Schedule F - PPO Summary of Benefits_nonMedicare.pdf

Michigan Public School Employees‘ Retirement System

Non-Medicare Blue Preferred® PPO

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

About the medical plan When you retire, you and your family are eligible for Michigan Public School Employees’ Retirement System’s health care coverage. If you’re not yet eligible for Medicare, you have a nationwide preferred provider organization (PPO) medical plan administered by Blue Cross Blue Shield of Michigan which provides additional savings when you use preferred providers. That includes hospital, medical and surgical care, emergency care and diagnostic services.

When you become eligible for Medicare, you’ll have a Medicare Advantage plan that is administered by Blue Cross. You’ll receive information about the retirement system Medicare Advantage plan in the mail three months before your 65th birthday.

Using preferred providers saves money, offers convenience The national Blue Cross PPO network offers providers selected for their quality of care and ability to provide cost-effective services. In Michigan, Blue Preferred® PPO plan offers the largest statewide network of physicians, specialists and other providers — including every acute care hospital in the state. Outside Michigan, you have access to network providers through the BlueCard® PPO program. Your out-of-pocket costs are lower when you use network providers and it’s convenient because you never have to file a claim.

For most services, you’re free to choose your own physicians and hospitals and still have coverage. But, if you select a provider that’s not part of the PPO network, you share a higher percentage of the cost.

Your routine hearing care benefit is brought to you through an arrangement between Blue Cross and TruHearing. Routine hearing exams and hearing aids are covered only when you call TruHearing at 1-855-205-6305 and follow the instructions you’re given. TruHearing does not provide Blue Cross branded products and services.

In Michigan, in addition to the Blue Cross network, you’ll also have:

• Quest Diagnostics, offering a network of independent labs within the state of Michigan.

To find a Quest Diagnostics lab visit www.questdiagnostics.com* or call

1-866-MYQUEST (697-8378).

What you pay Your retirement system medical plan has cost-sharing features in which you pay a percentage of the cost of services through coinsurance or copay and a deductible. Coinsurance is applied before you meet your deductible. The annual deductible in 2019 is $1,000 per member. For members enrolled in LivingWell, the annual deductible is $850 or $800 based on the number of program steps completed.

The following summary lists your out-of-pocket costs for covered services. Covered services will cost you less when you use a network provider. When you don’t use network providers, you’ll pay an additional 20 percent coinsurance for most services. The additional 20 percent does not apply to your coinsurance maximum.

If your out-of-network provider doesn’t participate with Blue Cross Blue Shield, in addition to the out-of-pocket cost indicated for the covered services, you’re also responsible for the difference between the provider’s charge and the Blue Cross approved amount.

*Blue Cross Blue Shield of Michigan and BCN don’t control this website or endorse its general content.

Your health coverage What you pay

Hospital care In network Out of network

Inpatient care Unlimited days 10% coinsurance plus deductible 30% coinsurance plus deductible

Outpatient care 10% coinsurance plus deductible 30% coinsurance plus deductible

Emergency services In network Out of network

Emergency medical care

10% coinsurance plus deductible.

$120 copay per visit once the annual coinsurance maximum is met. The $120 copay is waived if you’re admitted to the hospital within 72 hours.

10% coinsurance plus deductible.

$120 copay per visit once the annual coinsurance maximum is met. The $120 copay is waived if you’re admitted to the hospital within 72 hours.

Urgent care visit 10% coinsurance plus deductible $65 copay per visit once the annual coinsurance maximum is met.

10% coinsurance plus deductible $65 copay per visit once the annual coinsurance maximum is met.

Ambulance services At a Blue Cross approved provider At a non-approved provider

Ambulance 10% coinsurance plus deductible 10% coinsurance plus deductible plus the difference between the Blue Cross approved amount and charged amount

Surgical services In network Out of network

Inpatient or outpatient surgery 10% coinsurance plus deductible 30% coinsurance plus deductible

Organ and tissue transplants Certain transplants are only covered in Blue Cross designated transplant facilities.

