BCN Advantage SM HMO-POS. Enrollment Booklet. Michigan Public School Employees Retirement System

Transcription

1 2018 BCN Advantage SM HMO-POS Enrollment Booklet Michigan Public School Employees Retirement System

2 Dear Member: As a member of the Michigan Public School Employees Retirement System, the Office of Retirement Services provides health insurance for you and your dependents. In 2018, your retirement system will continue to partner with Blue Care Network to offer BCN Advantage HMO POS as another option for your health plan. You can keep the plan you have or choose a new one, it s your choice. This booklet provides details on the coverage the BCN Advantage plan offers. Before you decide to enroll, here are a few things to keep in mind: Your annual premium will remain the same, regardless of the plan you are enrolled in. Your current providers may not be a part of the BCN Advantage provider network. It s important to make sure that your providers are in the BCN Advantage network before you change from your current plan. If you change your mind for any reason after you switch to BCN Advantage, please contact the Office of Retirement Services for information about changing plans. BCN Advantage offers reduced costs compared to the Blue Cross Blue Shield Medicare PLUS Blue SM PPO plan: Lower annual deductible and 10% coinsurance Unlimited office visits are covered with a $25 copay per visit, $45 copay per visit for specialists Additional wellness programs and discounts For information about how to enroll in BCN Advantage, please visit the ORS website at or call the Office of Retirement Services at , 8:30 a.m. to 5 p.m., Eastern time, Monday through Friday. For all other questions, please call the BCN Advantage Customer Service center at , 8 a.m. to 8 p.m., Eastern time, Monday through Friday. TTY users call 711. The Customer Service center is also open on weekends Oct. 1 through Feb. 14. No action is required if you do not want to change your plan. Sincerely, Betsy Geis Director Medicare Government Programs

3 Welcome to BCN Advantage HMO-POS BCN Advantage is the Medicare Advantage plan in Michigan offered by Blue Care Network, the HMO affiliate of Blue Cross Blue Shield of Michigan. Our coverage is designed to promote healthy living, give you access to the doctors and hospitals you want, and help you get the most value for your medical care dollar. As a Michigan-based plan, we have a longstanding relationship with your retirement system. We ve worked together for many years to provide high-quality, affordable coverage. Blue Care Network and Blue Cross Blue Shield of Michigan proudly serve more than 200,000 Michigan Public School System retirees and their families with member-friendly coverage. Join the plan at the top of its class in 2018 for access to high quality health care from thousands of network providers. One amazing card gives you Exceptional health and wellness support Valuable online tools to help you take charge of your health $25 copay per visit on unlimited office visits, $45 per visit for specialists Coverage for preventive services, such as immunizations, wellness checks and important health screenings SilverSneakers Fitness program Improve your overall well-being with SilverSneakers Fitness program. This program is available to BCN Advantage HMO-POS members at no additional cost, including: A fitness membership with access to basic amenities at more than 13,000 participating fitness centers nationwide, and customized SilverSneakers classes at many locations Online resources including tools to assess your health, track your activity, get fitness advice, healthy recipes and connect with the SilverSneakers community SilverSneakers FLEX TM which offers classes like dance, tai chi, yoga and walking groups in participating neighborhood locations like parks, recreation areas and adult-living communities To find participating fitness locations or learn more about the program, visit silversneakers.com or call SilverSneakers at , 8 a.m. to 8 p.m., Eastern time, weekdays. You must use network facilities to obtain this benefit. Tivity Health is an independent company not associated with the Blue Cross Blue Shield Association. Blue Care Network and BCN HMO-POS contract with Tivity Health to offer the SilverSneakers fitness program benefit. 3

4 Our providers have you covered We have more than 5,000 primary care physicians, more than 20,500 specialists and 123 hospitals in our service area, including University of Michigan hospitals*, health centers and physicians. Our growing network of providers is ready to meet your health care needs. Up to date information about doctors, hospitals and other providers is available at Our BlueCard program travels with you When you travel, you re always covered for medical emergencies and urgent care. Plus, routine and follow up care are covered anywhere in the U.S. at in network rates when you use a participating provider. *Source: December 2017 Statewide Provider Counts report. 4

