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Blue Cross Medicare Advantage Select (HMO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$0.00
Monthly Premium
Blue Cross Medicare Advantage Select (HMO) is a HMO plan offered by Health Care Service Corporation
Plan ID: H3251-002
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Blue Cross Medicare Advantage Select (HMO) - H3251-002 by Health Care Service Corporation as well as other Medicare Advantage plans available in your area.
$0.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3900 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $10 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $300 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services |
| Urgent Care | Urgent Care: Copayment for Urgent Care $20 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $120 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300 Air Ambulance: Coinsurance for Air Ambulance Services $20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Blue Cross Medicare Advantage Select (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: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services Only chiropractic services related to the subluxation of the spine require authorization. |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| 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 to $50 Copayment for Medicare-covered Lab Services $5 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services $0 copay for the Diagnostic Bone Mass Measurement and Diagnostic Colonoscopy test performed on the same date of service as the corresponding preventive test. All other services are covered at a $50 copay. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $250 Copayment for Medicare-covered Therapeutic Radiological Services $30 Copayment for Medicare-covered X-Ray Services $10 to $100 |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $324 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $25 Copayment for Medicare-covered Group Sessions $25 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $265 Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $175 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $75 Copayment for Medicare-covered Group Sessions $75 Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
$160/qtrly (Note: Unused OTC amounts roll over from quarter to quarter, but do not roll over to the next calendar year. Members may use their pre-loaded card on select OTC item(s) from plan approved catalog and item(s) are shipped to members. Additionally, members may use their pre-loaded card at select retail stores for select OTC items. Only the amount allocated for OTC items may be used on the pre-loaded card. No cash is exchanged.) |
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $50 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 49 $0 per day for days 50 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $35 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $0 Coinsurance for Endodontics 20% Coinsurance for Periodontics 0% to 20% Coinsurance for Prothodontics, removable 20% Coinsurance for Maxillofacial prosthetics 20% Coinsurance for Prothodontics, fixed 20% Coinsurance for Maxillofacial surgery 0% to 20% Copayment for Adjunctive general services $0 Maximum Plan Benefit of $1,500 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 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglass Lenses $0
|
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 $50 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $699 to $999
|
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 |