BCN Advantage HMO ConnectedCare (HMO)
BCN Advantage HMO ConnectedCare (HMO) H5883-007 Plan Details
BCN Advantage HMO ConnectedCare (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-007
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$56.00
Monthly Premium
BCN Advantage HMO ConnectedCare (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-007
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
BCN Advantage HMO ConnectedCare (HMO) H5883-007 Plan Details
BCN Advantage HMO ConnectedCare (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-007
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$56.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3800 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 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $225.00 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 |
| Urgent Care | Copayment for Urgent Care $0.00 to $45.00 Minimum copay applies to urgent care services rendered in a PCP office and maximum copay applies to urgent care services rendered in urgent care. 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 $230.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $230.00 Air Ambulance: Copayment for Air Ambulance Services $230.00 |
Health Care Services and Medical Supplies
BCN Advantage HMO ConnectedCare (HMO) 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 $40.00
Prior authorization required |
| 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 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage 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 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 Copayment for Medicare-covered Therapeutic Radiological Services $25.00 Copayment for Medicare-covered X-Ray Services $20.00 to $100.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $225.00 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 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $225.00 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 Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
| Over-the-counter (OTC) Items | $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 qualifying 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 $40.00 Prior Authorization Required for Podiatry Services Prior authorization required |
| 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 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 $225.00 Copayment for Diagnostic Services $0.00
|
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 $40.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $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 $40.00 |
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 |
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