Non-Medicare Blue Preferred PPO

Transcription

1 2018 Non-Medicare Blue Preferred PPO Summary of Benefits January 1, 2018 December 31, 2018 Michigan Public School Employees Retirement System

2 About the medical plan When you retire, you and your family are eligible for Michigan Public School Employees Retirement System 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 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 or call MYQUEST ( ). What you pay The medical plan has cost-sharing features in which you pay a percentage of the cost of services through coinsurance or copay and a. Coinsurance is applied before you meet your. The annual in 2018 is $1,000 per member. For members enrolled in LivingWell, the annual 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 pay more: an additional 20 percent coinsurance for most services that doesn t 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 Blue Shield approved amount. *Blue Cross Blue Shield of Michigan and BCN don t control this website or endorse its general content.

3 Your health coverage What you pay Hospital care In network Out of network Inpatient care Unlimited days Outpatient care Emergency services In network Out of network Emergency medical care Urgent care visit 10% coinsurance plus. $100 copay per visit once the annual coinsurance maximum is met. The $100 copay is waived if you re admitted to the hospital within 72 hours. 10% coinsurance plus $65 copay per visit once the annual coinsurance maximum is met. 10% coinsurance plus. $100 copay per visit once the annual coinsurance maximum is met. The $100 copay is waived if you re admitted to the hospital within 72 hours. 10% coinsurance plus $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 Surgical services In network Out of network 10% coinsurance plus plus the difference between the Blue Cross approved amount and charged amount Inpatient or outpatient surgery Organ and tissue transplants Certain transplants are only covered in Blue Cross designated transplant facilities. Doctor visits and services In network Out of network Inpatient visits Office visits For diagnosis and treatment of general medical conditions Annual gynecological exam Covered once per calendar year Routine physical exam and standard, routine labs done in conjunction with the physical exam Once per calendar year Flu shot Once per calendar year, in the fall or winter Screening colonoscopy People at high risk once every 24 months People who are not at high risk once every 120 months (10 years) 20% coinsurance 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 and s, is subject to change.

4 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 laboratory (Out of Michigan) At a physician s office (In Michigan) At a physician s office (Out of Michigan) In an outpatient hospital setting At a Quest Diagnostics lab: At a participating lab: 10% coinsurance plus In network: In network: 10% coinsurance plus In network: 10% coinsurance plus Diagnostic imaging services In network Out of network Routine mammograms Covered once per calendar year Imaging services Includes X-ray, and CAT, MRI, PET scans At a non-participating lab: You pay the difference between the the provider s charge and the Blue Cross approved amount. At a non-participating lab: 30% coinsurance plus plus the difference between the provider s charge and the Blue Cross approved amount. Out of network: 30% coinsurance plus Out of network: 30% coinsurance plus Out of network: 30% coinsurance plus 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) Home health care Unlimited days Hospice Covered up to two 90-day periods plus one 30-day period Private duty nursing Limited and temporary in-home nursing care 10% coinsurance plus All charges Deductible All charges All charges 10% coinsurance plus All charges Other covered services In network Out of network Allergy testing and treatment Blood and blood products Cardiac rehabilitation Chemotherapy services Chiropractic visits Covered up to 26 visits per year for spinal manipulations, X-rays Dental services Dental surgery when hospitalized; treatment for injuries

5 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 Physical, occupational and speech therapy Substance abuse treatment at an outpatient facility Payable up to the annual minimum dollar amount designated by state law Mental Health Treatment at an Outpatient Facility 10% coinsurance plus All charges 10% coinsurance plus All charges Mental health treatment In network Out of network At a physician s office Services from Clinical Licensed Master Social Worker Durable medical equipment and supplies, prosthetics and orthotics From an independent medical supplier At a Blue Cross approved provider 10% coinsurance plus At a non approved provider 30% coinsurance plus 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 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 and follow the instructions you re given. Note: Your routine hearing benefits are not subject to the annual. 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 Flyte 770 advanced aids $799 copay per hearing aid for Flyte 990 premium aids All charges Benefit maximums Coinsurance maximum Lifetime benefit maximums Organ transplant After you reach the $900 annual coinsurance maximum, your 10% coinsurance is waived for the remainder of the calendar year, and the 30% coinsurance for out-of-network services is reduced to 20%. $1 million lifetime maximum per member for outpatient services Separate $1 million maximum per organ for specific organ transplants 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. 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 and s, is subject to change.

6 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 Call BlueCard Access at BLUE (2583). Call TruHearing for routine hearing care benefits. Routine hearing exams and hearing aids are only covered when you call TruHearing at and follow the instructions you re given. Helping to keep you in the best of health The 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 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 Blue Shield Customer Service toll free at , 8:30 a.m. to 5 p.m., Monday through Friday. For current information about providers participating in the network, visit our website at or call Customer Service.

7 Questions? Customer Service TTY users should call 711 Monday through Friday 8:30 a.m. to 5 p.m. Eastern time

8 CF 1106 SEP 17 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. R072644