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Blue Care Network

Plan ID: H5883-1-2

BCN Advantage Elements (HMO-POS)

2024 BCN Advantage Elements (HMO-POS) H5883 — 001 — 2 is a Medicare Advantage plan . It has received a 4-out-of-5 star rating from CMS for 2024.

Learn more about BCN Advantage Elements (HMO-POS) H5883 - 001 - 2, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4 / 5 stars for 2024

$0.00 /mo

Monthly premium

$0

Health deductible

$4500.00

Out-of-pocket maximum

Enroll online

Call to enroll

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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 BCN Advantage Elements (HMO-POS) H5883 — 001 — 2 is a Local HMO offered in Region 2 by Blue Care Network. It has a monthly premium of $0.00.

Premium Breakdown

Standard Part B Premium

$174.70

Part B premium reduction

- $0

Monthly Plan Premium

$0.00

Total Premium:

$174.70

Note:

The standard Part B premium for 2024 is $174.70. Your Part B premium may differ based on factors including late enrollment, income, and disability status. Higher-income beneficiaries may pay an income-related monthly adjustment amount (IRMAA). The Part B premium is required to be paid by everyone enrolled in Medicare Part B.

Special needs plan type

No

Out-of-pocket maximum

$4500.00

Plan Organization:

Blue Care Network

Plan Type:

Local HMO

Location:

Region 2

Drugs Covered:

No

Drug Formulary:

Pharmacies:

Pharmacies Link

Doctor Choice:

Plan Doctors Only (some exceptions)

Doctors Link:

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

$0

Sign up for BCN Advantage Elements (HMO-POS)

Enroll online

Call to enroll

Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

BCN Advantage Elements (HMO-POS) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.

Additional Benefits

BCN Advantage Elements (HMO-POS) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Restorative services

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Endodontics

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Periodontics

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Extractions

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Preventive dental

Oral exam

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Cleaning

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Fluoride treatment

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Dental x-ray(s)

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: $0-20 copay

Out-Of-Network: $0-20 copay

Lab services

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic radiology services (eg, MRI)

In-Network: $20-100 copay

Out-Of-Network: $20-100 copay

Outpatient x-rays

In-Network: $20-100 copay

Out-Of-Network: $20-100 copay

Doctor visits

Primary

In-Network: $0 copay

Out-Of-Network: $0-35 copay per visit

Specialist

In-Network: $35 copay per visit

Out-Of-Network: $0-35 copay per visit

Emergency care/Urgent care

Emergency

$90 copay per visit (always covered)

Urgent care

$0-45 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $35 copay

Out-Of-Network: $0-35 copay

Routine foot care

Not covered

Ground ambulance

Service

In-Network: $250 copay

Out-Of-Network: $250 copay

Hearing

Hearing exam

In-Network: $0-35 copay

Out-Of-Network: $0-35 copay

Fitting/evaluation

In-Network: $0 copay

Hearing aids

In-Network: $0 copay

Inpatient hospital coverage

Service

In-Network: $205 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: $205 per day for days 1 through 6 $0 per day for days 7 through 90

Outpatient hospital coverage

Service

In-Network: $0-200 copay per visit

Out-Of-Network: $0-200 copay per visit

Optional benefits

Service

Yes

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 0-20% coinsurance per item

Out-Of-Network: 0-20% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Out-Of-Network: 0-20% coinsurance per item

Diabetes supplies

In-Network: $0 copay

Out-Of-Network: $0 copay

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 20% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 20% coinsurance

Part B Insulin drugs

In-Network: 0-20% coinsurance (up to $35)

Out-Of-Network: 20% coinsurance

Mental health services

Inpatient hospital - psychiatric

In-Network: $205 per day for days 1 through 6 $0 per day for days 7 through 90

Out-Of-Network: $205 per day for days 1 through 6 $0 per day for days 7 through 90

Outpatient group therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: $0-35 copay

Outpatient individual therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: $0-35 copay

Outpatient group therapy visit

In-Network: $20 copay

Out-Of-Network: $0-35 copay

Outpatient individual therapy visit

In-Network: $20 copay

Out-Of-Network: $0-35 copay

Preventive care

Service

In-Network: $0 copay

Out-Of-Network: $0 copay

Rehabilitation services

Occupational therapy visit

In-Network: $30 copay

Out-Of-Network: $30 copay

Physical therapy and speech and language therapy visit

In-Network: $30 copay

Out-Of-Network: $30 copay

Skilled Nursing Facility

Service

In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100

Out-Of-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100

Transportation

Service

In-Network: $0 copay

Vision

Routine eye exam

In-Network: $0 copay

Other

Not covered

Contact lenses

In-Network: $0 copay

Eyeglasses (frames and lenses)

Not covered

Eyeglass frames

In-Network: $0 copay

Eyeglass lenses

In-Network: $0 copay

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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