Frequently asked questions for agents

Last updated 5/18

Information provided by Priority Health is for educational purposes only and is not intended as legal advice. The information provided is based on regulations and legislation, which are updated frequently. Please consult your benefits attorney with any legal questions.

COVID-19 testing, virtual care and treatment

For virtual care related to COVID-19 diagnostic tests and the administration of the test: members are covered 100%.

For all other virtual care: Priority Health covers the cost of virtual care for fully funded members and will temporarily waive costs before deductible for HSA plan members, through June 30, 2020. Self-funded members are covered 100% until April 30. Starting May 1, their standard coverage applies.

No, amounts paid by the plan will not accumulate toward the member deductible, coinsurance maximum, or TrOOP accumulators.

In non-emergent situations, care provided by an out-of-network provider will be covered at the alternate or out-of-network benefit level on POS and PPO plans, including member cost-sharing. As always, emergency care, including hospitalizations, are covered as in-network, regardless of the provider’s participation status. Services rendered by field hospitals, temporary clinics, or in a non-traditional/overflow setting will be considered emergent care and covered in-network. If a patient must be transferred to an out-of-network facility due to capacity issues, that care will be covered as in-network. Priority Health will work with our providers partners throughout the state to ensure that members are not balance billed due to receiving care at an out-of-network provider during this time.

CMS has issued guidance to providers on specific codes that should be used to identify claims related to COVID-19 treatment. This is universal, not specific to an individual health plan. Priority Health will use this information to determine which claims will be paid in full. We expect many claims will be for emergency department visits, observation care, and inpatient stays.

Starting April 1, 2020 through June 30, 2020 Priority Health will be covering the full cost of outpatient and inpatient medical care related to the testing and treatment of COVID-19 for our commercial membership. For our self-funded employers, Priority Health will be covering the member cost share portion of these claims.

Claims for observation or inpatient care will be paid based on the admission date. Priority Health will continue to monitor this rapidly changing situation and make determinations for coverage with dates of service beginning after June 30 as we approach that date.

No, Priority Health coverage decisions will apply to our members regardless of where they live. While Priority Health utilizes Cigna’s national network for our members that reside outside of Michigan, Priority Health makes all benefit decisions impacting our members.

For all members, including Commercial Group, Individual, Medicare, and Medicaid membership, as well as HSA plan members, as part of the Families First Coronavirus Response Act, the cost of COVID-19 diagnostic testing and the administration of the test such as office visits, blood draws, or specimen handling are covered 100%, with no member cost sharing applied. Applies to in-network and out-of-network providers. NOTE: Self-funded groups may not opt-out.

HDHP members are covered in full, before deductible, as are self-funded group members and grandfathered plan members.

Self-funded groups may not opt-out. All members, as part of the Families First Coronavirus Response Act are 100% covered with no member cost share for COVID-19 diagnostic test and the administration of the test.

There is a notification on the home page that links to constantly updated coverage information for Priority Health members. This microsite is the best place for members to find the most up-to-date information on coverage. Members can also call the customer service number on the back of their ID card.

Pharmacy FAQs

Priority Health is already allowing early refills for our members that have 30 day prescriptions, and encouraging members to switch to 90 day prescriptions where possible. Early refills on 30 day prescriptions are not available on controlled substances, or specialty medications filled through a specialty pharmacy. Applicable member copays and cost sharing apply to all medication fills. This executive order also allows pharmacists the ability to substitute therapeutically equivalent medications without prescriber approval if there are critical shortages.

CVS, Walgreens and Meijer offer free in-home delivery of prescriptions for all Priority Health plans. Members can get more information in the member FAQs. If members already have an automatic 90-day refill set up, then there is no need to change a thing. They get discounted rates and their prescriptions delivered to their home already.

Employee eligibility

Yes, employers are permitted to subsidize COBRA. However, if the subsidy ends before the maximum COBRA coverage period, that may not be considered a qualifying event for the employee to enroll in Individual Marketplace coverage outside of the open enrollment period. To avoid a lapse in coverage, the employee would be required to pay the entire cost of the COBRA premium until they are able to enroll in Individual coverage.

No, COBRA continuation coverage is available only to "qualified beneficiaries" and only after a qualifying event has occurred. COBRA defines "qualified beneficiaries" as an employee who was covered by a group health plan on the day before a qualifying event occurred. If the employee was not covered on the health plan when the lay-off occurred, they are not eligible for COBRA.

Collecting unemployment does not affect the employer's ability to offer health benefits during this time.

Yes, if an employee is laid off before they meet the group's new hire waiting period, they will be eligible to begin coverage as of their planned effective date, provided the employer still considers laid off employees as "active" for benefits purposes.

Employer groups may continue to utilize our standard enrollment spreadsheet for making coverage changes during this time.

