BCN Advantage HMO-POS Community Value (HMO-POS)

Blue Cross Blue Shield of Michigan
BCN Advantage HMO-POS Community Value (HMO-POS) H5883-012 Plan Details
4 out of 5 stars

BCN Advantage HMO-POS Community Value (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan.
Plan ID: H5883-012.

$20.00
Monthly Premium

BCN Advantage HMO-POS Community Value (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan.
Plan ID: H5883-012.

Blue Cross Blue Shield of Michigan
BCN Advantage HMO-POS Community Value (HMO-POS) H5883-012 Plan Details
4 out of 5 stars

BCN Advantage HMO-POS Community Value (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan.
Plan ID: H5883-012.

$20.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $-1
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 35%
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:
Coinsurance for Medicare Covered Physician Specialist Office Visit 35%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$300.00 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:
Coinsurance for Acute Hospital Services per Stay 35%
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

The Maximum Plan Benefit is lifetime limit for emergency, urgent care
services and worldwide transportation received outside the U.S. and itsTerritories.
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

The Maximum Plan Benefit is lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories
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 HMO-POS Community Value (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 $20.00
Copayment for Routine Care $20.00
  • Maximum 1 Routine Care every year
Copayment for Chiropractic X-Rays $20.00
  • Maximum 1 Set every year
Prior Authorization Required for Chiropractic Services

POS (Out-of-Network):
Coinsurance for Medicare Covered Chiropractic Services 35%
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
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 35%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
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 20%
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 $20.00
Copayment for Medicare-covered Lab Services $0.00
COVID-19 testing: In-network: $0 cost
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
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $20.00 to $100.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 35%
Coinsurance for Medicare Covered Lab Services
35%
Coinsurance for Medicare Covered Diagnostic Radiological Services 35%
Coinsurance for Medicare Covered Therapeutic Radiological Services 35%
Coinsurance for Medicare Covered Outpatient X-Ray Services 35%
COVID-19 testing: Out-of-network: $0 cost
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
POS (Out-of-Network):
Copayment for Medicare Covered Home Health $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$300.00 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:
Coinsurance for Psychiatric Hospital Services per Stay 35%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25.00
Copayment for Medicare-covered Group Sessions $25.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual Sessions 35%
Coinsurance for Medicare Covered Group Sessions 35%
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 - Per stay $90.00

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:
Coinsurance for Medicare Covered Outpatient Hospital Services 35%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35%
Please refer to Summary of Benefits for copay information on Hospital Observation Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 35%
Over-the-counter (OTC) Items
$100 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, no rollover.
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):
Coinsurance for Medicare Covered Podiatry Services 35%
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
Out-of-Network:
35% per day for days 1 to 100

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
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every two years

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00 to $225.00
Coinsurance for Diagnostic Services 25%
Coinsurance for Restorative Services 25%
Coinsurance for Endodontics 25%
Coinsurance for Periodontics 25%
Coinsurance for Extractions 25%
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 25%

Dental X-rays include up to 4 bitewing or 6 periapical every 2 years
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 50%
Maximum Plan Benefit of $2000.00 every year for Non-Medicare Covered Comprehensive Dental.
Please see Evidence of Coverage for full list of benefits and limitations

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
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair
Maximum Plan Benefit of $150.00 for non-Medicare
covered contact lenses or frames every 12 months. Lenses are covered in full every 12 months.

POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 35%
Coinsurance for Medicare Covered Eyewear 35%

Maximum Plan Benefit of $150.00 for non-Medicare covered contact lenses or frames every 12 months. Lenses are covered in full every 12 months.

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
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every three years

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every three years
Maximum Plan Benefit up to $750.00 every three years per ear
Hearing aids are covered up to a $1500 maximum benefit ($750 per ear) every three years. Excludes hearing aid repairs, adjustments or reconfigurations.

POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 35%

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:
  • COVID-19 shots
Flu shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit


POS (Out-of-Network):

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

Glaucoma, Colorectal and Diabetes self-management training services 35%