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BCN Advantage Local (HMO) - H5883-015-000
$0.00
Monthly Premium
BCN Advantage Local (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-015-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
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 | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $4,175.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $325 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 to $45 Minimum copayment amount applies to services provided in a PCP office. Maximum copayment amount applies to services provided in an urgent care facility. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $45 Worldwide Emergency Coverage $125 Worldwide Emergency Transportation $275 Maximum Plan Benefit of $50,000 |
| 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 Copayment for 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 Local (HMO) covers a range of additional benefits. Learn more about BCN Advantage Local (HMO) 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 $35
Medicare covers limited acupuncture |
| 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 Enrollee must obtain diabetic supplies and services including diabetic shoes and inserts from a plan contracted vendor. |
| 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 |
| 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 Copayment for Medicare-covered Therapeutic Radiological Services $25 Copayment for Medicare-covered X-Ray Services $20 to $100 |
| 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 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $100 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. |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Allowance benefit of $75.00 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) (No Rollover) |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35 Prior Authorization Required for Podiatry Services |
| 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 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 | In-Network: $0-275 copay for Medicare-covered Dental Services. Cost share may vary depending on where the service is provided. $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 Cleaning (2 visits per calendar year): In-network: You pay nothing Fluoride Treatment (1 visit per calendar year): In-network: You pay nothing Dental X-rays (One set of up to 4 bitewings or 6 periapical films every 2 calendar years: In-network: You pay nothing Prophylaxis (Cleaning) 2 visits per calendar year $0 Fluoride Treatment 1 visit per calendar year $0 Comprehensive Dental services: $0 copay In-network 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 tooth per lifetime Periodontics: Deep Cleaning 1 per quadrant per 24 months 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 $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses and Frames $150 max allowance per year used for contact lenses or one pair of frames Copayment for Lenses and Frames Covered in full once per year Maximum 1 Pair (Please see Evidence of Coverage for details) Maximum Plan Benefit of $150 every year 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. Please see Evidence of Coverage for details 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 $35 Copayment for Routine Hearing Exams $0 to $35
Hearing Aids: Copayment for Hearing Aids $0
Hearing aids are covered up to a $1200 maximum benefit ($600 per ear) every three years. Excludes hearing aid repairs, adjustments or reconfigurations. |
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 | In-Network: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots: COVID-19 shots Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation Yearly "Wellness" visit |
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
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.