Currentpriority healthPolicy N/A

Priority Health Medicare Supplement Certificate Plan G

This Certificate governs Medicare Supplement (Plan G) benefits, eligibility, enrollment, coverage, exclusions, premiums, and member rights for individual subscribers residing primarily in Michigan. It affects Medicare Part A and B enrollees aged 65+ who meet the residency and other eligibility requirements.

Policy Summary

Payerpriority health

PolicyPriority Health Medicare Supplement Certificate Plan G

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMedicare providers must bill Medicare first; Priority Health pays coinsurance, copayments or deductible amounts after Medicare processes the claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysright-to-cancel period with full refund

65+minimum subscriber age for eligibility

6 monthsMI residence requirement each year

$250foreign emergency deductible

$50,000foreign emergency lifetime max

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Coverage, Eligibility, and Limitations

Coverage Criteria

Covered services are provided per the Certificate terms and Medicare coordination rules. Benefits apply only for services that are reasonable and Medically Necessary, and Medicare benefits will not be duplicated. Benefit amounts and member Premiums will adjust to coincide with applicable Medicare deductible, copayment, and coinsurance changes.

ALL of the following

Coverage applies only to services described in Section 6 of the Certificate and when they are reasonable and Medically Necessary for admission as an Inpatient or for diagnosis and treatment of an Illness or Injury.
We will pay Medicare-eligible amounts as specified below, subject to Medicare deductible/copayment/coinsurance coordination and Certificate limits.
Hospital, SNF, Hospice and Professional Benefits
- Hospital Inpatient Benefits: payment of Medicare Part A inpatient deductible per Benefit Period; payment of daily copayments per Certificate (days 61–90, lifetime reserve days 91–150); additional 365-day lifetime extension at applicable Medicare rate with prohibition on balance billing during that extension.
- Skilled Nursing Facility Care: payment of coinsurance for Medicare Part A eligible SNF days 21–100 when all Medicare qualifying conditions are met (including 3-day inpatient stay, Medicare-covered services, and admission to a Medicare-participating SNF within 30 days of hospital discharge). No coverage beyond day 100 for Custodial, Maintenance or Supportive Care.
- Hospice Care: member must have physician certification of terminal illness; Medicare pays 100% of Hospice costs and the Certificate pays Medicare Part A daily coinsurance for inpatient respite care and 100% of Part A copayments for prescription drugs prescribed as part of Hospice Care; other hospice-related costs may apply.
- Professional and Other Services: member pays Medicare Part B deductible; after deductible we'll pay coinsurance for outpatient/hospital departmental services and DME per Medicare-eligible amounts; payment of 100% of Medicare Part B excess charges; payment rules for blood (first 3 pints under Part A and Part B) as specified.
- Emergency Services Outside the United States: $250 deductible applies; after deductible, 80% of billed charges for Medically Necessary emergency hospital, physician and medical care received in a foreign country, limited to the first 60 consecutive days of each trip and a lifetime maximum of $50,000; care must be Medicare-covered if received in the U.S.

Administrative Coverage & Confidentiality Provisions

Exclusions and administrative limitations — services not covered under this Certificate and coordination with other payers or programs.

ALL of the following

Services not covered by Medicare are excluded unless the Certificate explicitly provides coverage.
Services paid for by Medicare or another government entity or program are not covered to the extent they are paid by those programs; this exclusion does not apply to employee health plans of such entities.
Excluded items include care resulting from war, personal comfort/convenience items, routine physical/eye/hearing exams and related items (unless covered by Medicare), orthopedic shoes/routine foot care not covered by Medicare, private duty nursing, long term care, Custodial, Maintenance or Supportive Care, cosmetic surgery except when medically necessary for accidental Injury repair or functional improvement of a malformed part, domestic help and services by household members, dental care except Medicare-eligible dental services, and over-the-counter and Medicare Part D drugs except outpatient drugs covered as part of Medicare-approved Hospice Care.

