Blue Medicare HMO Medical Only is a Medicare Advantage HMO plan without prescription drug coverage. This 2018 health plan is for seniors living in Bertie County, NC. It is an alternative to Original Medicare (Parts A & B). It may include additional benefits not provided by Original Medicare, however, this plan DOES NOT include coverage for prescriptions (Part D).
Why Consider a HMO Plan from Blue Cross and Blue Shield of North Carolina?
The benefit of an HMO plan is lower, predictable out-of-pocket expenses. Although more restrictive than Original Medicare, a Health Maintenance Organization plan limits your annual out-of-pocket costs. With Medicare Parts A and B, there's no cap, leaving you vulnerable to excessive medical bills.
CRITICAL: This plan does not include Medicare Part D benefits. If you choose this plan you will need to join a stand-alone North Carolina Medicare Part D plan to get help paying for your prescriptions.
IMPORTANT: With an HMO you must use healthcare providers in the plan's network. If you go outside of the network you will incur extra costs. In most cases, your primary care doctor must refer you to specialists and other healthcare services.
TIP: Even though this plan is more restrictive than Original Medicare, Blue Medicare HMO Medical Only caps your annual out-of-pocket shared-costs. This is not the case with Medicare Parts A and B. Without a full coverage Medicare Supplement, Original Medicare leaves you susceptible to high medical bills.
HMO Plan Features & Limitations
- Limited network of providers (e.g., doctors, hospitals, skilled nursing facilities).
- Responsible for 100% of cost for all out-of-network services (EXCEPT emergencies).
- Referrals required from primary care physician (EXCEPT emergencies).
- "Pay as you go" design with co-payments or co-insurance at time of care.
- Plan is NOT transferable if you move out of the service area.
- Premiums and benefits are subject to change every January 1st
Here are the important parts of the plan that need to be reviewed and carefully considered:
- Premium: This is the amount you will pay monthly, above and beyond your Medicare Part B.
- Maximum-Out-Of-Pocket (MOOP): This is the most you will pay for co-pays and co-insurance before the plan pays 100%.
- CMS Ratings: Important measurements across 5 different areas that will help you understand how well this plan will care for you.
- Co-pays & Co-insurance: If you see the doctor regularly, including specialists, you need to know what you'll pay for each visit.
Premiums and Deductibles
The monthly premium for this plan is $0.00. Plus, most healthcare services, except those for preventive care, include shared costs (e.g., co-payments or co-insurances). Review the H3449-012 Summary of Benefits for details.
IMPORTANT: The premium and deductible are important, but they are just one piece of the cost puzzle. Be sure to look at the variable costs and apply them to the healthcare services you use most. This is the only way to determine if Blue Medicare HMO Medical Only is right for you.
NOTE: This plan is Part C only, and does not have a Part D component. Therefore, no deductibles apply.
NOTE: The plan's premium does not include Part B. You must continue to pay your monthly Medicare Part B premium.
Co-Payments & Co-Insurance (Shared Costs)
All Medicare Advantage plans include shared costs (co-payments and co-insurances) for inpatient, outpatient, transportation and emergency healthcare services. Understanding your shared costs is important, particularly if you have one or more chronic health conditions.
Preventative Care Shared Costs
As required by Medicare Part B, the following preventative healthcare services are covered at no cost to the member:
- Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colorectal cancer screenings
- Depression screening
- Diabetes screenings
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling
- Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
- "Welcome to Medicare" preventive visit
- Yearly "Wellness" visit
NOTE: Any additional preventative health services approved by Medicare during the plan year will also be covered at no cost.
