Medical Benefits

For Medicare Members

Newly covered services: Please click here to see a list of new benefits.

Visiting the Doctor and Other Providers1

Your primary care physician (PCP) will coordinate your health care. You're not required to see your PCP before visiting a specialist, but it's strongly recommended so that your PCP is fully aware of the medical care you're receiving. Learn more about choosing a PCP and how to access your health care.

Blue Medicare HMO

For Blue Medicare HMO, you must use plan providers1, except in emergency/urgent care situations, or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Original Medicare nor Blue Medicare HMO is responsible for the costs.

Blue Medicare PPO

Member liability with Blue Medicare PPO may be greater for services received out of network than services received in network. Many out-of-network services are subject to coinsurance, which is based on the Medicare allowed amount and not on the potentially lower contract amount. With the exception of emergency or urgent care, it may cost more to get care from non-plan or non-preferred providers. Out-of-network/non-contracted providers are under no obligation to treat Blue Cross NC members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.


Summary of Benefits

2019

2018

 

Did You Know?

Medicare Advantage Members: We'll mail you a monthly Explanation of Benefits that lists all of your claims processed the previous month.

 


1 Formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. 

PPO Travel Program

Our Blue Medicare PPO Travel Program enables Blue Medicare PPO members traveling in certain states and Puerto Rico to use the networks of other participating Blue Cross and/or Blue Shield Medicare Advantage PPO plans. Please call for more details.

States/territory with visitor/traveler benefits for PPO members only:

  • Alabama
  • Connecticut
  • Hawaii
  • Indiana
  • Louisiana
  • Michigan
  • Montana
  • New Jersey
  • Ohio
  • Pennsylvania
  • Tennessee
  • Virginia
  • Wisconsin
  • California
  • Florida
  • Idaho
  • Kansas
  • Maine
  • Minnesota
  • Nevada
  • New Mexico
  • Oklahoma
  • Puerto Rico
  • Texas
  • Washington
  • Colorado
  • Georgia
  • Illinois
  • Kentucky
  • Massachusetts
  • Missouri
  • New Hampshire
  • New York
  • Oregon
  • South Carolina
  • Utah
  • West Virginia

Blue 365

Blue365

Blue3651 offers access to health and wellness deals exclusive to Blue members at no additional cost.

Savings for every aspect of your life:

  • Fitness: Gym memberships & fitness gear
  • Personal Care: Vision & hearing care
  • Healthy Eating: Weight loss & nutrition programs
  • Lifestyle: Travel & family activities
  • Wellness: Mind/body wellness tools & resources

It's easy to get started:

Deals delivered right to you

When you sign up, you'll get deal alerts via email. You won't receive any spam, and we only send out one deal alert per week to help you keep your inbox clutter-free.

Visit bcbsnc.com/blue365 to register online. For assistance, call 1-855-511-BLUE (2583)

1 Blue365 offers access to savings on items that Members may purchase directly from independent vendors, which are different from items that are covered under the policies with Blue Cross NC. Any disputes regarding these products and services may be subject to Blue Cross NC's grievance process. Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors. Neither Blue Cross NC nor BCBSA recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. This program may be modified or discontinued at any time without prior notice.

The Silver&Fit® Exercise & Healthy Aging Programs

Blue Medicare HMO and Blue Medicare PPO members have access to a no cost fitness membership through the Silver&Fit® Exercise & Healthy Aging program, which makes it easy to get more active and stay fit. Members can work out at a participating fitness center or YMCA, or, if at home workouts are preferred, up to two home fitness kits can be requested each calendar year through the Silver&Fit Home Fitness program. For more information go to www.Blueconnectnc.com, on the Home page click on Silver&Fit or call Monday through Friday between 8 a.m. to 9 p.m. Eastern Time, toll free at 1-888-797-8058 (TTY/TDD 711).

The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH and used with permission herein. ASH is an independent company that is solely responsible for fitness services it is providing. American Specialty Health does not offer Blue Cross or Blue Shield products or services.

