PriorityMedicare D-SNP® (HMO)

Dual-eligible special needs plans (D-SNPs) are a type of Medicare Advantage plan designed to care for beneficiaries who have both Medicare and Medicaid coverage. Priority Health offers two D-SNP plans: PriorityMedicare D-SNP and PriorityMedicare D-SNP Advantage as its dual-eligible plan options.

Eligibility requirements

Must meet all the following:

  • Are eligible for and enrolled in Medicare Parts A and B, and;
  • Are eligible for full Medicaid benefits, and;
  • Live permanently within the Priority Health Medicare service area (see below)
  • Are 21 years of age or older

Priority Health Medicare service area:

  • PriorityMedicare D-SNP (all 68 counties in Michigan's lower peninsula)
  • PriorityMedicare D-SNP Advantage (Arenac, Bay, Branch, Clinton, Genessee, Huron, Ingham, Livingston, Macomb, Oakland, Saginaw Tuscola, Washtenaw and Wayne counties

PriorityMedicare D-SNP and PriorityMedicare D-SNP Advantage plan benefits

PriorityMedicare D-SNP and PriorityMedicare D-SNP Advantage coordinate care and coverage between Medicaid and Original Medicare. When services are covered by both Medicare and Medicaid, the member’s cost-share will be $0. These plans also offer benefits beyond Medicaid and Original Medicare benefits, including:

  • Routine vision, dental and hearing coverage
  • PriorityFlex card that covers over-the-counter items, health food and produce, pest control services and select utility bills*
  • Companion care and caregiver support through PriorityCare
  • SilverSneakers fitness benefit
  • Transportation to medical appointments

*Member must receive Extra Help/LIS (Low Income Subsidy) in order to receive this benefit

As a type of Medicare Advantage plan, PriorityMedicare D-SNP shares the same formulary and authorization requirements as our other Medicare Advantage plans.

PriorityMedicare D-SNP network

PriorityMedicare D-SNP shares the same network as our other Medicare Advantage plans. As an HMO plan, it does not include coverage outside the Priority Health Medicare network except in urgent or emergent situations.

If you are contracted with Priority Health Medicare then you are also contracted with Priority Health Medicare DSNP.

Provider billing requirements for dually-eligible members

PriorityMedicare D-SNP is Priority Health's dual-eligible special needs plan. Members with this plan are eligible for both Medicare and full Medicaid benefits and cannot legally be held liable for Medicare cost-sharing (i.e. copays, coinsurance or deductibles). If you provide services to PriorityMedicare D-SNP members, please review our billing guidelines for dually-eligible beneficiaries.

Certain billing prohibitions apply to the dual-eligible beneficiaries you serve. Federal law prohibits all Medicare providers and suppliers from billing dual-eligible beneficiaries (also known as Qualified Medicare Beneficiaries or QMBs) for Medicare Part A and Part B cost-sharing (i.e. copays, coinsurance or deductibles) under any circumstances. These beneficiaries have Medicaid coverage of Medicare Part A and Part B premiums and cost-sharing.

Providers and suppliers may bill state Medicaid agencies (Michigan Department of Community Health) for Medicare cost-sharing amounts. However, as permitted by federal law, states can limit Medicare cost-sharing payments under certain circumstances. Individuals enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions.

For more information, see MLN Matters SE1128 and Dually Eligible Beneficiaries Under Medicare and Medicaid (cms.gov).

Model of Care training requirement for providers

All dual-eligible special needs plans have a Model of Care, which ensures the unique needs of each plan member are met. Health care providers play a key role in the PriorityMedicare D-SNP Model of Care.

The Centers for Medicare and Medicaid Services (CMS) requires all special needs plans (SNPs), like PriorityMedicare D-SNP and PriorityMedicare D-SNP Advantage, to provide initial and annual Model of Care training to providers who are contracted with Priority Health Medicare. All providers who see PriorityMedicare D-SNP and PriorityMedicare D-SNP Advantage members should take our Model of Care training. Training must be completed by Dec. 31 of each year.

PriorityMedicare D-SNP Model of Care training is available as an on-demand webinar and takes approximately 15 minutes to complete. Alternatively, some practices and provider groups who are part of an organization may receive Priority Health Model of Care training along with other annual training requirements. If you’re not sure which option applies to you, contact your Provider Strategy & Solutions specialist.

How to complete training

Option #1: virtual training (this only takes 15 minutes)
Training is available as an on-demand webinar and only takes 15 minutes to complete. Provider registration for the on-demand webinar counts as attestation, which means no additional documentation is required.

Providers who take training through our on-demand webinar can receive a certificate of completion by clicking the certification icon in the webinar console. The attendee's name and date of completion will populate into the certificate, which can be downloaded to your computer.

Option #2: bulk attestations
You can group our D-SNP MOC training with existing, required training (like compliance training) so you can submit attestation for providers at the same time. If this option is selected, you’ll need to:

  1. Distribute training to your providers using this link.
  2. To attest to training, you must fill out the roster template with providers who’ve received training. If you choose to submit a provider roster, only the Priority Health MOC roster Excel sheet provided will be accepted.
  3. Send attestation rosters to DSNPtraining@priorityhealth.com.

When an attestation is submitted, one of two automated messages will be sent:

  • A confirmation email stating the roster was successfully processed.
  • An email stating the roster wasn’t processed and the reason(s) why.

Be sure to submit the correct provider NPI
Ensure the correct provider NPI number is included when submitting the provider roster or registering for the online training. If the NPI is incorrect, the provider’s status will be marked "incomplete" in our system. To correct an "incomplete" status due to an incorrect NPI, resubmit the provider roster or re-register for the online training with the correct provider NPI.

Late submissions will not be accepted.