Schedule F - PPO Summary of Benefits_Medicare Advantage.pdf

Medicare Plus BlueSM Group PPO

Summary of Benefits January 1, 2019 – December 31, 2019 www.bcbsm.com/mpsers

Michigan Public School Employees‘ Retirement System

This information is a summary document and not a complete description of benefits. Call 1-800-422-9146 (TTY call 711) for more information. To get a complete list of services covered by your retirement system, call Medicare Plus Blue Group PPO Customer Service and ask for the Evidence of Coverage (phone numbers are printed on the back of this booklet).

Medicare Plus BlueSM is a Medicare Advantage Preferred Provider Organization (PPO) with a network of doctors, hospitals, and other providers. If you use the providers that are in our network, you may pay less for your covered services. But you can also use providers that are not in our network. For more detailed information about our providers, and our provider network, you can call BCBSM Medicare Plus Blue Group PPO Customer Service Customer Service (phone numbers are printed on the back cover of this booklet) or visit our website at www.bcbsm.com/providersmedicare.

Out-of-network/non-contracted providers are under no obligation to treat Medicare Plus Blue Group PPO members, except in emergency situations. To find out if your out-of-network service is covered, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call BCBSM Medicare Plus Blue Group PPO Customer Service (phone numbers are printed on the back cover of this booklet) or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

The provider network may change at any time. You will receive notice when necessary.

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

To join Medicare Plus Blue Group PPO, you must be enrolled in Medicare Part A and Medicare Part B and live in our service area. Our service area includes all 50 states and all U.S.

territories.

Monthly premium, deductible and limits on how much you pay for covered services

Monthly Plan Premium

You are required to pay a premium contribution defined by the Office of Retirement Services. You, or others on your behalf, must continue to pay your Medicare Part B premium.

Coinsurance Maximum

$900 is the maximum amount you’ll pay in coinsurance during 2019.

Deductible $800 is the annual amount you’re responsible for paying for covered medical expenses before your retirement system begins to pay.

Maximum Out-of-Pocket Responsibility

$1,700 is the maximum dollar amount you’ll pay in coinsurance, copay and deductible during the calendar year. Once you reach the maximum, you pay nothing for covered hospital and medical services for the remainder of the year. Copays for routine hearing exams and hearing aids are not included in the out-of-pocket maximum.

Plan Limit Your retirement system has a $1 million lifetime maximum for services not covered by Original Medicare.

These services are identified by ** following the benefit. If you reach the $1 million maximum, an additional $1,000 per calendar year will be restored as long as uninterrupted coverage is in effect. The additional $1,000 allowance is renewed on January 1 the following calendar year.

Benefits Medicare Plus Blue Group

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Ambulance You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Chiropractic Services*

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Chiropractic benefits are limited to spinal X-rays** and spinal manipulations for diagnoses related to the spine (subluxation of the spine).

Dental Services Your Medicare Plus Blue Group PPO plan will cover the same medically necessary services that Original Medicare covers.

For cost-sharing information for those services (surgery, office visits, X-rays), contact BCBSM Customer Service.

Diabetes Programs and Supplies

Includes glucose monitors, test strips, lancets, screening tests, therapeutic shoes or inserts due to severe diabetic foot disease, and self-management training

You pay $0 of the approved amount.

Deductible does not apply.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Diagnostic Services/Clinical Labs/Imaging*

Clinical lab services

Diagnostic radiology service (e.g., MRI)

Diagnostic tests and procedures

Outpatient X-rays

Therapeutic radiology services

You pay $0 of the approved amount for clinical lab services.

For all other diagnostic services, you pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

*Only high-tech X-rays require preauthorization.

Doctor Visits

Includes primary and specialist visits.

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Durable Medical Equipment and Supplies*

Includes wheelchairs, oxygen, home dialysis equipment and supplies, colostomy supplies, home infusion needles, surgical dressings, adult briefs** and adult diapers** and up to eight (four pair) of gradient compression stockings per year **, etc.

In-network:

You pay 10% of the approved amount, deductible applies.

Out-of-network:

You pay 30% of the approved amount, deductible applies.

The coinsurance and deductible apply to the annual out-of-pocket maximum.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Emergency Room Care

You pay $120 copay.

Deductible does not apply.

Copay applies to annual out-of-pocket maximum.

Copay is waived if admitted to the hospital within 3 days.

You may go to any emergency room if you reasonably believe you need emergency care.

Foot Care (podiatry)

Includes foot exams and treatment.

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

You must have diabetes-related nerve damage and/or meet certain conditions.

Hearing Aids and Routine Exams

Hearing aids includes standard monaural and binaural

Routine Exam

Includes audiometric exam, hearing aid evaluation test, and hearing aid conformity test.

TruHearing Providers

Your copay depends on the type of hearing aid you purchase. For a monaural hearing aid, your copay will either be $499 or $799. For binaural hearing aids, your copay will be either $998 or $1,598.

You pay $45 copay for routine exams.

You have no benefits if you see a non-TruHearing provider.

Hearing aids and routine exams are covered every 36 months.

Call TruHearing at 1-855-205-6305 and follow the instructions you are given.

The copay does not apply to the annual out-of-pocket maximum.

Hearing Services – Medically Necessary

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to the annual out-of-pocket maximum.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Home Health Care* You pay $0 for approved home health services.

Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services.

Custodial care is not a benefit.

