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BCN Advantage HMO-POS Community Value (HMO-POS) - H5883-012-001
$12.00
Monthly Premium
BCN Advantage HMO-POS Community Value (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-012-001
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$12.00
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
| Coverage | Details |
|---|---|
| Monthly plan premium | $12.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $4,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Primary Care Office Visit 35% |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment or Coinsurance per Day $300 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond Out-of-Network: Acute Hospital Services: 35% per day for days 1 to 7 35% per day for days 8 to 90 35% per day for days 90 and beyond |
| Urgent care | Urgent Care: Emergency Services: $125 Copayment for Urgent Care $0 to $45 Worldwide Emergency Coverage $125 Worldwide Emergency Transportation $275 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $45 Maximum Plan Benefit of $50,000 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 room visit | Emergency Care: Copayment for Emergency Care $125 Urgently Needed Services / Urgent Care Centers $0-$45 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Worldwide Urgent Coverage $45 Copayment for Worldwide Emergency Transportation $275 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275 Air Ambulance: Copayment for Air Ambulance Services $275 Please see Evidence of Coverage for details |
Health Care Services and Medical Supplies
BCN Advantage HMO-POS Community Value (HMO-POS) covers a range of additional benefits. Learn more about BCN Advantage HMO-POS Community Value (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $40
Chiropractic X-rays (1 visit/year) $20 Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 35% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-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 35% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts 35% |
| 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-rays | In-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 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $20 to $100 Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0% to 35% Coinsurance for Medicare Covered Lab Services 35% Coinsurance for Medicare Covered Diagnostic Radiological Services 35% Coinsurance for Medicare Covered Therapeutic Radiological Services 35% Coinsurance for Medicare Covered Outpatient X-Ray Services 35% $0 cost share applies to COVID-19 testing. The maximum applies to other outpatient diagnostic tests and procedures. |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $300 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond Out-of-Network: 35% per day for days 1 to 7 35% per day for days 8 to 90 35% per day for days 90 and beyond |
| Mental health outpatient care | Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 35% Coinsurance for Medicare Covered Group Sessions 35% |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $260 Observation Services (Per day/stay/other) $90 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $90 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $150 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: Coinsurance for Medicare Covered Outpatient Hospital Services 35% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35% Observation Services (Per day/stay/other) $90 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Out-of-Network: Outpatient Substance Abuse Services: |
| Over-the-counter items | In-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 services | Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 35% |
| Skilled Nursing Facility (SNF) care | In-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: 35% per day for days 1 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.
| Coverage | Details |
|---|---|
| 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-$260 Point-of-service: 35% 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 lifetime per tooth Periodontics: Deep Cleaning 1 per 24 months per quadrant 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
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $40 Copayment for Routine Eye Exams $0
Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
The mandatory vision benefit provides a $150 maximum benefit every calendar year that applies to frames and elective contact lenses only. The maximum does not apply to eyeglass lenses or medically necessary contact lenses. Benefit may be used for contact lenses or one pair of frames, but not both. If contact lenses are chosen, they are unlimited up to the maximum plan allowance. One pair of lenses for glasses is covered in full every calendar year.For the Optional Supplemental Step-Up Benefit, please reference Optional Supplemental Packages.Routine vision care must be obtained through a plan contracted vision provider. Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 35% Coinsurance for Medicare Covered Eyewear 35% 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.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 to $40 Copayment for Routine Hearing Exams $0 to $40
Minimum copay reflects Primary Care Physician services and maximum applies to Specialty Care Physician services. Fitting evaluation for hearing aids is provided at no cost every three years. Hearing Aids: Copayment for Hearing Aids $0
Hearing aids are covered up to a $1500 maximum benefit ($750 per ear) every three years. Excludes hearing aid repairs, adjustments or reconfigurations. Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance 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.
| Coverage | Details |
|---|---|
| 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
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