TruHearing Hearing Aid Benefit

Blue Medicare HMO and Blue Medicare PPO members have access to a hearing aid benefit through TruHearing. This benefit makes it more affordable for members to treat hearing loss by lowering out-of-pocket costs. TruHearing Advanced and Premium hearing aids are high-quality, digital hearing aids featuring the latest advances in hearing technology. They are smartphone-compatible, allowing you to stream audio directly from your iPhone (available to Android phones with the use of an additional accessory), and come in a variety of styles and colors. As part of the program, a TruHearing provider will consult with you to determine the best type and style of hearing aid to address your lifestyle and unique hearing needs. For more information and to schedule a hearing exam with a provider in your area call TruHearing at 1-866-202-0093. For TTY, dial 711 8 a.m. – 8 p.m., Monday through Friday.

All content ©2018 TruHearing, Inc. All Rights Reserved. TruHearing® is a registered trademark of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners. TruHearing is an independent company that is solely responsible for the hearing aid services it is providing. TruHearing does not offer Blue Cross or Blue Shield products or services.

Blue Medicare HMO and PPO Frequently Asked Questions

What happens to my Medicare coverage when I join a Blue Medicare HMO or Blue Medicare PPO plan?

Once you become a Blue Medicare HMO or Blue Medicare PPO member, you transfer the administration of your Medicare benefits to Blue Medicare HMO or Blue Medicare PPO. This means you maintain your status as a Medicare beneficiary, plus gain the enhanced coverage available through your Blue Medicare HMO or Blue Medicare PPO health plan. You will receive a Blue Medicare HMO or Blue Medicare PPO Member ID card that you will present when using your Blue Medicare HMO or PPO benefits. You should present your Blue Medicare HMO or PPO ID card when using your pharmacy1 benefits. You are still responsible for paying your Medicare Part B premium.

Are annual physicals covered?

Yes, Blue Medicare HMO and Blue Medicare PPO recognize the importance of preventive care and encourage routine health examinations for all members.

What happens if I have a medical emergency?

If you have a medical emergency, go to the nearest medical facility or call 911. Blue Medicare HMO and Blue Medicare PPO plans cover eligible emergency services for you in or out of the service area. Please contact your primary care physician or Blue Medicare HMO or Blue Medicare PPO within 48 hours so your PCP can coordinate follow-up care. Emergency services require a copayment, but it will be waived if you are admitted to the hospital on an inpatient basis within 48 hours.

If I'm a military retiree, can I join a Blue Medicare HMO or Blue Medicare PPO plan without losing my military benefits?

Yes. Once you join Blue Medicare HMO or Blue Medicare PPO, you can continue to use your military benefits at military facilities and your Blue Medicare HMO or Blue Medicare PPO benefits outside of the military system.

Can I qualify for financial assistance if I have a limited income?

If you have Medicare and Medicaid, you already qualify for low income assistance. If you don't qualify for Medicaid, you may still qualify for some assistance. The amount of assistance will depend on your income and resources and will be applied to the cost of the Medicare prescription drug coverage portion of your Blue Medicare HMO or PPO plan. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call 1-800-MEDICARE (1-800-633-4227). Hearing and speech impaired users should call 1-877-486-2048 (TTY/TDD), 24 hours a day/7 days a week or The Social Security Administration at 1-800-772-1213 between 7:00 a.m. and 7:00 p.m., Monday - Friday. Hearing and speech impaired users should call 1-800-325-0778 (TTY/TDD) or your State Medicaid Office.

If you do qualify for additional assistance for your Medicare prescription drug coverage costs, the amount of your premium and cost at the pharmacy will be lower. Once you have enrolled in a Blue Medicare HMO or Blue Medicare PPO plan, Medicare will tell us how much assistance you are receiving and we will send you information on the amount you will pay.

Can I buy a stand-alone Medicare prescription drug plan from Blue Cross NC?

Yes, but if you enroll in a Medicare Advantage plan and want Medicare prescription drug coverage, you must enroll in a Medicare Advantage prescription drug plan - one that includes both medical and prescription drug benefits.

Can I use my Medicare prescription drug coverage to order my drugs from Canada?

No. Only drugs purchased in the United States are eligible for Medicare prescription drug coverage.

What is a "Welcome to Medicare" Physical with Original Medicare vs. Blue Cross NC Annual Physical?