5 2018 BCN Advantage benefits at a glance for Michigan Public School Employees Retirement System members Deductible, copays, and dollar maximums Deductible $400 per member per calendar year Copays Fixed dollar copays $25 for office visits, $45 for specialist visits, $50 for urgent care, $20 for chiropractic visits, $150 high tech imaging and $100 for emergency room visits Percent copay 10% coinsurance for various services listed below Copay dollar maximums Fixed dollar copay None Fixed dollar and percent copay (Maximum out-of-pocket) Maximum out-of-pocket Dollar maximums $2,100 per member per calendar year $2,100 per member per calendar year None Preventive services* *For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you are also treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for the existing medical condition. Health maintenance exam Covered 100% Annual gynecological exam Covered 100% Pap smear screening laboratory Covered 100% services only Immunizations Covered 100% Prostate specific antigen (PSA) screening laboratory service only Covered 100% Mammography screening Covered 100% Physician office services Office visits Consulting specialist care when referred Emergency medical care Hospital emergency room copay waived if admitted; inpatient hospital benefits apply Urgent care center Ambulance services medically necessary Covered $25 copay Covered $45 copay after deductible Covered $100 after deductible Covered $50 copay Covered 90% after deductible 5

6 6 Diagnostic services Laboratory and pathology tests Diagnostic tests and X-rays High Technology Imaging (includes MRI, MRA, CAT, PET) Radiation therapy Hospital care Inpatient physician care, general nursing care, hospital services and supplies Outpatient surgery Alternatives to hospital care Skilled nursing care Covered 100%, office visit copay may apply per member, per visit Covered 90% after deductible, office visit copay may apply per member, per visit Covered $150 copay or 50% coinsurance, after deductible Covered 90% after deductible, office visit copay may apply per member, per visit Covered 90% after deductible, unlimited days Covered 90% after deductible Home health care Covered 100% Surgical services Surgery includes all related surgical services and anesthesia Human organ transplants Mental health care and substance abuse treatment Inpatient mental health care and substance abuse care Outpatient mental health care Outpatient substance abuse care Other services Allergy testing and therapy Allergy injections Chiropractic spinal manipulation when referred Outpatient physical, speech and occupational therapy Durable medical equipment Covered 80% Covered 100% after deductible, up to 100 days per benefit period Covered See Hospital Care for inpatient and outpatient copays Covered 100% after deductible; subject to medical criteria Mental health care: Covered 100%, up to 190 days per Medicare lifetime maximum. Prior authorization required. Substance abuse care: Covered 100%, unlimited days Covered 100%, unlimited days Covered 100%, unlimited days Prosthetic and orthotic appliances Covered 100% Hearing Covered 100% after deductible, office visit copay may apply per member, per visit Covered 100%, office visit copay may apply per member, per visit Covered $20 copay after deductible Covered $40 copay after deductible Covered One hearing aid and one exam every 36 months, binaural hearing aids for children under 19

