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BCN Advantage Elements (HMO-POS) - H5883-001-004

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

BCN Advantage Elements (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan

Plan ID: H5883-001-004

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Michigan Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Michigan Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible-$1.00
Out-of-pocket maximum$4,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

Out-of-Network:

Doctor Office Visit Services:
Copayment for Primary Care Office Visit $35
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35
Prior Authorization Required for Doctor Specialty Visit

Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Physician Specialist Office Visit $35
Inpatient hospital careIn-Network:

Acute Hospital Services:
$205 per day for days 1 to 7
$0 per day for days 8 to 90
$0 per day for days 90 and beyond
Prior Authorization Required for Acute Hospital Services

Out-of-Network:

$205 per day for days 1 to 7
$0 per day for days 8 to 90
$0 per day for days 90 and beyond
Urgent care
Urgent Care:
Copayment for Urgent Care $0 to $45

Minimum copayment amount applies to services provided in a PCP office. Maximum copayment amount applies to services provided in an urgent care facility.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $45
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $125

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $300
Copayment for Worldwide Urgent Coverage $45
Maximum Plan Benefit of $50,000
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Ambulance Services - Ground $300
Copayment for Ambulance Services - Air $300

Please see Evidence of Coverage for details

Health Care Services and Medical Supplies

BCN Advantage Elements (HMO-POS) covers a range of additional benefits. Learn more about BCN Advantage Elements (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Copayment for Routine Care $35
  • 1 Routine Care every year
Prior Authorization Required for Chiropractic Services
Chiropractic X-rays (1 visit/year) $20

Out-of-Network:

Medicare Covered Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $15
Chiropractic Services:
Copayment for Non-Medicare Covered Chiropractic Services $35.00. Please see Evidence of Coverage for more details.
Chiropractic X-rays (1 visit/year) $20
Routine care 1 visit per year

Medicare covers limited acupuncture
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies 0%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0%

Out-of-Network:
Diabetic Supplies and Services:
Copayment for Medicare Covered Diabetic Supplies and Services 0%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0%

Enrollee must obtain diabetic supplies and services including diabetic shoes and inserts from a plan contracted vendor
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 0% to 20%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $20
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$0 cost share applies to COVID-19 testing. The maximum applies to other outpatient diagnostic tests and procedures.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $20 to $100
Copayment for Medicare-covered Therapeutic Radiological Services $25
Copayment for Medicare-covered X-Ray Services $20 to $100
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$205 per day for days 1 to 7
$0 per day for days 8 to 90
$0 per day for days 90 and beyond
Prior Authorization Required for Psychiatric Hospital Services

Out-of-Network:
$205 per day for days 1 to 7
$0 per day for days 8 to 90
$0 per day for days 90 and beyond
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $20
Copayment for Medicare-covered Group Sessions $20

Out-of-Network:

Medicare Covered Mental Health Services:
Copayment for Medicare Covered Individual Sessions $35
Copayment for Medicare Covered Group Sessions $35
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $200
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $100
Prior Authorization Required for Ambulatory Surgical Center Services
Minimum copay applies to arthroplasty knee and hip. Maximum copay applies to services performed in an ambulatory surgical center.

Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $200
Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $100
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:

Allowance benefit of $50.00 every three months for Over-The-Counter (OTC) Items
The benefit is administered through a plan approved network of retail and mail order partners. (No Rollover)
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35
Prior Authorization Required for Podiatry Services

Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $35
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Out-of-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100

Prior authorization may apply to certain services.

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental care$1,500 combined in-network and out-of-network allowance for preventive and comprehensive dental services.

Preventive dental services:
Oral Exams (2 visits per calendar year):
In-network: You pay nothing
Point-of-service: 50% of the cost
Cleaning (2 visits per calendar year):
In-network: You pay nothing
Point-of-service: 50% of the cost
Fluoride Treatment (1 visit per calendar year):
In-network: You pay nothing
Point-of-service: 50% of the cost
Dental X-rays (One set of up to 4 bitewings or 6 periapical films every 2 calendar years) and Full Mouth X-Rays (every 5 years):
In-network: You pay nothing
Point-of-service: 50% of the cost

Medicare Covered Dental Services:
In-network: $0-$200
Point-of-service: $35-$200

Comprehensive Dental services:
$0 copay In-network and 50% coinsurance for Point-of-service for the following services:
Diagnostic: Exams - 2 per calendar year; X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical
Restorative: Fillings once per tooth/surface every 48 months, Crown repairs (3 per permanent tooth per calendar year), Crowns (once per permanent tooth every 84 months)
Endodontic: Root canal once per tooth per lifetime
Periodontics: Deep Cleaning 1 per quadrant per 24 months
Extractions: Once per tooth per lifetime
Prosthodontics/Other/Oral Maxiofacial Surgery, and Other services: Oral Surgery (2 per tooth per lifetime), Brush Biopsy (2 per calendar year)
Please see Evidence of Coverage for details

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision care
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $35
Copayment for Medicare Covered Eyewear $0

Please see Evidence of Coverage for details

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0 to $35
Copayment for Routine Hearing Exams $0 to $35
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
  • Maximum 1 visit every three years
Minimum copay reflects Primary Care Physician services and maximum applies to Specialty Care Physician services.

Hearing Aids:
Copayment for Hearing Aids $0
  • Maximum 2 Hearing Aids every three years
Maximum Plan Benefit of $600 every three years
Hearing aids are covered up to a $1200 maximum benefit ($600 per ear) every three years. Excludes hearing aid repairs, adjustments or reconfigurations.

Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $35

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0

When reviewing Michigan Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Michigan that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Michigan Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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