You can get this introductory visit only within the first 12 months you have Part B. This visit includes a review of your medical and social history related to your health and education and counseling about preventive services, including certain screenings, shots, and referrals for other care. Blue Cross NC covers an annual physical with your Primary Care Physician every 12 months.

If I choose the Blue Medicare HMO plan that does not include Medicare prescription drug coverage, can I buy separately from another source?

No. If you choose to enroll in the Blue Medicare HMO Medical only plan that does not include prescription drug coverage, federal regulations prohibit you from purchasing a separate Medicare prescription drug plan as a separate policy or from another company.

Is Blue Medicare HMO or Blue Medicare PPO a Medicare Supplement policy?

No, a Medigap (Medicare Supplement) policy fills the gaps in Original Medicare Plan coverage. If you join a Medicare Advantage Plan, you'll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of North Carolina and not Original Medicare.


1 Pharmacy network may change at any time. You will receive notice when necessary.

Low Income Subsidy and Best Available Evidence

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

2019 LIS Table

Your level of extra help Monthly Premium for Blue Medicare
HMO Essential (H3449-023-001)* HMO Essential (H3449-023-002)* HMO Essential (H3449-023-004)* HMO Enhanced (H3449-024-001)* HMO Enhanced (H3449-024-002)* PPO Enhanced (H3404-003-001)* PPO Enhanced (H3404-003-002)*
100% $0.00 $1.40 $35.40 $24.70 $56.70 $48.80 $58.80
75% $0.00 $6.90 $40.90 $31.90 $63.90 $56.00 $66.00
50%  $0.00 $12.50 $46.50 $39.10 $71.10 $63.20 $73.20
25%  $0.00 $18.00 $52.00 $46.40 $78.40 $70.50 $80.50

2018 LIS Table

Your level of extra help Monthly Premium for Blue Medicare
HMO Essential (H3449-023-001)* HMO Essential (H3449-023-002)* HMO Enhanced (H3449-005)* PPO Enhanced (H3404-003-001)* PPO Enhanced (H3404-003-002)*
100% $26.60 $45.80 $80.20 $67.80 $83.40
75% $34.20 $53.40 $87.80 $75.40 $91.00
50%  $41.70 $60.90 $95.30 $82.90 $98.50
25%  $49.30 $68.50 $102.90 $90.50 $106.10

*This does not include any Medicare Part B premium you may have to pay.

Blue Medicare HMO's and Blue Medicare PPO's premium includes coverage for both medical services and prescription drug coverage.

If you aren't getting extra help, you can see if you qualify by calling:

  • Your State Medicaid Office, or
  • The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call Customer Services at 1-888-310-4110 for HMO, 1-877-494-7647 for PPO, (TTY: 1-888-451-9957). We are available for phone calls 8 a.m. to 8 p.m. daily. Calls to these numbers are free.

In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.

To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.

Please click on the link to CMS website below for materials related to the CMS Best Available Evidence (BAE) policy.

http://www.cms.hhs.gov/prescriptiondrugcovcontra/17_best_available_evidence_policy.asp

Help with Premiums for Eligible Individuals

Blue Cross and Blue Shield of NC partners with Change Healthcare to help you get the benefits and extra help to which you may be entitled. Change Healthcare through its MyAdvocateTM program assistance will discuss your personal situation and provide an assessment of the availability of assistance.


MEDICARE SAVINGS CompleteTM

MyAdvocateTM will perform an individual screening to determine your eligibility for Medicaid services and government assistance with your MedAdvantage premium based on your income and financial asset level. If eligible, it will help you through the enrollment process.


Extra Help (Part D) Program

This program identifies qualifying seniors and the disabled who are eligible to receive extra help to pay for prescription medication and help to complete the program application.


Your Privacy is Important

In order to make the assessment, MyAdvocateTM will gather personal financial information necessary to make a determination, so be prepared for questions regarding your finances. Rest assured that Change Healthcare does not share this information with any company or agency other than government agencies that require it should you qualify. The Blue Cross NC contract with Change Healthcare requires that your information be protected. Blue Cross NC does not receive the information that Change Healthcare gathers.

Source: http://www.changehealthcare.com/eligibility-enrollment-solutions/