CurrentPriority HealthPolicy N/A

Priority Health Medicare Supplement Certificate Plan F

This document governs the terms, conditions, benefits, exclusions, eligibility, enrollment, premium rules, and administrative provisions for Priority Health's Medicare Supplement (Plan F) certificate issued to eligible Medicare beneficiaries residing in Michigan.

Policy Summary

PayerPriority Health

PolicyMedicare Supplement Certificate Plan F

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMedicare providers must first bill Medicare for Medicare-covered services; Priority Health will pay applicable Medicare coinsurance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysright-to-cancel period with full refund

100 daysmaximum SNF days covered

$250emergency foreign deductible

$50,000lifetime max for emergency foreign care

30 daysgrace period for premium payment

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Claim Submission and Payment

ALL of the following

We pay the coinsurance required by Medicare. Payments are based on Medicare's approved amount for Covered Services.
All claims are subject to review of availability of benefits at the time the claim is processed, and are subject to the exclusions and maximums under your Coverage.
Provider claims must show: your contract number; type and date of service; and the diagnosis. Providers may be required to verify services were provided.
If the provider does not send a claim, you may submit a copy of the Explanation of Medicare Benefits (EOMB) you receive from Medicare.
If you authorized Medicare to send payment to the provider, we will send our payment to the provider. If Medicare sends its payment to you, we will send our payment to you. We may, at our option, pay benefits directly to you or to the provider; such payments discharge our liability for the amounts paid.
Claim Forms: Upon receipt of notice of claim, we will furnish the forms usually furnished for filing proofs of loss. If such forms are not furnished within 15 days after notice, the claimant will be deemed to have complied by submitting written proof within the time fixed by the Certificate.
Proof of Loss: Written proof of loss must be furnished within 90 days after the termination of the period for which the insurer is liable for periodic payments, and within 90 days after the date of loss for other claims. Late proof will not invalidate a claim if it was not reasonably possible to give proof in time, provided proof is furnished as soon as reasonably possible and not later than 1 year except in absence of legal capacity.
Time of Payment: Indemnities payable other than periodic payments will be paid immediately upon receipt of due written proof. Accrued periodic indemnities will be paid weekly and any balance unpaid upon termination of liability will be paid immediately upon receipt of due written proof.
Payment of Claims: Indemnity for loss of life will be payable in accordance with beneficiary designation or to the estate if none. Other accrued indemnities unpaid at Subscriber's death may be paid to beneficiary or estate. All other indemnities will be payable to the Subscriber.

Termination and Renewal

ALL of the following

Termination for Nonpayment of Premium: If you fail to pay Premium by the due date you are in default. If default continues you will be terminated as of the last date through which Premium was paid. A 30-day grace period will be granted for each Premium after the first; during the grace period the Certificate remains in force. Benefits incurred and paid after termination will be charged to you.
Termination for Other Reasons: Subject to reasonable notice, Coverage may be terminated if: you are no longer eligible for Medicare; you no longer meet Certificate eligibility requirements; you provide false or misleading information or withhold material information; or we no longer offer this Coverage. The contract ends the last day covered by your last payment. If you permanently move outside Michigan, Coverage continues if all other eligibility requirements are satisfied.
Extension of Benefits: Termination is without prejudice to a continuous loss which commenced while the Certificate was in force. Extension of benefits is available while you are continuously totally Disabled, subject to all maximum benefit amounts and duration limits of the Certificate. Receipt of Medicare Part D does not affect determination of a continuous loss. 'Totally Disabled' is defined by Physician-certified confinement, inability to perform substantial duties of any job with no salary/profit, or substantial inability to engage in normal activities for an individual of same age/sex.

