Blue Cross Medicare Advantage Basic Plus (HMO-POS)

Blue Cross Medicare Advantage Basic Plus (HMO-POS) H3822-007 Plan Details
3.5 out of 5 stars

Blue Cross Medicare Advantage Basic Plus (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3822-007.

$0.00
Monthly Premium

Blue Cross Medicare Advantage Basic Plus (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3822-007.

Blue Cross Medicare Advantage Basic Plus (HMO-POS) H3822-007 Plan Details
3.5 out of 5 stars

Blue Cross Medicare Advantage Basic Plus (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3822-007.

$0.00
Monthly Premium

Illinois Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3450
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:
Copayment for Medicare Covered Primary Care Office Visit $60.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Prior authorization required
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $75.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$220.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 40%
Urgent Care
Copayment for Urgent Care $30.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00
Emergency Room Visit
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Basic Plus (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
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Chiropractic Services 40%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
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 40%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Durable Medical Equipment 30%
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 $50.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $175.00 to $225.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 40%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$215.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services
Referral Required for Outpatient Mental Health Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $250.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $235.00
Prior Authorization Required for Outpatient Observation Services
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services

POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%

Outpatient Observation Services:
Coinsurance for Medicare covered Observation Services: 40%

Prior Authorization Required for Outpatient Observation Services

Referral Required for Outpatient Observation Services
Prior authorization required

Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $75.00
Copayment for Medicare-covered Group Sessions $75.00
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 40%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $75.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services
Prior authorization required
POS (Out-of-Network):
Coinsurance for Medicare Covered Podiatry Services 40%
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
Referral Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 40%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%

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
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $35.00
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%

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 $5.00
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 40%

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 shots
  • Hepatitis B shots
  • Pneumococcal 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 $60.00