BCN Advantage Elements (HMO-POS)
BCN Advantage Elements (HMO-POS) H5883-001 Plan Details
BCN Advantage Elements (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-001
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Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
BCN Advantage Elements (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
BCN Advantage Elements (HMO-POS) H5883-001 Plan Details
BCN Advantage Elements (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Michigan Counties Served
Gratiot
Montcalm
Ingham
Calhoun
Van Buren
Branch
Monroe
Saint Joseph
Hillsdale
Berrien
Eaton
Jackson
Kalkaska
Mason
Ottawa
Gladwin
Wayne
Kalamazoo
Oscoda
Midland
Cheboygan
Allegan
Montmorency
Isabella
Presque Isle
Iosco
Newaygo
Missaukee
Barry
Oakland
Lapeer
Macomb
Kent
Osceola
Tuscola
Wexford
Alcona
Alpena
Arenac
Muskegon
Antrim
Mecosta
Washtenaw
Bay
Lenawee
Clare
Genesee
Sanilac
Saginaw
Roscommon
Ogemaw
Shiawassee
Grand Traverse
Emmet
Crawford
Benzie
Otsego
Leelanau
Huron
Livingston
Oceana
Lake
Charlevoix
Saint Clair
Manistee
Clinton
Schoolcraft
Mackinac
Luce
Ionia
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $4500 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 POS (Out-of-Network): Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00 to $35.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required POS (Out-of-Network): Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $0.00 to $35.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $205.00 per day for days 1 to 6 $0.00 per day for days 7 to the end of your stay Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: $205.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 |
| Urgent Care | Copayment for Urgent Care $0.00 to $45.00 Minimum copayment amount applies to services provided in a PCP office. Maximum copayment amount applies to services provided in an urgent care facility. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $45.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $250.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 POS (Out-of-Network): Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $250.00 Copayment for Medicare Covered Ambulance Services - Air $250.00 |
Health Care Services and Medical Supplies
BCN Advantage Elements (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15.00 Copayment for Routine Care $35.00
Prior authorization required POS (Out-of-Network): Copayment for Medicare Covered Chiropractic Services $15.00 Copayment for Non-Medicare Covered Chiropractic Services $0.00 to $35.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required POS (Out-of-Network): Copayment for Medicare Covered Diabetic Supplies and Services $0.00 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%. Please see Evidence of Coverage for more details. Prior Authorization Required for Durable Medical Equipment This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage. POS (Out-of-Network): Coinsurance for Medicare Covered Durable Medical Equipment 0% to 20%. Please see Evidence of Coverage for more details. Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $20.00. Please see Evidence of Coverage for more details. Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $20.00 to $100.00. Please see Evidence of Coverage for more details. Copayment for Medicare-covered Therapeutic Radiological Services $25.00 Copayment for Medicare-covered X-Ray Services $20.00 to $100.00. Please see Evidence of Coverage for more details. Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services POS (Out-of-Network): Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $20.00. Please see Evidence of Coverage for more details. Copayment for Medicare Covered Lab Services $0.00 Copayment for Medicare Covered Diagnostic Radiological Services $20.00 to $100.00. Please see Evidence of Coverage for more details. Copayment for Medicare Covered Therapeutic Radiological Services $25.00 Copayment for Medicare Covered Outpatient X-Ray Services $20.00 to $100.00. Please see Evidence of Coverage for more details. Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 POS (Out-of-Network): You pay nothing. Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $205.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: $205.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 POS (Out-of-Network): Copayment for Medicare Covered Individual Sessions $0.00 to $35.00 Copayment for Medicare Covered Group Sessions $0.00 to $35.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $200.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $100.00 Prior Authorization Required for Ambulatory Surgical Center Services POS (Out-of-Network): Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $200.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $200.00 Please see Evidence of Coverage for more details. Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $35.00 Copayment for Medicare-covered Group Sessions $35.00 POS (Out-of-Network): Copayment for Medicare Covered Individual or Group Sessions $0.00 to $35.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 $50 quarterly Advantage Dollars card allowance that can be used at participating retailers towards eligible Over-the-Counter (OTC) drugs, health related items, and healthy foods for qualified members . Carry forward allowed within plan year. Nicotine Replacement Therapy (NRT) offered as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35.00 Prior Authorization Required for Podiatry Services Prior authorization required POS (Out-of-Network): Copayment for Medicare Covered Podiatry Services $0.00 to $35.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 100 POS (Out-of-Network):You pay nothing per day for days 1 through 20. $188 copay per day for days 21 through 100. Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 to $200.00 Copayment for Diagnostic Services $0.00
POS (Out-of-Network): Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $0.00 to $200.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 50% Coinsurance for Non-Medicare Covered Comprehensive Dental 50% Maximum Plan Benefit of $1500.00 every year |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $35.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 POS (Out-of-Network): Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $35.00 Copayment for Medicare Covered Eyewear $0.00 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 to $35.00 Copayment for Routine Hearing Exams $0.00 to $35.00
Hearing Aids: Copayment for Hearing Aids $0.00
Hearing aids are covered up to a $1200 maximum benefit ($600 per ear) every three years. Excludes hearing aid repairs, adjustments or reconfigurations. POS (Out-of-Network): Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $0.00 to $35.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
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