Coverage principles

Coverage Principles

ALL of the following

Covered Services: Services described in the Certificate will be paid under its terms, conditions and provisions. Services must be reasonable and Medically Necessary for inpatient admission or for diagnosis and treatment of an Illness. Benefits will not duplicate Medicare benefits.
Benefits Change with Medicare: Benefits of this Certificate will automatically change to coincide with changes in applicable Medicare deductible amounts and coinsurance percentage factors; when benefits change, your Premium may change.
Specific Benefit Limits: Hospital inpatient, skilled nursing facility, professional and other services, and emergency services outside the United States are covered as described in the Certificate and are subject to the stated deductibles, coinsurance, lifetime and per-period limits.
Non-Duplication and Charges: Priority Health Coverage does not duplicate benefits or pay more for Covered Services than the actual fees. We pay only up to the reasonable Charges set by Medicare and treat hospital or SNF stay charges as incurred on date of admission; other charges are treated as incurred on date service or item was received.

Coding, Payment Basis, and Covered Thresholds

Part B deductible (covered)mixedCovered

Medicare Part B Calendar Year deductible	We'll pay the Medicare Part B Calendar Year deductible regardless of Hospital Confinement.
Medicare Part B excess Charges	We'll pay 100% of Medicare Part B excess Charges.
Part B coinsurance/copayment	We'll pay the coinsurance amount, or the copayment amount paid for Hospital outpatient department services under a prospective payment system, of Medicare Eligible Expenses under Part B regardless of Hospital Confinement, subject to the Medicare Part B deductible.
First 3 pints of blood (Part B)	We'll pay the Medicare Part B Eligible Expenses for the first 3 pints of blood (or equivalent quantities of packed red blood cells) unless replaced in accordance with federal requirements.

Payment basismixed

Medicare's approved amount	Our payments are based on Medicare's approved amount for Covered Services.
Coinsurance required by Medicare	We pay the coinsurance required by Medicare.

Charge determinationmixed

Charges (reasonable charges set by Medicare)

The reasonable Charges for items or services set by Medicare. We treat Charges for stays in a Hospital or Skilled Nursing Facility as incurred on the date of admission; all other Charges are treated as incurred on the date you get the service or item. We pay only up to the reasonable Charges set by Medicare; no agreement between you (or someone acting for you) and any other person, group or provider of services will cause us to pay more.

Covered day or dollar thresholds

Hospital inpatient deductiblePays the Medicare Part A Hospital Inpatient deductible amount per Benefit Period.

Part A hospital coinsurance (days 61–90)Pays 100% of Medicare Part A Hospital daily coinsurance from the 61st through the 90th day of Confinement.

Medicare lifetime inpatient days (days 91–150)Pays 100% of Medicare Part A Hospital daily coinsurance for each Medicare lifetime inpatient day used from the 91st through the 150th day in any Benefit Period.

Additional lifetime inpatient daysPays 100% of Medicare Part A Eligible Expenses at applicable prospective payment rates for up to an additional 365 lifetime inpatient days (subject to limits).

Skilled Nursing Facility coinsurance (days 21–100)Pays the coinsurance for Medicare Part A Eligible Expenses for the 21st through the 100th day of Skilled Nursing Facility care, subject to Medicare qualifying rules.

Part B calendar year deductible and excess chargesPays the Medicare Part B calendar year deductible and 100% of Medicare Part B excess charges; also pays Part B coinsurance/copayment as described (subject to Part B deductible).

Payment basis

Payment basisPayments for Covered Services are based on Medicare's approved amount for those services.

Claims subject to benefit reviewAll claims are subject to review of availability of benefits, exclusions and maximums at time of processing.

Payment recipient rulesIf Medicare authorizes payment to the provider, we will pay the provider; if Medicare pays you, we will pay you; we may choose to pay either you or the provider to discharge liability.

Charge payment limit

Charge limitationWe pay only up to the reasonable Charges set by Medicare.

Timing of incurred ChargesCharges for Hospital or Skilled Nursing Facility stays are treated as incurred on the date of admission; other Charges are treated as incurred on the date the service or item is provided.

No contract overrideNo agreement between you (or someone acting for you) and any other person, group or provider will cause us to pay more than the Medicare reasonable Charges.