7 Other services continued SilverSneakers fitness benefit Benefits include: A fitness center membership at any participating location across the country Conditioning classes, exercise equipment, pool, sauna and other available amenities Customized SilverSneakers classes and seminars Prescription drugs Formulary drug Preferred generic Formulary drug Generic Formulary drug Preferred brand name Formulary drug Non-preferred brand name Covered $0 copay for fitness services Fitness services must be provided at SilverSneakers participating locations. You can find a location or request information at or by calling , Monday - Friday, 8 a.m. to 8 p.m., Eastern time. TTY users call 711. Covered Standard Pharmacy: $20 copay up to a 31-day supply Preferred Pharmacy: $12 copay up to a 31-day supply Covered Standard Pharmacy: $20 copay up to a 31-day supply Preferred Pharmacy: $12 copay up to a 31-day supply Covered Standard Pharmacy: $75 copay up to a 31-day supply Preferred Pharmacy: $55 copay up to a 31-day supply Covered Standard Pharmacy: $100 copay up to a 31- day supply Preferred Pharmacy: $80 copay up to a 31-day supply Formulary drug Specialty drugs Covered Standard and Preferred Pharmacy: 20% coinsurance, $200 maximum per prescription, up to a 31- day supply Mail order prescription drugs Drugs for the treatment of sexual dysfunction Covered Two times the applicable generic and brand copay for 32-day to a 90-day supply Covered 50% coinsurance Part D Catastrophic coverage Once member s out-of pocket costs reach over $5,000, the copay is the greater of 5% or $3.35 generics and $8.35 brands, not to exceed base copay. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year. You must receive all routine care from plan providers. You must have both Medicare Part A and Part B to enroll. For questions about how to enroll, please visit the ORS website at or you can contact the Office of Retirement Services at , 8:30 a.m. to 5 p.m., Eastern time Monday through Friday. Contact BCN Advantage for more information. This document may be made available in other formats such as Braille, large print, or other alternate formats. For more information, call a.m. to 8 p.m. Monday through Friday with weekend hours Oct. 1 through Feb. 14. TTY users call 711. You may call MEDICARE ( ), or visit for more information about Medicare benefits and services, including general information about the health or prescription drug benefits. TTY users call Hours are 24 hours a day, seven days a week. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 7

8 2018 Medicare Star Ratings* The Medicare Program rates all health care and prescription drug plans each year, based on a plan s quality and performance. Medicare Star Ratings help you know how good a job a plan is doing. You can use these Star Ratings to compare our plan s performance to other plans. The two main types of Star Ratings are: 1. An Overall Star Rating that combines all of our plan s scores. 2. Summary Star Rating that focuses on our medical or our prescription drug services. Some of the areas Medicare reviews for these ratings include: How our members rate our plan s services and care How well our doctors detect illnesses and keep members healthy How well our plan helps our members safely use recommended prescription medications For 2018, Blue Care Network received the following Overall Star Rating from Medicare: 4 Stars We received the following Summary Star Rating for Blue Care Network s health/drug plan services: Health Plan Services: Drug Plan Services: 3.5 Stars 4.5 Stars The number of stars shows how well our plan performs. Excellent Above average Average Below average Poor Learn more about our plan and how we are different from other plans at You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at (toll free) or 711 (TTY), from October 1 to February 14. Our hours of operation from February 15 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call (toll free) or 711 (TTY). *Medicare evaluates plans based on a 5 star rating system. Star Ratings are calculated each year and may change from one year to the next. 8

9 Discrimination is Against the Law Blue Cross Blue Shield of Michigan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of Michigan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of Michigan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact the Office of Civil Rights Coordinator. If you believe that Blue Cross Blue Shield of Michigan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Office of Civil Rights Coordinator 600 E. Lafayette Blvd. MC 1302 Detroit, MI , TTY: 711 Fax: civilrights@bcbsm.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Office of Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at 9

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12 Luce Schoolcraft Mackinac 2018 BCN Advantage HMO POS service area Benzie Leelanau Grand Traverse Emmet Charlevoix Antrim Cheboygan Presque Isle Otsego Shiawassee Montmorency Alpena Kalkaska Crawford Oscoda Alcona Manistee Wexford MissaukeeRoscommon Ogemaw Iosco St. Joseph ZIP Codes Served Mason Oceana Muskegon Ottawa Van Buren Lake Newaygo Allegan Kent Osceola Clare Gladwin Mecosta Barry Montcalm Gratiot Saginaw Ionia Isabella Eaton Clinton Midland Ingham Arenac Bay Genesee Livingston Tuscola Oakland Kalamazoo Calhoun Jackson Washtenaw Wayne St. Joseph Branch Hillsdale Lenawee Monroe Huron Lapeer Sanilac Macomb St. Clair BCN Advantage SM is an HMO-POS plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. H5883_S_18MPSERSEnrlBkR1 FVNR 1017 R074255