10% coinsurance plus deductible 30% coinsurance plus deductible

Doctor visits and services In network Out of network

Inpatient visits 10% coinsurance plus deductible 30% coinsurance plus deductible

Office visits For diagnosis and treatment of general medical conditions

10% coinsurance plus deductible 30% coinsurance plus deductible

Annual gynecological exam — Covered once per calendar year 10% coinsurance plus deductible 30% coinsurance plus deductible

Routine physical exam and standard, routine labs done in conjunction with the physical exam Once per calendar year

Covered in full 20% coinsurance

**Flu shot — Once per calendar year, in the fall or winter Covered in full Covered in full

Screening colonoscopy People at high risk – once every 24 months People who are not at high risk – once every 120 months (10 years)

10% coinsurance plus deductible 30% coinsurance plus deductible

The Michigan Public School Employees’ Retirement System medical plan is administered by Blue Cross Blue Shield of Michigan under an agreement with the Michigan Office of Retirement Services. This publication is not a contract for coverage, but a brief outline of benefits offered to retirees and their eligible dependents who are not yet eligible for Medicare. The information provided here does not include all covered and noncovered services or conditions of coverage. Members who enroll in the medical plan are provided detailed information about the plan and terms of coverage. Coverage, including coinsurances, copays and deductibles, are subject to change.

**Flu shots and other services received at retail health clinics, such as CVS MinuteClinics or Walgreens Healthcare Clinics are not covered by your retirement system medical plan. If you need help finding no-cost flu shot locations, call Blue Cross Customer Service at 1-800-422-9146 from 8:30 a.m. to 5 p.m. Monday through Friday.

TTY users should call 711.

Your health coverage What you pay

Diagnostic services

Laboratory and pathology services — Includes Routine Pap smear and Prostate Specific Antigen screening — Covered once per calendar year

At a laboratory (In Michigan) At a Quest Diagnostics lab:

Covered in full

At a non-participating lab: You pay the difference between the the provider’s charge and the Blue Cross approved amount.

At a laboratory (Out of Michigan) At a participating lab: 10% coinsurance plus deductible

At a non-participating lab: 30% coinsurance plus deductible plus the difference between the provider’s charge and the Blue Cross approved amount.

At a physician’s office (In Michigan) In network: Covered in full Out of network: 30% coinsurance plus deductible

At a physician’s office (Out of Michigan) In network: 10% coinsurance plus deductible

Out of network: 30% coinsurance plus deductible

In an outpatient hospital setting In network: 10% coinsurance plus deductible

Out of network: 30% coinsurance plus deductible

Diagnostic imaging services In network Out of network

Routine mammograms Covered once per calendar year 10% coinsurance plus deductible 30% coinsurance plus deductible

Imaging services Includes X-ray, and CAT, MRI, PET scans 10% coinsurance plus deductible 30% coinsurance plus deductible

Alternatives to hospital care At a Blue Cross approved provider At a non-approved provider

Skilled nursing care Covered up to 100 days (days can be renewed)

10% coinsurance plus deductible All charges

Home health care Unlimited days Deductible All charges

Hospice Covered up to two 90-day periods plus one 30-day period

Covered in full All charges

Private duty nursing Limited and temporary in-home nursing care

10% coinsurance plus deductible All charges

Other covered services In network Out of network

Allergy testing and treatment 10% coinsurance plus deductible 30% coinsurance plus deductible

Blood and blood products 10% coinsurance plus deductible 30% coinsurance plus deductible

Cardiac rehabilitation 10% coinsurance plus deductible 30% coinsurance plus deductible

Chemotherapy services 10% coinsurance plus deductible 30% coinsurance plus deductible

Chiropractic visits Covered up to 26 visits per year for spinal manipulations, X-rays

10% coinsurance plus deductible 30% coinsurance plus deductible

Dental services Dental surgery when hospitalized;

treatment for injuries

10% coinsurance plus deductible 30% coinsurance plus deductible

The Michigan Public School Employees’ Retirement System medical plan is administered by Blue Cross Blue Shield of Michigan under an agreement with the Michigan Office of Retirement Services. This publication is not a contract for coverage, but a brief outline of benefits offered to retirees and their eligible dependents who are not yet eligible for Medicare. The information provided here does not include all covered and noncovered services or conditions of coverage. Members who enroll in the medical plan are provided detailed information about the plan and terms of coverage. Coverage, including coinsurances, copays and deductibles, are subject to change.