Priority Health is not opening up our commercial book of business for a special open enrollment at this time. Employers may still add employees or change coverage at qualifying events, including loss of other coverage. If you are unsure what constitutes a qualifying event, or if you have extenuating circumstances for an employee, please reach out to your Priority Health client services team for assistance.

Employees that are no longer paying for child care may, but are not required to, change their election. The change in election must be consistent with the reason, e.g. if a child is no longer in care, the election could be reduced or eliminated. Enrollment forms for flexible spending plans can be found in the Priority Health agent center. Members with flexible spending or health savings accounts administer by our partner, HealthEquity, can access additional information on their website.

Priority Health will not be changing our current policies regarding dependents aging off a group plan. For those dependents in need of ongoing coverage, they can purchase an individual plan or see if they qualify for a Healthy Michigan plan.

While Priority Health encourages, and is providing the flexibility to our employers, to continue coverage for employees during any layoffs resulting from temporary business closures due to COVID-19, we understand that will not be possible for all employers. If a group must terminate coverage during this time period, Priority Health will waive any applicable waiting periods if the employee returns to work within 6 months. An employer can decide if they want to enact a shorter waiting period, but must apply that to all employees.

No, accumulators will remain with the member under the same plan, for the remainder of the plan year. Accumulators don’t automatically transfer between HSA and non-HSA plan types. It would need to be done manually.

Due to the state of emergency we are not requiring any changes to your plan documents at this time. We will continue evaluate this as the situation continues to evolve.

Priority Health will extend the 30-day timeframe through June 30, 2020 for fully funded employers.

Premium and administrative information

Small group employers (2-50 employees): a 15% premium credit will be issued in June and July 2020 invoices against premiums billed for April and May.

Large, fully funded employers (51+ employees): consideration for premium credits will happen upon renewal, beginning with 4th quarter 2020 renewals. We’ll share more information within the next 30 days.

Self-Funded groups pay for all their members medical and pharmacy claim cost so the impact to the lower than projected utilization will be realized immediately in their weekly funding.

All ACA and pre-ACA small group employers (50 or fewer full-time equivalent employees) with active policies in effect on the first day of the upcoming invoice month that had premium billed during the credit invoice months. Credit will be extended to existing employers under a payment plan or deferral options. If a customer is no longer insured with Priority Health, they are not eligible for this credit.

The credit will show at the bottom of the invoice noted as “Premium credit due to COVID-19” with a dollar amount.

Priority Health will not be making an adjustment to premium but reflecting this as an adjustment to the total amount due. A group can continue to pay the full premium amount reflected on the invoice and the credit will just roll over to their next billing cycle.

The small group credit will not impact agent commission on small group business.

Priority Health will follow our current process for alerting our self-funded groups of inpatient admissions and potential high-cost cases.

For fixed fees:

Priority Health will apply our extended grace period to fixed fees (e.g. administrative fees and stop-loss) for our self-funded employer groups. Self-funded groups with a stop-loss carrier other than Priority Health should reach out to the carrier to discuss how any delays in stop-loss premium may affect their coverage.

For claims funding:

Claims funding occurs on a weekly basis, and must be funded in order for provider payments to be made. Groups using EFT as a payment method should work with their Priority Health account manager to discuss delayed or partially funded payment options and timing.

While an employer group could choose to shift premium costs in part or in whole to their employees, any group considering this approach should absolutely consult with their benefits attorney. As a reminder, terminating employee coverage due to failure to pay premium is not a COBRA qualifying event, nor does it provide the employee with an SEP for Individual coverage.

  • Priority Health will be waiving NSF Fees for employer groups, including employer group Medicare plans, from 3/12/2020 through 6/30/2020. Employer groups must contact Priority Health to set up a payment plan prior to becoming delinquent in their payments.
  • Priority Health will not be making mid-year rating adjustments due to changes in enrollment at this time.
  • Enrollment changes will continue to be reflected in the next billing cycle.

Employers may need to provide information on health care premiums for up to 24 months. Some individual lenders may request copies of invoices be provided. Employer groups, or their designated agent, may access historical invoices through their Priority Health employer center. If the employer or agent do not have access to the portal, a report will be provided upon request supplying this information, or copies of invoices if required by the lender. Please email your group name, group number, and the time period for reporting to Allow 1-2 business days for a billing receipt summary report, and 2-3 business days for copies of invoices.

Priority Health's legal counsel has determined that modifications to our plan documents are not required at this time. Our SBCs do not call out specific diagnostic test coverage (e.g. influenza testing). Our plan documents (Certificates of Coverage, Insurance Policies, and Summary Plan Descriptions) each have sections addressing the fact that our plans all comply with applicable state and federal law, and in any instance where the plan document does not comply with applicable law or regulation, it will be deemed amended to the extent necessary to comply with such law.

An employer's status as an applicable large employer (ALE) is based on the sum of its full-time employees and its full-time equivalent employees for the prior calendar year, regardless of plan year.

