2018 Medicare Plus Blue SM Group PPO Resource Guide Put your coverage to work Michigan Public School Employees Retirement System www.bcbsm.com/mpsers
Make your coverage work for you We want you to know we re happy you chose our medical plan. Whether you joined for the first time this year or have been with the Blue Cross Blue Shield of Michigan family for years, you might be wondering what you should do to make the most out of your coverage this year. Here s an easy guide to get you up to speed so you can start taking advantage of your plan coverage. We ll keep you informed... 2 What can you do online?... 4 Take an active role in your care... 5 What's up, doc?... 5 In sickness and in health: We ve got you covered... 6 Terms to know... 8 Get the right care when you need it... 10 Healthy savings... 11 A guide to your Evidence of Coverage... 12 Contact us... Back cover This information is not a complete description of benefits. Contact BCBSM Customer Service for more information. Limitations, copayments, and restrictions may apply. ii
You re a member of a PPO plan Your preferred provider organization covers everything that Original Medicare does, plus more, all in one plan. You have access to thousands of primary care doctors and specialists as well as hundreds of hospitals. These health care providers accept our payment, and the share of the costs that you pay, as payment in full. You pay less if you use providers that belong to the Medicare Plus Blue Group network. You may pay more to use doctors, hospitals and other providers outside of the network. Health care works best when you have a steady relationship with a trusted primary care doctor for ongoing care. Your primary doctor helps coordinate all your care, which helps ensure they stay informed of your current health status. As a PPO plan member, you don't need a referral to see a specialist. The provider network may change at any time. You will receive notice when necessary. Out of network/non contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out of network service, we encourage you or your provider to ask us for a pre service organization determination before you receive the service. Please call BCBSM Customer Service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out of network services. 1
We ll keep you informed Part of our commitment to you is to help you make the best possible use of your plan. You ll hear from us throughout the year as we keep you informed about your plan and your health. Membership ID card Welcome kit and plan materials or Welcome call Start using your ID card New members: If you haven't already received your new Blue Cross membership ID card, it will arrive soon. You can put your red, white and blue Medicare card away in a safe place and use your Blue Cross membership ID card instead. Show your doctor and other providers this card every time you need care. New member: You ll find helpful tools, resources and important tips in this Resource Guide. Other important plan materials were sent with this mailing, including a complete description of your plan coverage and your member rights in the Evidence of Coverage. Keep all these documents to reference throughout the coming year. Renewing members: This Resource Guide is part of your annual renewal mailing, which also includes the Annual Notice of Changes, Evidence of Coverage and other important plan information. You ll want to keep these documents handy so you can reference them throughout the coming year. New members: We will call you to make sure you received your welcome kit and membership ID card, help answer any questions about your coverage and tell you about programs we offer to help you stay healthy. Guide to your costs Early next year, we will send you a wallet-sized card that lists the out-of-pocket costs for the medical services you use most. Medicare Advantage health assessment Medicare requires us to send members a brief survey about their health. The information does not affect your enrollment or costs and is kept confidential. We send you the results to share with your doctor. 2
Doctor visit Explanation of benefits or Make an appointment for either your Annual Wellness Visit or Annual Routine Physical with your doctor so you can begin taking advantage of your preventive benefits. See page 5 for more information on these benefits, which are covered at 100 percent. If you don t have one, pick a primary care doctor. See page 4 for how to find a doctor online. You can also look in your copy of our Provider Directory or call BCBSM Customer Service at the number on the back cover of this booklet (this number is also on your Blue Cross membership ID card). When you use your medical coverage, we ll send you a detailed statement. It is not a bill. Instead, it lists the services you received, what your provider billed, what your plan paid, and how much you may owe. This is the source of truth on your cost share. You