Here is how Priority Health coordinates a member's benefits when they are eligible for Medicare.
Medicare Part B Eligibles
If a patient is eligible for Medicare Part B but does not elect it, Priority Health pays 20% of allowable charges. The remainder is the patient's responsibility.
Authorizations required when Priority Health is secondary
When Priority Health is secondary to CMS or Original Medicare, we require prior authorization on obesity-related surgery, transplant services and home infusion services.
Determining primary or secondary
In order to determine whether Medicare is primary or secondary, Priority Health needs to know the reason why the member is Medicare-eligible. Medicare eligibility falls under one of the following categories:
End-stage renal disease
Medicare is secondary during the first 30 months after dialysis is initiated or after a kidney transplant.
Medicare entitlement begins with the fourth month of renal dialysis or the first month of dialysis for patients who take a course in self-training during the three-month waiting period; employer may be primary for up to 21 months total.
Disability, under age 65
Primacy is determined by employer group size. Normally, for the disabled individual, the health plan is secondary to Medicare either because:
- The employer group size is under 100 total employees, or
- The employer group size is over 100 and the individual is not "currently employed."
Each case is individually reviewed in order to determine correct primacy.
Retiree, over age 65
Medicare is primary.
Working, age 65 and over
Primacy is determined by employer group size. If the employer group size is under 20 employees, Medicare is primary. If the employer group size is 20 or more, Medicare is secondary.
Medicare in Michigan is secondary in all instances for claims resulting from a car accident.