Blue Cross Medicare Private Fee For Service. Summary of Benefits. January 1, 2018 December 31, 2018
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1 Blue Cross Medicare Private Fee For Service Summary of Benefits January 1, 2018 December 31, 2018 This information is not a complete description of benefits. Contact the plan for more information. To get a complete list of we cover, call Customer Service and ask for the Evidence of Coverage (phone numbers are printed on the back cover of this booklet). To join, you must be enrolled in Medicare Part A and Medicare Part B, and live in our service area. Our service area includes the state of Michigan. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. has a network of doctors, hospitals, and other providers. If you use the providers in our network, you may pay less for your covered But if you want to, you can also use providers that are not in our network. For more detailed information about our providers, you can call Customer Service (phone numbers are printed on the back cover of this booklet) or visit our website at A Private Fee for Service plan is not Medicare supplement insurance. Providers who do not contract with our plan are not required to see you except in an emergency. The provider network may change at any time. You will receive notice when necessary. Blue Cross Medicare Private Fee for Service is a PFFS plan with a Medicare contract. Enrollment in Blue Cross Medicare Private Fee for Service depends on contract renewal. bcbsm.com/medicare
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3 Premium/Cost-sharing Table for Premiums vary by county in which you permanently reside (rates are based on the use and cost of health care in each regional segment). You must continue to pay your Medicare Part B premium. 1) Find the county and region that you live in. 2) Look across the plan option columns to find your monthly premium rate. Regions with counties Blue Cross Medicare PFFS premium rates per month Region 1 Barry, Kalamazoo and Newaygo counties $170 Region 2 Branch, Calhoun, Eaton, Gratiot, Hillsdale, Ingham, Montcalm and Van Buren counties $200 Region 3 Alcona, Alger, Arenac, Bay, Charlevoix, Cheboygan, Clare, Crawford, Gladwin, Huron, Iosco, Kalkaska, Luce, Montmorency, Ogemaw, Oscoda, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee and Tuscola counties $220 Region 4 Antrim, Benzie, Clinton, Emmet, Genesee, Grand Traverse, Isabella, Lake, Lapeer, Leelanau, Livingston, Marquette, Mecosta, Midland, Missaukee, Osceola, Otsego and Wexford counties Region 6 Macomb, Oakland, Washtenaw and Wayne counties $200 $220 Region 5 is not being used at this time. 1
4 Deductible Benefits This plan has deductibles for some hospital and medical You pay $1000 per year for most in-network and Maximum Out-of- Pocket Responsibility Combined $6,000 annually If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical and we will pay the full cost for the rest of the year. You will still need to pay your monthly plan premiums, Medicare Part B premiums, and cost sharing for your Part D drugs. Inpatient Hospital Coverage Our plan covers an unlimited number of days for an inpatient hospital stay. Services require prior authorization. Outpatient Hospital Coverage 2
5 Benefits Doctor Visits o Primary o Specialists Preventive Care Emergency Care Our plan covers many preventive, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy Medicare Diabetes Prevention Program (MDPP) Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including flu shots, hepatitis B shots, pneumococcal shots Welcome to Medicare preventive visit (onetime) Yearly Wellness visit Any additional preventive approved by Medicare during the contract year will be covered. There are some items not covered at $0 cost. 3
6 Benefits Urgently Needed Services Diagnostic Services/Labs/ Imaging o Diagnostic radiology service (e.g., MRI) o Lab o Diagnostic tests and procedures o Outpatient X-rays o Therapeutic radiology Hearing Services o Hearing exam to diagnose and treat hearing and balance issues The plan only covers those hearing that are covered under Original Medicare. It does not cover routine hearing exams, or hearing aids. Dental Services o Limited dental (this does not include in connection with care, treatment, filling, removal, or replacement of teeth) These are only Medicare covered benefits. This does not include in connection with care or treatment of teeth. 4
7 Benefits Vision Services o Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) o Eyeglasses or contact lenses after cataract surgery Mental Health Services o Inpatient visit o Outpatient therapy visit Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental provided in a general hospital. Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. Physical Therapy 5
8 Ambulance Benefits Transportation Not covered Medicare Part B Drugs o Part B drugs such as chemotherapy drugs Infusion therapy Other Part B drugs $0 or 20%, depending on service Foot Care (podiatry ) o Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions Rehabilitation Services o Cardiac (heart) rehab (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks) o Occupational therapy visits o Speech and language therapy visits o Pulmonary rehabilitation 6
9 Benefits Medical Equipment/Supplies o Durable Medical Equipment (e.g., wheelchairs, oxygen) o Prosthetics (e.g., braces, artificial limbs) o Diabetes supplies (e.g., monitoring, shoes or inserts Wellness programs (e.g., fitness) Not covered Chiropractic Care o Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) Home Health Care Hospice You pay $0 for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details (phone numbers are on the back of this booklet). 7
10 Benefits Outpatient Substance Abuse o Group therapy visit o Individual therapy visit Outpatient Surgery o Ambulatory surgical center o Outpatient hospital Renal dialysis 8
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12 For more information, please call us at the phone number below or visit us at If you are a member of this plan, call toll free TTY users should call 711. If you are not a member of this plan, call toll free TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 9 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 9 p.m. Eastern time. If you want to more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document is available in other formats such as audio CD and large print. This document may be available in a non English language. H4262_C_18PFFSSB CMS Accepted DB SEP 17 R067438
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