ll receive an Explanation of Benefits the month after the claim is processed. Look for helpful tips on page 2 of your Explanation of Benefits. If you want to receive your Explanation of Benefits via email, instead of receiving paper copies, see Getting too much mail? on page 4. Member news We do our best to combine helpful information, useful reminders and healthy tips to help you get more out of your plan in Best of Health, your quarterly member newsletter. Special information or Surveys There may be events during the year that we want you to be aware of, so we ll send you notices. If you need help with a chronic illness, such as heart disease or diabetes, we may send you materials or call you about a specific program. You may receive surveys asking for your opinion of our plan, our network doctors and the care you receive. We re always looking for ways to provide better coverage and service. Your answers are confidential. They don t affect your coverage or costs. We appreciate your honest feedback. 3
What can you do online? We re committed to providing you easy-to-use online We have thousands of doctors in our networks, tools to help you track and manage your health. so depending on how you search, you may get a long list of doctors. Fear not, there are many By registering in the secured member section of ways to refine your search results. For example, www.bcbsm.com/mpsers, you can: to find a patient-centered medical home Find information doctor, look under Refine your results for about your plan No Internet? Quality Recognitions and click the check benefits No problem. box next to PCMH. This new list will Sign up to receive If you don t use the Internet, include only doctors who have received a electronic benefit don't worry. You can still PCMH designation from Blue Cross. statements and access most of this information other documents through a phone call to online instead of BCBSM Customer Service by mail using the number on the back cover or by using the Look up discounts other phone numbers listed and special throughout this booklet. savings programs Track your spending Access a wealth of timely health information and tools in the Blue Cross Health & Wellness tab Everything is right at your fingertips. Online, anytime. You'll need your Blue Cross membership ID card when you first register on the members-only site. Find a doctor Go to www.bcbsm.com Click on the blue Find a Doctor box, on the left Click on the GET STARTED box Under Choose a health plan, click on All Plans and then select the Medicare (65 and over) category and click on Medicare Plus Blue (PPO) You can search your plan s network by either typing your ZIP code in the Location box or by typing a name into the Search for a doctor or hospital by name box and then hit Search What is a PCMH and why should I use one? A patient-centered medical home is a care team led by a primary care doctor that focuses on your health goals and needs. These groups offer 24-hour access to your medical team and a personalized approach to managing your health. To find a PCMH doctor, follow the instructions above. Getting too much mail? We can send you less mail if you register to go paperless on our website. Log in to your member account at www.bcbsm.com and go to Account Settings at the top Choose Paperless Options Under Your Settings, select Yes under the Online column to receive your documents online After you sign up, we ll send you an email that lets you know when a new document is posted for you to view. You ll no longer receive paper copies of these documents. You can change your delivery method back to paper (mail) at anytime by using the same directions. 4
Take an active role in your care Your Medicare Plus Blue PPO plan offers 25 preventive services covered at 100 percent, including flu and pneumonia vaccines, mammograms and colorectal cancer screenings. If you are new to Medicare, schedule a Welcome to Medicare Exam within your first 12 months with Medicare. If you ve been enrolled in Medicare for more than a year, you can take advantage of your Annual Wellness Visit, which includes personalized prevention plan, screening schedules, referrals and education based on your specific health situation. Effective January 1, 2018: Annual Routine Physicals (checkups) and standard, routine labs done in conjunction with physicals are covered at 100%. An Annual Routine Physical is more comprehensive than an Annual Wellness Visit ask your doctor which preventive service is right for you. You can empower yourself and get more out of your doctor visits by: Writing down questions you want to ask as well as symptoms you want your doctor to be aware of Taking notes as the doctor answers your questions Reviewing your medications (dose, side effects and over-the-counter supplements) Speaking up if you have any health concerns Being involved in your care decisions You are a key player on your medical care team. What's