Covered Cost Buckets, Billing Basis, and Deductibles

Covered cost bucketsmixedCovered

No codes listed

Billing basismixed

No codes listed

inv-06: Hospital inpatient deductible coverage — pays Medicare Part A hospital inpatient deductible per Benefit Period

What is paidPays your Medicare Part A Hospital inpatient deductible amount per Benefit Period.

ScopeApplies to Hospital inpatient deductible only; benefits change automatically to coincide with Medicare deductible changes.

TimingPer Benefit Period (a Benefit Period starts with the first full day you are in a Hospital and ends after 60 consecutive days without a Hospital or Skilled Nursing Facility stay).

inv-07: Foreign emergency deductible — $250 per trip period

Amount$250 per trip period deductible applies to Emergency Services Outside the United States.

When it applies

Provider Billing, Claims, and Record Release Requirements

Billing Rule

Billing order for Medicare and Supplement

For Covered Services where Medicare applies, Medicare must be billed first. Priority Health Medicare Supplement Plan G will pay the Medicare coinsurance, copayment or deductible amount as specified in the Certificate. If Medicare changes its benefits, coinsurance, copayments or deductibles, this Certificate will automatically adjust to reflect those changes.

Medicare provider must bill Medicare first for Medicare Covered Services.
Priority Health pays Medicare coinsurance/copayment/deductible amounts as specified in the Certificate.
Certificate adjusts automatically if Medicare changes benefits or cost-sharing.

Documentation Required

Claims submission and documentation

Key Terms and Definitions

inv-13: You / Subscriber — definition of Subscriber / You

Who 'You' refers to'You', 'your' and 'yourself' refer to the Subscriber (the person enrolled under the Certificate).

Subscriber responsibilitiesSubscriber must understand terms of the Certificate and keep Priority Health informed of any application misstatements.

ContactSubscriber may contact Priority Health Customer Service for questions (800.852.9780; TTY 711).

inv-14: Covered Services — definition and interplay with Medicare; requirements for services to be covered

DefinitionCovered services are those services and supplies you are entitled to under this Certificate if they are Medically/Clinically Necessary and you have met all other requirements of this Certificate.

Medicare coordination

Policy Summary

Payerpriority health

PolicyPriority Health Medicare Supplement Certificate Plan G

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMedicare providers must bill Medicare first; Priority Health pays coinsurance, copayments or deductible amounts after Medicare processes the claim.

SourceLink

On This Page

Additional exclusions: services for confinement, surgery or care prior to effective date or after coverage ends except as stated in Section 9.D; services not provided by a Health Professional; services deemed unreasonable or unnecessary by Medicare (including FDA-unapproved drugs/devices or experimental/investigational services); routine immunizations except when eligible under Medicare; treatment of service-related conditions at military or veterans facilities; Medicare Part B deductible; services available free absent coverage; services covered by any group health contract; and transportation and travel.

Coordination rule: benefits will not duplicate Medicare payments and will coordinate with other responsible payers including workers' compensation and group health contracts.

title":"Coverage Terms, Exclusions, and Administrative Rules","type":"criteria_group"},{

Expenses covered under the foreign emergency benefit must add up to the $250 deductible amount before benefits are payable.

Related paymentAfter deductible, plan pays 80% of billed Charges for covered emergency care (subject to lifetime maximum).

inv-08: Foreign emergency benefit deductible — $250.00

Deductible$250.00 per trip period for Emergency Services Outside the United States.

DefinitionApplies to medically necessary emergency Hospital, Physician and medical care received in a foreign country that would have been covered by Medicare if received in the U.S.

TriggerCare must begin during the first 60 consecutive days of each trip outside the United States.

inv-09: Foreign emergency benefit lifetime max — $50,000

Lifetime maximum$50,000 lifetime maximum benefit for Emergency Services Outside the United States.

Coverage periodBenefits payable up to the lifetime maximum while you are Covered under this Certificate.

