are paid, and electronic claims filing is available. Claims must be submitted to Moda Health within 12 months of the date the expense was incurred except when prevented by legal incapacity. For out-of-country emergency claims, members must supply detailed documentation including patient and ID information, itemized bills, medical records (translated if available), and proof of payment. Foreign emergency benefits are paid directly to the subscriber in U.S. currency based on the bank transfer exchange rate on the claim processing date.

The handbook also sets clear exclusions and limits important to billing and clinical operations: no coverage for the Medicare Part B deductible or Part B excess charges, no outpatient prescription drug coverage except as required for Part A hospice, no at-home personal care for activities of daily living, and no coverage for services not covered by Medicare or provided without charge. For hospital, medical, and skilled nursing facility benefits the Plan follows Medicare’s conditions — for example, hospital and SNF stays must be covered under Medicare Part A and begin while the subscriber is covered under the Plan; SNF stays must begin within 30 days of a qualifying 3-day inpatient hospital stay and relate to the same condition if multiple admissions occur within a benefit period.

Policy Updates

Policy Summary

PayerModa Health

PolicyModa Health Medicare Supplement Plan N — policy handbook (part 1)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare first and submit Moda Health claims (with Medicare payment notification) within 12 months of the date the expense was incurred.

SourceLink

On This Page

Calendar-year foreign emergency deductible of $250 has been satisfied.

Care is received on or after the policy effective date.

Payments are made to subscriber in U.S. currency based on bank transfer exchange rate on claim processing date.

For out-of-country emergency or urgent care claims, the subscriber must provide specific documentation to Moda Health to support payment.

Patient's name, subscriber name, and group and identification numbers.
Statement explaining where the subscriber was and why they sought care.
Itemized bill for each date of service.
Copy of the medical record (translated if available).
Proof of payment (credit card/bank statement or cancelled check).

Prior Authorization
Provider acceptance of Plan payment
When the Plan pays for covered stays or charges, the service provider must accept Moda Health's payment as payment in full and may not bill the subscriber for any remaining balance.

Billing Rule
Payment of foreign emergency benefits
Foreign travel emergency benefits are payable directly to the subscriber (not to providers) and are paid in U.S. currency based on the bank transfer exchange rate in effect on the day the claim payment is processed in the United States.

Denial Risk
Non-covered items and denial risks
The Plan does not cover certain items and charges; providers and members should expect denials for these non-covered items.
Medicare Part B deductible.
Medicare Part B excess charges.
Outpatient prescription drugs (except outpatient drugs covered by Medicare Part A for hospice).
At-home personal care for activities of daily living (e.g., bathing, eating, ambulating).
Services or stays provided by government-owned hospitals or institutions unless payment is required by law.
Conditions covered by workers' compensation or similar law.
Care provided without charge.
Any charges that are not covered expenses under the subscriber's Medicare plan.

Documentation Required
Third-party liability cooperation
Subscribers (and their providers or attorneys) must notify Moda Health of potential third-party claims, sign documents Moda reasonably requires, provide medical records and settlement information, and cooperate to protect Moda Health's subrogation and recovery rights; failure to cooperate can result in suspension or recovery of benefits.
Notify Moda Health in advance of any claim or lawsuit against a third party.
Sign and deliver documents Moda Health reasonably requires (e.g., Third Party Recovery Questionnaire and Agreement).
Provide medical information, settlement correspondence, pleadings, settlement agreements, releases or judgments.
Provide settlement information and cooperate in subrogation/recovery actions.
Failure to cooperate may lead to Moda suspending payment or recovering benefits.

Documentation Required
Filing a written complaint to Moda
Members or providers who believe they were not offered services or were discriminated against may file a written complaint to Moda Partners, Inc., Attention: Appeal Unit by mail or fax at the address and fax number shown.
Mailing address: Moda Partners, Inc., Attention: Appeal Unit, 601 SW Second Ave., Portland, OR 97204.
Fax: 503-412-4003.

Documentation Required
Filing a civil rights complaint with HHS OCR
Members may file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights via the OCR portal or by mail/phone; OCR complaint forms are available on the HHS OCR website.
OCR web portal: ocrportal.hhs.gov/ocr/portal/lobbyjsf.
Mailing address: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F HHH Building, Washington, DC 20201.
Phone: 800-368-1019; TDD: 800-537-7697.
OCR complaint forms: hhs.gov/ocr/office/file/index.html.

Prior Authorization
Contact Customer Service for help filing a complaint
If members need help filing a complaint, they should call Customer Service. Use the Medicaid-specific number for Medicaid matters and the general number for all other plans; both include TTY access via 711.
Medicaid Customer Service: 888-788-9821 (TTY: 711).
Customer Service for all other plans: 888-217-2363 (TTY: 711).

Documentation Required
Compliance Officer contact for nondiscrimination
Scott White is the Compliance Officer who coordinates nondiscrimination work; providers or members may contact him for nondiscrimination issues using the listed address, phone, and email.
Scott White, Compliance Officer
Address: 601 SW Second Ave., Portland, OR 97204.
Phone: 855-232-9111.
Email: compliance@modahealth.com

Documentation Required
Language assistance availability
Moda provides free language assistance services in multiple languages. A central access number with TTY is available for members to request interpretation and translated materials.
Central language assistance number: 1-877-605-3229 (TTY: 711).
Services are provided at no cost and include interpretation and translated materials.

Medicare Eligible ExpensesExpenses of the kind covered by Medicare to the extent recognized as reasonable and medically necessary by Medicare.

Newly EligibleIndividual who became eligible for Medicare on or after January 1, 2021.

Plan N core benefitsIncludes Part A coinsurance for days 61-90, lifetime reserve days coinsurance, 100% of Part A eligible hospital expenses after Medicare exhaustion (up to 365 days), first 3 pints of blood, Part B office/ER copay limits, Part A hospice/respite coinsurance.

Appeal UnitModa Partners, Inc. unit that receives written complaints related to services or discrimination (Appeal Unit, 601 SW Second Ave., Portland, OR 97204; Fax: 503-412-4003).

Office for Civil Rights (OCR)U.S. Department of Health and Human Services office that accepts civil rights complaints; contact via OCR portal or by mail/phone (200 Independence Ave. SW, Room 509F HHH Building, Washington, DC 20201; Phone: 800-368-1019 or 800-537-7697).

Members and providers should also note administrative contacts and resources: the Member Dashboard at modahealth.com and Customer Service numbers listed in the handbook for Medicare and other plans; discrimination or service complaints may be filed in writing to Moda Partners, Inc., Attention: Appeal Unit, or with the HHS Office for Civil Rights. The policy identifies a Compliance Officer for nondiscrimination coordination and provides language assistance and other member support resources to help members and providers with claims, appeals, and accommodations.