For example, an employer has 55 employees today. Due to temporary closures or COVID-19 related workforce reductions, their workforce drops to 25 for the months of March and April. Next year, they will calculate their workforce as follows:

55 employees for 10 months of the year = 550

20 employees for March and April = 40

(550 + 40) / 12 = 49 employees

Our standard grace period is 30 days from the due date of the invoice. If you are concerned about your ability to pay your premiums, please reach out to your account manager or the Small Business Sales team to discuss payment options prior to the due date.

Employee coverage options

Priority Health will continue to monitor the situation as it evolves, and make adjustments as needed to support our members and employer groups. Our temporary provisions do not extend past June 30th at this time. If an employer group chooses to make a permanent change to their plan, they should work with their Small Business sales team or Large Group account manager to do so.

Yes, employers can continue to provide benefits and should keep the employees status as "active", should employers choose to do so. This "active" status is effective Mar. 12, 2020 through June 30, 2020. Reminder: an employer must be consistent with what options they offer to all similarly situated employees.

There are multiple options for employees based on their specific circumstances. Learn more about coverage options for those losing health coverage.

This would be treated as an Special Enrollment (SEP) for loss of coverage. We're waiving the requirement for documentation due to loss of health coverage because of the COVID-19 crisis if individuals enroll directly through Priority Health. Documentation is still required if they choose to enroll through the Healthcare Marketplace.

Individuals enrolling thorough must choose the first of the month as their effective date (dates within their 60 day window from the date they loss coverage). For example if they lose coverage on 3/23, their effective date options would be 4/1 or 5/1.

Individuals enrolling directly in a health plan through Priority Health can select that next day for coverage to ensure they do not have a coverage gap or the first of the following month. For example, if they lose coverage on 3/23, their effective date options are 3/24 or 4/1.

For more information on SEP enrollments and other coverage options visit our info page.

Every individual’s needs will be different however, for many people the Marketplace will be less expensive than COBRA, especially if they are unemployed. To enroll on the Marketplace, enrollees just need to approximate their 2020 income on their application. If an employee takes COBRA for one month and it exhausts they would then be eligible for an SEP because the enrollee would be deemed 'newly eligible for assistance'.  The effective dates are applied as outlined above.

In addition, if the member is currently enrolled in COBRA and cannot afford to continue that coverage they can use their new eligibility to enroll on the Marketplace or directly through Priority Health.

IRS Notice 2020-29

The IRS has recently released guidance (Notice 2020-29) allowing health plans flexibility to let participants make mid-year changes to health, FSA, and dependent care plans outside of a regular open enrollment period, and without a qualified life event.

Learn more


Employees may choose to drop their current coverage, elect coverage if they have previously waived, add or remove eligible dependents, or move from one plan offering to another, if their employer offers multiple benefit plans. Employees may also newly elect, drop, or change contributions for flexible spending and dependent care accounts.

Priority Health is not offering large group plans the option to make mid-year changes to their plan design at this time, or add new plan offerings.

No, groups may choose to opt in. The Notice does not require that groups open their enrollment mid-year for elections without a qualifying event (such as marriage or birth).

No, an employer may limit the types of election changes allowed. For example, an employer may choose to allow only changes in election that provide an increase level of benefit, e.g. changing from self-only to family coverage, or changing from a plan that only offers in-network coverage to a plan that offers both in and out-of-network coverage. If an employees are allowed to drop coverage, the employer must receive an attestation in writing from the employee stating that they are or will immediately enroll in other comprehensive health coverage.

The Notice is applicable to employer-sponsored coverage offered through a section 125 cafeteria plan. This includes small and large employer groups, grandfathered and non-grandfathered plans, and all funding arrangements.

The open enrollment window will be determined by the employer. All changes must be for a prospective (future) effective date. For example, an employer may choose to open enrollments on May 18 for a two week time period, with an effective date of June 1. Priority Health will allow groups to offer one mid-year open enrollment.

Priority Health provides deductible credit mid-year when an employee moves to a like plan type. For example, an employee moving from a $4,000 deductible HSA to a $2,000 deductible HSA would receive credit for deductible amounts met during the current plan year. An employee that moves from a $2,000 Traditional HMO plan to a $2,000 Traditional POS plan would receive deductible credit. An employee moving from a plan with an embedded deductible (such as a Traditional or Tiered Copay plan) to a plan with an aggregate deductible (such as an HSA) or vice versa would NOT receive deductible credit.

Employees should work with their employer and HSA banking administrator to adjust contribution levels, to avoid penalties for exceeding contribution limits.

Yes. Employees may change the amount they contribute to their FSA during this period. This may be important for families who contribute the maximum to their dependent child care FSA if their daycare program is closed due to the pandemic. Similarly, employees who planned elective procedures for 2020 may wish to lower the amount in their healthcare FSA if the have delayed their elective procedure due to COVID-19.