up, doc? If you're looking for better dialogue with your doctor, try this: Pick at least one question from each row to ask every time you visit your doctor. What exercise is right for me? is a healthy weight for me? chronic conditions am I most at risk for? are my treatment options? How healthy am I? -orserious is my condition? will I know if the treatment is working? much does this cost? do my medications, blood pressure and cholesterol level affect my diabetes? When do vaccines for flu or bone mass cancer screenings? diabetes I need pneumonia? measurement for screenings? preventive osteoporosis? care, like Why do I need this treatment? does my medication make me feel weak or dizzy? am I forgetting things or feeling sad? am I on this medication? 5
In sickness and in health: We ve got you covered Our commitment to you includes coverage that works for you at every stage. Your benefits aren t just for when you re feeling sick or coping with a chronic condition. They can help you take charge of your health. Flu vaccine You can get your flu vaccine at your pharmacy, local health department or community center. If they cannot bill the flu vaccine under your Blue Cross coverage, you have an option to pay for your flu shot and be reimbursed by completing a claim form and mailing it to us with your receipt. You can also get your flu vaccine at your doctor s office and they can bill us directly; however they may charge an office visit copay, even if this is the only service provided at your visit. You can find the claim form online at www.bcbsm.com/claimsmedicare Or call BCBSM Customer Service team at the number on the back cover of this booklet. TTY users call 711. After the greeting and entering your information, say reimbursement form to get to the correct prompt. Considering surgery If you re thinking about having surgery, it s important to have the knowledge you need to make an informed decision. That s why we re providing you access to Welvie, an online support program with six steps that guide you from diagnosis to recovery. Learn more at www.welvie.com.* Serious illness When something serious happens, count on our dedicated nurse case managers to help you find the right care for you. They'll also provide the information and resources you need. We offer case management services based upon your medical claims or when your doctor refers you for assistance. In some cases, we partner with independent companies to provide services on our behalf. Diagnosis of a serious illness can be overwhelming. Our case management nurses work with your doctor to help you and your family: Understand your medical condition Coordinate care Review treatment options Connect with community resources Obtain equipment and medical supplies A personal case management nurse will support you and your loved ones as you consider options, make treatment decisions and handle emotional concerns. You'll find the support you need to feel more in control. If you re hospitalized, we can also help with the transition to your home or another facility to ensure you get the care you need. 1 800 845 5982, TTY users call 1 800 696 8350. 8 a.m. to 5 p.m. Monday through Friday *Welvie is an independent company contracted by Blue Cross Blue Shield to provide surgery decision support services to our members. 6
Chronic conditions Care management nurses help you understand and cope with your condition, develop skills for managing it and feel in control again. You ll work with your nurse to create a care plan and set goals to improve your health. Care management support Some health decisions aren't easy. Our Blue Cross Health & Wellness care management programs can assist you whether you're coping with a life-changing illness, unsure about your medications or need help as you leave the hospital. Our specialists can connect you to Blue Cross Health & Wellness care management programs. 1 800 775 2583, TTY users call 711, 8 a.m. to 6 p.m. Monday through Friday Review all our health and wellness programs online at www.bcbsm.com/mpsers Click on the LOGIN tab and log in to your secure member account. Click on the Health & Wellness tab Emotional and mental health Care is available for conditions that cause emotional or mental distress as well as substance abuse care. When you call, we ll evaluate your needs and arrange for services, including urgently needed care. 1 888 803 4960, TTY users call 711. 24 hours a day, seven days a week. Quit tobacco for good Increase your chances for successfully quitting in the next 30 days with support and resources through a phone-based health coach program from WebMD. WebMD Health Services is an independent company supporting Blue Cross Blue Shield of Michigan by providing health and wellness services. 1 855 326 5102, TTY users call 711. Monday through Thursday from 9 a.m. to 11:30 p.m., Friday from 9 a.m. to 8 p.m., Saturday from 9:30 a.m. to 6 p.m. and Sunday from 1 p.m. to 11:30 p.m. Health questions? Call our 24 Hour Nurse Line Whenever you have a health-related question, we re ready to help you. Please feel free to call us if you have a question about whether it s a cold or the flu, or if you need information on a surgical procedure or anything in between. You can also use this number to access our AudioHealth Library to listen to recordings on a variety of topics. Both are free and confidential. Call 1 855 678 1705, TTY users call 711, 24 hours a day, seven days a week. This line is not for emergencies. If you have a medical emergency, call 911 or go to the nearest emergency room. Benefits may change on January 1 of each year. 7