EligibilityOnly for medically necessary emergency care that would have been covered by Medicare and that begins within the first 60 consecutive days of a trip outside the U.S.

When submitting claims to Priority Health for Medicare Supplement benefits, providers must include: the member contract number, type and date of service, and the diagnosis. Claims are paid based on Medicare's approved amount for Covered Services and are subject to benefit availability, exclusions and maximums at time of processing. Providers may be required to verify that services were provided. If the provider does not submit a claim, the member may submit a copy of the Explanation of Medicare Benefits (EOMB) from Medicare.

Required claim elements: member contract number, type & date of service, diagnosis.
Payments are based on Medicare's approved amount for Covered Services.
Claims are subject to review for benefit availability, exclusions and maximums at processing.
Provider may be required to verify services were provided.
Members may submit EOMB if provider fails to file a claim.

Documentation Required

Provider Release of Records & Member Cooperation

Providers must permit release of medical records and claims information to Priority Health when requested. Members are responsible for cooperating by providing health history information and assisting in obtaining prior medical records. Priority Health and its contractors will keep received information confidential and use or disclose it only as authorized or required by law, consistent with the Notice of Privacy Practices.

Provider obligation: authorize release of medical record and claims information to Priority Health when requested.
Member obligation: cooperate, provide health history, and help obtain prior medical records.
Priority Health obligation: maintain confidentiality and limit use/disclosure consistent with Notice of Privacy Practices and legal requirements.
Customer Service contact for member requests: Priority Health Customer Service Department, MS1105 1231 East Beltline, NE Grand Rapids, MI 49525, 800.852.9780 (TTY 711) or secure message via member portal.

Medicare benefits must be billed first; Medicare Benefits won't be duplicated and Certificate benefits adjust automatically to Medicare changes.

RequirementServices must be reasonable and Medically Necessary for admission as an Inpatient or for diagnosis and treatment of an Illness or Injury.

inv-15: Benefit Period — definition of benefit period timing

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

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

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

inv-16: Covered Service/Coverage — definition of covered services and limits

What it meansA Covered Service or Coverage is a service or supply you are entitled to under this Certificate when Medically/Clinically Necessary and Certificate requirements are met.

LimitsThe Certificate may limit what will be paid for some services and supplies; when Priority Health says it will 'Cover' a service, it treats it as a Covered Service.

DependencyCoverage amounts and availability depend on Medicare's approved amounts and applicable Certificate provisions.

inv-17: Creditable Coverage — examples of prior coverage considered creditable

Examples includedCreditable Coverage includes Part A or Part B of Medicare, group health plans, health insurance coverage, Medicaid (except section 1928-only), TRICARE, Indian Health Service programs, Federal Employees Health Benefits Program, public health plans, and Peace Corps health benefits.

PurposeUsed to determine continuous periods of prior coverage and potential preexisting condition considerations.

Continuous coverageContinuous Period of Creditable Coverage means no breaks greater than 63 days during the period of Coverage.

inv-18: Charges — definition of Reasonable Charges and Medicare-limited payment

Reasonable Charges'Charges' are the reasonable Charges for items or services set by Medicare; Priority Health pays only up to those Medicare reasonable Charges.

Incurred timingCharges for Hospital or Skilled Nursing Facility stays are treated as incurred on the date of admission; other Charges on the date you receive the service or item.

Payment capNo agreement between you and a provider will cause Priority Health to pay more than Medicare's reasonable Charges.

inv-19: Totally Disabled — definition of Totally Disabled for eligibility

Definition'Totally Disabled' means a Physician states you are confined in a hospital or Medicare-certified Skilled Nursing Facility; or unable to perform substantial duties of any job and not working; or substantially unable to engage in normal activities for your age/sex.

UseThis definition is used to determine eligibility for extension of benefits after termination while you remain continuously Totally Disabled.

CertificationPhysician determination is required to establish Totally Disabled status under the Certificate.

inv-20: Covered Service / Coverage — (duplicate entry) services and supplies entitlement under Certificate

EntitlementServices and supplies you are entitled to under this Certificate when they are Medically/Clinically Necessary and you meet all other Certificate requirements.