Provider Billing, Claims and Cooperation Requirements

Billing Rule

Billing order for providers

Your Medicare provider must first bill Medicare for Medicare Covered Services. For services covered by Medicare, Priority Health will pay only the Medicare coinsurance amount. If Medicare changes benefits, coinsurance or deductibles, this Certificate will automatically adjust to include those changes.

Medicare provider must bill Medicare first.
Priority Health pays Medicare coinsurance only for Medicare-covered services.
Certificate adjusts automatically to Medicare benefit changes.

Billing Rule

Claim submission requirements and provider payment

When a provider submits a claim to Priority Health it must include the member's contract number, the type and date of service, and the diagnosis. Providers may be required to verify that services were provided. If a provider does not submit a claim, the member may send a copy of the Medicare Explanation of Benefits to Priority Health. If Medicare authorized payment to the provider, Priority Health will send payment to the provider; if Medicare paid the member, Priority Health will send payment to the member. Priority Health may, at its discretion, pay benefits directly to the provider or to the member — such payments discharge Priority Health's liability for the amounts paid.

Required claim elements: contract number, type and date of service, diagnosis.
Provider may be required to verify services were provided.
Member may submit Medicare EOB if provider does not file a claim.
Payment follows Medicare's payment direction; Priority Health may pay either provider or member.

Note

Subrogation and provider/member cooperation

Priority Health is subrogated to the member's rights to the extent of benefits paid under the Certificate and may pursue recovery from third parties responsible for the illness or injury. The member must promptly notify Priority Health in writing of any claim against another party, provide information reasonably requested, and fully cooperate in protecting Priority Health's rights. Members must not settle or compromise with other parties without Priority Health's prior written consent — doing so is a breach of the contract and may prejudice Priority Health's rights. Priority Health's assigned rights include, but are not limited to, rights against automobile liability, underinsured/uninsured motorist coverage, homeowner liability, medical malpractice, patient compensation funds, umbrella coverage, and other insurers.

Priority Health may sue third parties or their insurers to recover benefits paid.
Member must promptly advise Priority Health in writing of claims against others and provide requested information.
Member must fully cooperate and obtain prior written consent before settling with responsible parties.

Key Definitions and Administrative Terms

Certificate

Document of rights and dutiesThe Certificate is the document that describes your and our rights and duties and includes the application and any Amendments.

ApplicabilityThis Certificate sets terms, conditions, Covered services, and rights and obligations of the Subscriber and Priority Health.

Issuance conditionThe Certificate is issued after the applicant signs the application and we issue the Certificate.

Eligibility

Medicare enrollment requirementSubscriber must be enrolled in Medicare Part A and Part B to have Medicare Supplemental Plan F Coverage.

Michigan residencyMust be a permanent resident of Michigan and physically reside in Michigan at least nine (9) months of every year.

Age and medical criteriaSubscriber must be 65 years or older and meet Priority Health's medical criteria.

No concurrent Medicare supplement or Advantage coverageSubscriber must not be enrolled in any other group or non-group Medicare supplemental program or Medicare Advantage plan while Covered under this Certificate.

Totally Disabled

Definition of Totally Disabled'Totally Disabled' means a Physician certifies you are either: confined in a hospital or Medicare-certified Skilled Nursing Facility; unable to perform the substantial duties of any job for which you are qualified and not working for salary or profit; or substantially unable to engage in normal activities of an individual in good health of the same age/sex.

Extension conditionExtension of benefits is available only while you are continuously Totally Disabled and is subject to all Certificate maximums and duration limits.

Subrogation

Subrogation assignmentYou agree we are subrogated to all of your rights to the extent of benefits we provide under this Certificate; those rights are assigned to us to that extent.

Scope of assigned rightsAssigned rights include rights against liable persons and their insurers, automobile liability, underinsured/uninsured motorist coverage, homeowner liability, medical malpractice, patient compensation funds, and applicable umbrella coverage.

Member cooperationYou must promptly advise us in writing of any claim against a third party, provide requested information, fully cooperate, and not settle without our prior written consent.