Terms to know Coinsurance A percentage of the cost for certain medical services. The amount of your coinsurance is based on the Blue Cross approved amount for covered services. Your coinsurance is different from your deductible and is applied before and in addition to the deductible amount. Coinsurance maximum The maximum amount you will pay in coinsurance during one plan year. You start paying coinsurance for most covered services at the beginning of the year. After you reach the maximum amount, your plan pays your coinsurance for the rest of the year. Copayment A flat dollar amount you pay when you receive certain medical services. Deductible A fixed dollar amount you must pay for certain medical services before your medical plan begins to pay. Out of pocket maximum The maximum dollar amount you will pay in coinsurance, deductibles and copayments during one plan year. After you reach your out-of-pocket maximum, your plan covers 100 percent of the cost for covered services you receive the rest of the year. Copayments for routine hearing care are not included in your out-of-pocket maximum. Out-of-pocket maximum met $ $$ $$$$ You pay a coinsurance or copay and deductible when applicable. The plan pays the balance of the cost. - - - - - - - - - - - - - - - You pay $0. The plan pays 100% of your covered services. Exception: Routine hearing care copays are not included in the out-of-pocket maximum. 8
Hospital based practice Many provider offices, health centers or hospital-based outpatient clinics owned and operated by hospitals may charge an additional hospital usage fee or facility charge when you see any provider in the office, health center or clinic. These offices may cost you more. Additionally, your services may cost a different amount based on where they re performed (in office, outpatient in an ambulatory surgical center, outpatient hospital facility or hospital-owned doctor office). Inpatient versus outpatient If you are having a service in a hospital, you should check with your doctor to see if the service is inpatient or outpatient. Unless the doctor writes an order to admit you as an inpatient to the hospital and your plan authorizes admission, the service will be outpatient and you will pay the cost-sharing amounts for outpatient services. Even if you stay in the hospital overnight, the service might still be considered outpatient. If you are not sure if the service is considered outpatient, you should ask the hospital staff. Preventive screening versus diagnostic exam A preventive screening checks to see that you are healthy (no sign, symptom or disease present). A diagnostic exam is performed to diagnose and, consequently, start treatment if you are unhealthy (there is a sign, symptom or disease present). Diagnostic exams are prescribed when there are health concerns, such as certain symptoms or medical history. When a sign or symptom is discovered during a preventive exam, the testing may transition into a diagnostic procedure and different copays may apply. For example, if a physician performs a screening colonoscopy and a polyp or other abnormality is found, the procedure is now considered a diagnostic procedure per Medicare guidelines and diagnostic cost sharing will apply. Pre authorization Some medical services are covered only if your doctor gets pre-authorization (approval in advance) from your plan. Covered services that need pre-authorization are marked in the medical benefits chart included with your Evidence of Coverage booklet. Because your doctor gets the authorization before a service takes place, you won t be held responsible for any charges if a claim is denied for not having prior authorization. 9
Get the right care when you need it Type of care Best for Advantages Your costs Estimated wait times Your regular Annual Wellness Trusted doctor: doctor Visit Knows you and your medical Annual Routine history Physical Screenings/ vaccines Minor illnesses or injuries Can track and guide all care including specialist referrals After-hours access by phone or email minutes Will try to work you in if it s urgent. Specialist A particular area of expertise Specialized care: For issues, like heart or lung health or geriatric care minutes Two money bags Often takes 2 weeks+ to get appointment Urgent care Non-life Convenience: center threatening illnesses or issues when you can t get in to see your regular doctor Extended hours, walk-in service, convenient locations Two money bags minutes Emergency room Handles sudden, very serious or life-threatening illness or injury Accessibility: 24 hours a day, seven days a week to hours Three money bags Longer wait times for non-emergency care 10
