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BCN Advantage HMO ConnectedCare (HMO) - H5883-007-000

4.5 out of 5 stars* for plan year 2025

$46.00

Monthly Premium

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

Plan ID: H5883-007-000

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

$46.00

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$46.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$3,800.00
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
Specialty doctor visitIn-Network:

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

Acute Hospital Services:
$225 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
Urgent careUrgent Care:
Copayment for Urgent Care $0 to $45
Minimum copay applies to urgent care services rendered in a PCP office and maximum copay applies to urgent care services rendered in urgent care.
Emergency Services: $125
Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $45
Worldwide Emergency Coverage $125
Maximum Plan Benefit of $50,000
Worldwide Emergency Transportation $230
Emergency room visit
Emergency Care:
Copayment for Emergency Care $125
Urgently Needed Services / Urgent Care Centers (min copay services in PCP office; max copay services in Urgent Care) $0-$45
Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Worldwide Urgent Coverage $45
Copayment for Worldwide Emergency Transportation $230
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $230
Air Ambulance:
Copayment for Air Ambulance Services $230

Please see Evidence of Coverage for details

Health Care Services and Medical Supplies

BCN Advantage HMO ConnectedCare (HMO) covers a range of additional benefits. Learn more about BCN Advantage HMO ConnectedCare (HMO) 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
Chiropractic X-rays (1 visit/year) $20
Prior Authorization Required for Chiropractic Services



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
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
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Outpatient Diagnostic Procedures/Tests (Min copay is $0 COVID-19 testing INN/OON and max copay is other outpatient diagnostic procedures and tests) $0-$20

Outpatient Lab Services: (Diagnostic Labs: JVHL) $0
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:
$225 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
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $20
Copayment for Medicare-covered Group Sessions $20
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $225
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.
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 $75.00 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
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


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
Cleaning (2 visits per calendar year):
In-network: You pay nothing
Fluoride Treatment (1 visit per calendar year):
In-network: You pay nothing
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

Medicare Covered Dental Services:
In-network: $0-$225

Comprehensive Dental services:
$0 copay In-network 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 careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $35
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year $0
Copay minimum for Medicare covered services applies to diabetic retinopathy exam. Copay maximum for Medicare covered services applies to services rendered by a Specialty Care provider.

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:
Medicare Covered Hearing Exams $0 to $35
Minimum copay reflects Primary Care Physician services and maximum applies to Specialty Care Physician services.

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
In-Network:
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:
COVID-19 shots
Flu shots
Hepatitis B shots
Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

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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