Benefit Period

Benefit Period startA Benefit Period starts with the first full day that you are in a Hospital.

Benefit Period endIt ends when you have not been in a Hospital or Skilled Nursing Facility for at least 60 consecutive days.

Unlimited periodsThere is no limit to the number of Benefit Periods you can have.

Certificate of Creditable Coverage

Issuance upon terminationA Certificate of Creditable Coverage is a Certificate issued to you upon termination of Coverage under this Certificate to document prior coverage.

Request windowYou may request a Certificate of Creditable Coverage after termination (refer to Certificate for any specific timeframes).

Custodial Care

DefinitionCustodial Care is care given when you do not require the technical skills of a registered nurse at all times and includes services for activities of daily living such as dressing, bathing, eating, walking, taking medications and maintaining continence.

Includes Maintenance and Supportive CareCustodial Care includes Maintenance Care and Supportive Care as defined in the Certificate.

May be considered custodial despite Physician involvementCare may still be considered Custodial Care even if under a Physician's care or provided by a registered or licensed practical nurse, as determined by us.

Medically/Clinically Necessary

DefinitionMedically/Clinically Necessary means services or supplies needed to diagnose, care for or treat your physical or mental condition as determined by the Centers for Medicare and Medicaid Services (CMS).

CMS standardNecessity determinations are made per CMS standards referenced in the Certificate.

Subscriber

Subscriber definitionA Subscriber is a person who meets all applicable eligibility requirements of the Certificate, has enrolled for Coverage, and has paid any applicable Premium payments.

Subscriber responsibilitiesThe Subscriber is responsible for understanding Certificate terms and cooperating with Priority Health (e.g., providing health history and records when requested).

Clerical Errors

Effect of clerical errorsClerical errors (e.g., incorrect transcriptions of Effective Dates, termination dates, or erroneous mailings) do not change the rights or obligations of you or us under this Certificate and will not grant additional benefits or alter Coverage periods.

No effect on coverageClerical errors will not operate to terminate Coverage otherwise in force or continue Coverage beyond the date it would otherwise terminate.

Governing Law and Severability

Governing lawThis Certificate is governed by Michigan law and any applicable federal law.

SeverabilityIf any provision is held invalid or unenforceable, the remaining provisions will remain in full force and effect.

Notices

Written notice requirementAny notice required or permitted under this Certificate must be in writing.

Delivery rulesA notice is considered given on the date delivered in person, or if mailed by first-class U.S. mail, on the date mailed to the address in your application or a more recent address of which the sender has written notice.

Address for noticesNotices should be sent to the address in the application or the most recent address provided in writing.

Waiver

Waiver ruleA waiver of any provision by a party will not be considered a waiver of that provision at any other time or of any other provision.

Failure to exercise rightsThe failure to exercise any right under this Certificate does not operate as a waiver of such right.

Third Parties

No third-party rightsThis Certificate does not confer any rights, remedies, claims or obligations on third parties except as specifically provided in the Certificate.

Limited exceptionsAny third-party rights are only as specifically provided by the Certificate language.

Issuance of Certificate

Issuance conditionThe Certificate is issued after the applicant signs the application, which becomes part of the Certificate, and we issue the Certificate.

Application part of CertificateThe signed application is made part of the Certificate upon issuance.

Confidentiality of Health Care Records

Confidentiality commitmentPriority Health, its agents and providers keep healthcare records confidential and use or disclose information only as authorized or required by law consistent with the Notice of Privacy Practices.

Provider release permittedYou agree to permit providers to release medical record and claims information to Priority Health as permitted by member authorization and law.

Member rightsMembers may request a copy of Priority Health's Notice of Privacy Practices by contacting Customer Service.

OpenPayer

Priority Health Medicare Supplement Certificate Plan F

Coverage, Claims, Termination and Related Rules

Coding, Payment Basis, and Covered Thresholds

Provider Billing, Claims and Cooperation Requirements

Key Definitions and Administrative Terms