Healthy savings You can get healthy on a budget with Blue365. This program offers you exclusive savings on national and local products and services for a well-balanced lifestyle, including: Fitness and wellness health magazines, fitness gear and gym memberships Healthy eating cookbooks, cooking classes and weight-loss programs Lifestyle travel and recreation Personal care Lasik and eye care services, vitamins and more Enjoy great deals for every aspect of healthy living with savings on top brands like Jenny Craig, Seniorlink Care, Hope Paige Medical, Dental Solutions and Medical Alert. Take advantage of these savings: Log in to your member account at www.bcbsm.com/mpsers from your computer, 1 855 511 2583 tablet or smart phone. If you re a first-time user, TTY users call 711. you must register. Your Blue Cross membership 9 a.m. to 8 p.m. ID card has the information you need to register. Click the link under Member Discounts with Blue365 on the right side of your homepage Monday through Friday Blue365 is brought to you by the Blue Cross Blue Shield Association. Value added items and services are not a part of your insurance benefits. For complete terms and conditions, see www.blue365deals.com/terms use. 11
A guide to your Evidence of Coverage Your Evidence of Coverage is an important legal document that explains your coverage. A copy is included in your welcome kit. If you're a renewing member, your Annual Notice of Changes and EOC arrive in the same mailing as this Resource Guide. You can also find it at www.bcbsm.com/mpsers. The EOC is a long, complex book. One of the benefits of using the online EOC or of signing up for electronic delivery of the EOC (see Getting too much mail? on page 4) is that you can easily find key words and phrases. Just open the document and press "Ctrl + F" on your keyboard at the same time. Type in a keyword or phrase and select Next to search the EOC for it. Below are some of the more popular topics you may want to review in your EOC. How much do I pay for Annual deductible?...chapter 4 Doctor office visits?...chapter 4 Tell me about my plan. Helpful contact information...chapter 2 How do I use my coverage?...chapter 3 Definitions of key terms...last Chapter What am I covered for? Medical benefits chart with cost-sharing information...chapter 4 Services not covered by your plan...chapter 4 You may ask for reimbursement for a bill for covered services...chapter 5 What if I have a problem with my coverage? If you want to appeal a medical coverage decision, see Chapter 7, Sections 3 5. Check your appendix. At the end of the book, look for information on Quality Improvement Organizations, State Health Insurance Assistance Programs and State Medicaid Agencies. 12
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Contact us BCBSM Customer Service 1 800 422 9146. TTY users call 711. 8:30 a.m. to 5 p.m. Eastern time Monday through Friday TruHearing TM Routine hearing care: 1 855 205 6305. TTY users call 711. 8 a.m. to 8 p.m. Eastern time Monday through Friday Office of Retirement Services For information about your pension account, health insurance enrollment and eligibility: 1 800 381 5111 8:30 a.m. to 5 p.m., Eastern time Monday through Friday Address and membership changes: www.michigan.gov/orsmiaccount Your prescription, dental and vision coverage are provided by other vendors who partner with Michigan Public School Employees' Retirement System not through Blue Cross. 24 Hour Nurse Line 1 855 678 1705, TTY users call 711. 24 hours a day, seven days a week. Behavioral health and substance abuse care 1 888 803 4960. TTY users call 711. Access your plan on the go with the BCBSM mobile app The Blue Cross Blue Shield of Michigan mobile app provides the tools and features to help you access information and make informed decisions from the convenience of your smartphone. From seeing where you stand with your deductible and out-of-pocket balances, to reviewing service claims, to finding the best doctor or place to go for treatment count on our mobile app to give you the information you need when and where you need it. Visit www.bcbsm.com/app to learn more or search BCBSM in the Apple App store or Google Play and download it today. Report fraud 1 888 650 8136. TTY users call 711. 8:30 a.m. to 4:30 p.m. Monday through Friday Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Medicare Plus Blue SM is a PPO plan with a Medicare contract. Enrollment in Medicare Plus Blue depends on contract renewal. DB 14948 AUG 17 H9572_O_2018MPSERSRsrcGd FVNR 0917 R070598