LimitationsThe Certificate limits what will be paid for some services and supplies; benefits subject to exclusions, maximums and coordination with Medicare.

When 'Cover' is usedWhen Priority Health says it will 'Cover' a service or supply, it will treat it as a Covered Service under the Certificate's terms.

inv-21: Creditable Coverage — (duplicate entry) list of programs that count as creditable coverage

Programs listedCreditable Coverage includes group health plans, health insurance coverage, Medicare Part A or B, Medicaid (excluding section 1928-only), TRICARE, Indian Health Service or tribal programs, state health benefits risk pools, Federal Employees Health Benefits Program, public health plans, and Peace Corps health benefits.

ImplicationThese programs count as prior Creditable Coverage for continuity and preexisting condition purposes.

ReferenceCreditable Coverage is defined specifically in the Certificate's Definitions section listing eligible programs.

inv-22: Custodial Care — definition and scope of custodial care

DefinitionCustodial Care is care given when you do not require the technical skills of a registered nurse, need assistance with activities of daily living, and the services are not likely to improve your condition.

IncludesCustodial Care includes Maintenance Care and Supportive Care as defined in the Certificate.

DeterminationCare may still be considered Custodial Care even if prescribed by a Physician or provided by a licensed nurse, as determined by Priority Health.

inv-23: Home Health Care — definition and conditions for home health care

DefinitionHome Health Care is care you receive while confined to your home under a specific plan prepared by a licensed agency or organization and approved in writing by your Physician.

Plan reviewThe Physician must review the home health care plan at least every 2 months unless less frequent reviews are appropriate.

Agency requirementsThe plan must be created by a licensed agency or organization to qualify as Home Health Care under the Certificate.

inv-24: Maintenance Care — definition of maintenance care

DefinitionMaintenance Care is health care services delivered after the acute phase when maximum therapeutic benefit has occurred to promote optimal function despite absence of significant symptoms.

ContextMaintenance Care is included in Custodial Care when appropriate and may not be eligible for Certificate benefits if classified as custodial.

PurposeAims to promote optimal function rather than to provide acute therapeutic benefit.

inv-25: Medically/Clinically Necessary — definition per CMS/medical necessity standards

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).

ApplicabilityCoverage for services is contingent on a Medically/Clinically Necessary determination per CMS and meeting Certificate requirements.

Decision standardPriority Health follows CMS medical necessity standards when determining if a service is Medically/Clinically Necessary.

inv-26: Medicare Eligible Expenses — definition of Medicare-eligible expenses under Parts A and B

DefinitionMedicare Eligible Expenses are health care expenses covered by Medicare Parts A and B that are recognized as medically necessary and reasonable by Medicare and may not be fully reimbursed by Medicare.

Also calledMay also be referred to as the cost of Covered Services.

Relation to benefitsBenefits under this Certificate are provided for Medicare Eligible Expenses as described in the Coverage section and are subject to Medicare coordination and Certificate limits.

inv-27: Priority Health — definition of the insurer entity

EntityPriority Health is the Michigan nonprofit corporation and licensed health maintenance organization providing benefits under this Certificate.

RolePriority Health issues the Certificate, sets policy terms and administers claims and member services under the Certificate.

Contact detailsPriority Health Customer Service is listed in the Certificate for member questions and notices.

inv-28: Subscriber — definition of Subscriber eligibility and enrollment

Who qualifiesSubscriber is a person who: (a) meets all applicable eligibility requirements of the Certificate; (b) has enrolled for Coverage; and (c) has paid any applicable Premium payments under this Certificate.

Enrollment evidenceSubscriber receives an ID Card as evidence of enrollment and may designate a Remitting Agent to pay premiums.

ObligationsSubscriber must understand the Certificate terms, pay premiums, and notify Priority Health of any application errors or changes.