Schedule I2 PPO Medicare Summary of Benefits.pdf

Medicare Plus BlueSM Group PPO

Summary of Benefits January 1, 2024 – December 31, 2024

Michigan Public School Employees‘ Retirement System www.bcbsm.com/mpsers

SCHEDULE I2 - PPO MEDICARE SUMMARY OF BENEFITS

RFP NO. 230000003226

http://www.bcbsm.com/mpsers

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 Blue Cross 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 Blue Cross Medicare Plus Blue Group PPO 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 you, 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 Blue Cross 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.

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 meet the eligibility requirements for the Michigan Public School Employees' Retirement System, have both Medicare Part A and Medicare Part B, be a United States citizen or lawfully present in the United States and live in our geographic service area. Incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. Our service area includes all 50 states and all U.S. territories.

http://www.bcbsm.com/providersmedicare https://www.medicare.gov/

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 Michigan Office of Retirement Services. You, or others on your behalf, must also continue to pay your Medicare Part B premium.

Coinsurance Maximum

$900 is the maximum amount you’ll pay in coinsurance during 2024.

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

Out-of-Pocket Maximum

$1,700 is the maximum dollar amount you’ll pay in coinsurance, copays and deductible during 2024. 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 $2.5 million lifetime maximum for services not covered by Original Medicare.

These services are identified by ** following the benefit. If you reach the $2.5 million maximum, an additional $1,000 per calendar year will be restored as long as uninterrupted coverage remains 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 $2.5 million lifetime maximum.

Ambulance

• Ground or air

• Ambulance services without transportation**

You pay 10% of the approved amount;

deductible applies.

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

Cost sharing applies to each one-way trip.

Behavioral and 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 the annual out-of-pocket maximum.

You have unlimited days of inpatient care coverage.

Chiropractic Services*

You pay 10% of the approved amount;

deductible applies.

The coinsurance and deductible apply to the 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

Includes coverage for certain dental services that you get when you’re in a hospital.

Also covers services required for the initial treatment of an injury to the jaws, sound natural teeth, mouth or face. The injury must have occurred after the effective date of your

You pay 10% of the approved amount;

deductible applies.

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

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

Services must be performed by a physician or dentist.

The medical plan doesn’t cover most dental care, dental procedures, or supplies, like

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $2.5 million lifetime maximum.

coverage with your retirement system.

cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices.

Injuries from biting or chewing are also not covered.

Diabetes Programs and Supplies

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

You pay 10% of the approved amount for diabetes self-management training; deductible applies.

You pay $0 of the approved amount for diabetes supplies.

You pay $0 for diabetic test strips at participating pharmacies.

The coinsurance and deductible apply to the annual out-of-pocket maximum for diabetes self-management training.

Deductible does not apply to diabetes supplies.

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 the annual out-of-pocket maximum.

*High-tech radiology (X-rays) require prior authorization.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $2.5 million lifetime maximum.

Doctor Visits Includes primary and specialist visits.

Your plan also covers telehealth services including those for primary care physician services and specialty providers.

You pay 10% of the approved amount;

deductible applies.

The coinsurance and deductible

Durable Medical Equipment and Supplies*

Includes wheelchairs, oxygen, home dialysis equipment and supplies, colostomy supplies, home infusion needles, surgical dressings, monitoring (including therapeutic continuous monitors and supplies), adult diapers** (including adult briefs**) and up to eight (four pair) 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

Northwood is the in-network durable medical equipment supplier. Northwood can be reached at 1-800-667-8496, 8:30 a.m. to 5 p.m., Monday through Friday.

TTY users call 711.

Emergency Room Care

You pay $135 copay.

Deductible does not apply.

Copay applies to the annual out-of-pocket maximum.

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

You are covered for emergency medical care worldwide.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $2.5 million lifetime maximum.

Foot Care (podiatry)

Includes foot exams and treatment.

You pay 10% of the approved amount;

deductible applies.

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

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

Hearing Aids and Routine Hearing Exams from TruHearing

Includes TruHearing Advanced and TruHearing Premium hearing aids. Routine hearing exam includes audiometric exam, hearing aid evaluation test, and hearing aid conformity test performed by a TruHearing provider.

TruHearing Providers

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

You pay $45 copay for routine hearing exams.

Hearing aids and routine exams are covered every 36 months.

Call TruHearing at 1-855-205-6305, 8 a.m. – 8 p.m., Monday – Friday (TTY

711) and follow the instructions you are given.

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

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

Hearing Services – For Illness and Injury

You pay 10% of the approved amount;

deductible applies.

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

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

Includes medically necessary home health aide services and rehabilitation services.

Custodial care is not a covered benefit.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $2.5 million lifetime maximum.

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

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 the 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 the annual out-of-pocket maximum.

You have unlimited days for inpatient hospital coverage.

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 apply to the annual out-of-pocket maximum.

Outpatient clinics owned and operated by hospitals (known as hospital-based practices) may cost you more.

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $2.5 million lifetime maximum.

Prescription Drugs (limited)*

Includes coverage for 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.

You pay 10% of the deductible applies.

You pay no more than $35 for a one month’s supply of insulin.

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

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

• Cervical and Vaginal Cancer Screening

- Pap Exam

- Pelvic Exam

• Colorectal Cancer Screening (Blood-based Biomarker Test, Colonoscopy, Fecal Occult Blood Test, Flexible Sigmoidoscopy, Barium Enema, Multi-target Stool DNA Test)

• COVID-19 Shots (Vaccine)

• Depression 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 $2.5 million lifetime maximum.

• Diabetes Screening

• Flu Shots (Vaccine)

• Glaucoma Testing for Members at Risk

• Hepatitis B Screening

• 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 Preventive Visit

• Yearly “Wellness” Visit

Prosthetic and Orthotic Devices*

• Prosthetics (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; 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 $2.5 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 the annual out-of-pocket maximum.

Rehabilitation services available in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities.

Skilled Nursing Facility* (SNF)

You pay 10% of the approved amount;

deductible applies.

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

Your plan covers up to 100 days in a SNF. Your days renew after you’ve been out of a SNF or hospital for 60 consecutive days.

SilverSneakers® health and fitness benefit

Includes SilverSneakers’ in-person exercise classes, equipment use and other amenities, at thousands of participating locations nationwide.

SilverSneakers also offers many online exercise classes and videos.

You pay $0 for SilverSneakers’ benefits.

Fitness services must be provided through SilverSneakers.

SilverSneakers GO mobile app provides access to on-demand videos and live classes.

Go to www.silversneakers.com to learn more or call 1-866-584- 7352, 8 a.m. to 8 p.m. Eastern time, Monday through Friday.

TTY users call 711.

SilverSneakers is a registered trademark of Tivity Health, Inc.

© 2023 Tivity Health, Inc. All rights reserved.

http://www.silversneakers.com/

PPO

In- and out-of-network

What you should know

Note:

Services with * may require prior authorization.

Services with ** apply to the $2.5 million lifetime maximum.

Substance Use Disorder Services*

You pay 10% of the approved amount;

deductible applies.

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

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

Surgery Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers*

You pay 10% of the deductible applies.

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

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 and treat diseases and medical conditions of the eye

• One pair of eyeglasses or contact lenses after cataract surgery

You pay 10% of the approved amount;

deductible applies.

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

Routine eye exams and eyeglasses are not covered.

Worldwide Medical Care Your covered hospital and medical benefits, as well as the associated cost share, are 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.

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

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H9572_2024MPSERSSB_M FVNR 0923

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