Your health coverage What you pay

Other covered services At a Blue Cross approved provider At a non-approved provider

Hemodialysis Covers services at a hospital outpatient department or in your home from an approved provider

10% coinsurance plus deductible 30% coinsurance plus deductible

Physical, occupational and speech therapy 10% coinsurance plus deductible 30% coinsurance plus deductible

Substance abuse treatment at an outpatient facility Payable up to the annual minimum dollar amount designated by state law

10% coinsurance plus deductible All charges

Mental Health Treatment at an Outpatient Facility 10% coinsurance plus deductible All charges

Mental health treatment In network Out of network

At a physician’s office 10% coinsurance plus deductible 30% coinsurance plus deductible

Services from Clinical Licensed Master Social Worker

10% coinsurance plus deductible 30% coinsurance plus deductible

Durable medical equipment and supplies, prosthetics and orthotics At a Blue Cross approved provider At a non–approved provider

From an independent medical supplier 10% coinsurance plus deductible 30% coinsurance plus deductible plus difference between the Blue Cross approved amount and charged amount

Diabetic supplies At a Blue Cross approved provider At a non–approved provider

From an independent medical supplier Covered in full Covered in full

Routine hearing care At a TruHearing provider At a non–TruHearing provider

Routine hearing exams and hearing aids, covered every 36 months as long as you call TruHearing at 1-855-205-6305 and follow the instructions you’re given.

Note: Your routine hearing benefits are not subject to the annual deductible.

Copays for routine hearing exams and hearing aids are not included in the annual coinsurance maximum.

$45 for audiometric exam

$499 copay per hearing aid for TruHearing Advanced 19 aids

$799 copay per hearing aid for TruHearing Premium 19 aids

All charges

Benefit maximums

Annual coinsurance maximum Once coinsurance payments total $900 per member, all covered services that were paid at 90% will be paid at 100% of the Blue Cross approved amount for the rest of the calendar year. You pay a copay for emergency room and urgent care visits after the annual coinsurance maximum is met. The 30% coinsurance for out-of-network services is reduced to 20%.

Lifetime benefit maximums $1 million lifetime maximum per member for outpatient services Separate $1 million maximum per organ for specific organ transplants

Organ transplant Coverage includes $10,000 maximums for organ procurement/storage, travel/lodging, and immunosuppressive drugs for heart, heart-lung, lung, liver, pancreas and intestine transplants that are included in the $1 million organ transplant lifetime benefit maximum.

Coverage outside of Michigan Whether you’re traveling across the country, around the world, or you live outside of Michigan, your medical benefits travel with you. The BlueCard® program provides access to providers without added cost. As part of the national Blue Cross Blue Shield Association of plans, you’ll find Blue Preferred PPO providers in every state. Using BlueCard® will minimize your cost and, in most cases, eliminate the need to file a claim.

To locate doctors and hospitals wherever you or a covered dependent need care (have your membership ID card handy):

• Use the Find a Doctor tool at www.bcbs.com

• Call BlueCard Access® at 1-800-810-BLUE (2583).

• Call TruHearing for routine hearing care benefits.

Routine hearing exams and hearing aids are only covered when you call TruHearing at 1-855-205-6305 and follow the instructions you’re given.

Helping to keep you in the best of health Your retirement system medical plan is designed to help you stay well, and provide quality care when you’re not.

Blue Cross network hospitals and physicians are selected for their commitment to providing high quality care.

You have access to the Cardiac Centers of Excellence, a statewide collection of hospitals specializing in treating heart disease.

You’ll also have access to free health information via Blue Cross® Health & Wellness, a comprehensive health and information program. You can speak directly with a health coach for answers to your health questions by calling the Health Coach Hotline at 1-800-775-BLUE (2583).

The quarterly member newsletter, Best of Health, keeps you up to date about your medical plan, shows you how to make the most of your health coverage and offers information on wellness and important health issues.

Have questions? Call Blue Cross Customer Service toll-free at 1-800-422-9146, 8:30 a.m. to 5 p.m.

Eastern time, Monday through Friday. For current information about providers participating in the network, visit our website at www.bcbsm.com/mpsers or call Customer Service.

http://www.bcbsm.com/mpsers

Questions?

Customer Service

1-800-422-9146

TTY users should call 711

Monday through Friday

8:30 a.m. to 5 p.m. Eastern time www.bcbsm.com/mpsers

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Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

CF 1106 SEP 17