Hospice You pay $0 for care from a Medicare-certified hospice.

Hospice is covered outside your Medicare Plus Blue Group PPO plan. Original Medicare covers hospice when you enroll in a Medicare-certified hospice program.

Infusion Therapy

Includes home infusion therapy **

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Home infusion therapy includes nursing visits and related durable medical equipment and supplies.

Inpatient Hospital Care*

Includes rehabilitation services, and human organ transplants.

You pay 10% of the approved amount, deductible applies.

You pay $0 for Medicare-approved clinical lab services and preventive services.

The coinsurance and deductible apply to annual out-of-pocket maximum.

You have unlimited days for inpatient hospital coverage.

Mental Health Services*

Inpatient visit

Outpatient group therapy visit

Outpatient individual therapy visit

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

You have unlimited days of inpatient care coverage.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Outpatient Hospital Care*

You pay 10% of the approved amount, deductible applies.

You pay $0 for Medicare-approved clinical lab services and preventive services.

The coinsurance and deductible

Prescription Drugs (limited)*

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to out-of-pocket maximum.

Your plan covers a limited number of prescription drugs, like chemotherapy (including certain oral anti-cancer drugs), injections you get in a doctor's office, drugs used with some types of durable medical equipment, and immunosuppressant drugs.

Self-administered drugs you normally take on your own are not covered.

Step therapy may apply.

Preventive Care

Covered at 100% of the approved amount. Some limitations apply.

Abdominal Aortic Aneurysm Screening Alcohol Misuse Screening and Counseling Annual Physical Exam and Approved Related

Laboratory Tests

Bone Mass Measurement Breast Cancer Screening (Mammogram) Cardiovascular Disease Behavioral Therapy Cardiovascular Disease Screening

Any additional preventive services approved by Medicare during the contract year will be covered.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Cervical and Vaginal Cancer Screening

- Pap Exam

- Pelvic Exam

Colorectal Cancer Screening

- Screening Fecal Occult Blood Test

- Screening Flexible Sigmoidoscopy

- Screening Colonoscopy

- Screening Barium Enema

Depression Screening Diabetes Screening Diabetes Self-Management Training Flu Shots (Vaccine) Glaucoma Testing for members at risk Hepatitis B Shots (Vaccine) Hepatitis C Screening HIV Screening Kidney disease education Lung Cancer Screening with Low-Dose Computed

Tomography Medical Nutrition Therapy Services Medicare Diabetes Prevention Program Obesity Screening and Counseling Pneumococcal Shot (Vaccine) Prostate Cancer Screening Sexually Transmitted Infections Screening and

Counseling Tobacco Use Cessation Counseling for people with no sign of tobacco-related disease Welcome to Medicare Prevention Visit Yearly “Wellness” Visit

Any additional preventive services approved by Medicare during the contract year will be covered.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Private Duty Nursing**

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to the annual out-of-pocket maximum.

Skilled nursing services are services that must be performed by a registered nurse or licensed practical nurse in the member’s home or other BCBSM–approved place of service.

Private duty nursing is considered medically necessary if both general and specific clinical criteria are met.

Prosthetic and Orthotic Devices*

Prosthetics (braces, artificial limbs, mastectomy supplies, etc.)

Orthotic devices such as leg braces, back braces and ankle or wrist supports

In-network: You pay 10% of the approved amount, deductible applies.

Out-of-network: You pay 30% of the approved amount.

The coinsurance and deductible

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

Rehabilitation Services*

Cardiac and Pulmonary rehabilitation services

Occupational therapy visits

Physical therapy

Speech and language therapy visits

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Skilled Nursing Facility* (SNF)

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Your plan covers up to 100 days in a SNF.

Substance Abuse Services*

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible apply to annual out-of-pocket maximum.

Your plan covers an unlimited number of days for inpatient hospital stay.

Surgery Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers*

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible maximum.

Supervised Exercise Therapy (SET)

SET is covered for members who have

You pay 10% of the approved amount, deductible applies.

The coinsurance and deductible

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment.

Up to 36 sessions over a 12-week period are covered if the SET program requirements are met.

The SET program must:

Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication.

Be conducted in a hospital outpatient setting or a physician’s office.

Urgently Needed Services

You pay $65 copay, deductible does not apply.

The copay applies to annual out-of-pocket maximum.

Vision Services

Exam to diagnose

You pay 10% of the approved amount, The coinsurance and deductible

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $1 million lifetime maximum.

and treat diseases and medical conditions of the eye

Eyeglasses or contact lenses after cataract surgery deductible applies.

Routine eye exams and eyeglasses are not covered.

Worldwide Medical Care Your covered hospital and medical benefits and cost share is the same when you travel to a foreign country as if the services were rendered in the United States. For covered services performed abroad, your plan will pay the approved amount at the rate of exchange in effect on the date of service. You are responsible for costs that exceed the Medicare Plus Blue Group PPO approved amount plus your coinsurance, copay and deductible.

Medicare Plus BlueSM is a PPO plan with a Medicare contract. Enrollment in Medicare Plus Blue depends on contract renewal.

Customer Service for Medicare Plus Blue Group PPO

1-800-422-9146

TTY users should call 711

Monday through Friday

8:30 a.m. – 5 p.m.

Eastern time

DB 13346 SEP 18 R079458

H9572_2019MPSERS SB_M FVNR 0918