Outpatient Shared Costs
All outpatient health services, covered under the Medicare Part B component of this plan, have shared costs as follows:
|Primary Care Doctor:||$25 co-payment|
|Physician Specialist:||$50 co-payment|
|Occupational Therapist:||$40 co-payment|
|Physical Therapist:||$40 co-payment|
|Speech Terapist:||$40 co-payment|
Lab and Diagnostic Shared Costs
Lab and diagnostic services covered by this plan have the following shared costs:
|Medicare-covered Diagnostic Procedures/Tests:||20% co-insurance|
|Medicare-covered Lab Services:||20% co-insurance|
|Medicare-covered Diagnostic Radiological Services:||20% co-insurance|
|Medicare-covered Therapeutic Radiological Services||20% co-insurance|
|Medicare-covered X-Ray Services||20% co-insurance|
Emergency and Urgent Care Shared Costs
Emergency and urgent care services are Medicare Part B benefits and have shared costs. Some plans cover these shared costs if you become an inpatient within a specified period of time. Here are the shared costs with this plan:
|Urgent Care:||$65 co-payment|
|Emergency Care:||$80 co-payment |
Co-payment waived if admitted within 48 Hours
NOTE: Plans are not required to offer worldwide emergency care.
Inpatient Shared Costs
Shared costs on inpatient services (e.g., when admitted into a hospital or skilled nursing facility) are based on benefit periods. A benefit period starts when you are admitted and ends after you are no longer in an inpatient status for 60 consecutive days.
With each benefit period you pay a deductible, as permitted under Medicare Part A. There are no limits on the number of benefit periods. Here are the shared inpatient costs with this plan:
- Day 1 to 6: $300
- Day 7 to 90: $0
Hospice Shared Costs
You pay nothing. Hospice is covered in full if you use a Medicare-approved (certified) hospice facility. You may have some shared costs for drugs and respite care.
Medicare Part D Coverage (Rx)
Blue Medicare HMO Medical Only does not include Part D coverage for prescriptions. You can join a stand-alone North Carolina Medicare Part D plan.
Maximum Out-of-Pocket Limit
One of the most important features of Medicare Advantage is the annual Maximum Out-of-Pocket (MOOP) limit. This is the safety net that ensures your shared costs (co-payments and co-insurance) won't bankrupt you.
The Blue Medicare HMO Medical Only MOOP is $5,500 . If you spend more than this amount on your co-payments and co-insurance in this plan year, you'll pay no more towards your Medicare Part A and Part B healthcare services for the remainder of the year.
CMS allows plans to set MOOP at a voluntary level of $0 to $3,400 (in-network) or a at a mandatory level of $3,401 to $6,700 (in-network). For combined in- and out-of-network totals, MOOP can be up to $10,000.
NOTE: MOOP applies to Medicare Part C shared costs only. It does not include premiums or Part D (precscription costs).
IMPORTANT: It's important to calculate and compare annual premiums, shared costs and the MOOP with the cost of a North Carolina Medicare Supplement. Some Medicare Supplements offer shared costs with an annual cap that's much lower than $6,700 per year.
Confused by this? If you're not sure if a particular Medicare Advantage plan offers as much coverage as a Medigap plan, or how MOOP factors in, speak with a Medicare Adviser.
CMS 5-Star Ratings
Below are the CMS quality rating for this Blue Cross and Blue Shield of North Carolina plan. CMS rates health plans (Part C) in five broad categories. The prescription component (Part D) has its own rating, covered in four broad categories. We advise against enrolling in a plan with an overall score less than 3.0 stars.
|2018 Overall Rating|
|Part C Summary Rating|
|Part D Summary Rating|
|Staying Healthy: Screenings, Tests, Vaccines|
|Managing Chronic (Long Term) Conditions|
|Member Experience with Health Plan|
|Complaints and Changes in Plans Performance|
|Health Plan Customer Service|
|Drug Plan Customer Service|
|Complaints and Changes in the Drug Plan|
|Member Experience with the Drug Plan|
|Drug Safety and Accuracy of Drug Pricing|
Contact Blue Cross and Blue Shield of North Carolina
For more information about this plan, call their prospective members line, or visit their website:
For assistance 24 hours a day, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 or visit www.medicare.gov
Medicare Advantage Availability
Blue Medicare HMO Medical Only is available to residents of Aulander, Kelford, Lewiston Woodville, Roxobel, Colerain, Merry Hill, Powellsville, Windsor, and all other areas of Bertie County, North Carolina, with Medicare Benefits.
The Medicare Advantage plan data on MedicareNavigators.com comes from CMS.gov Landscape Source files and is subject to change. The Centers for Medicare and Medicaid Services has neither reviewed nor endorsed the information on this site. This web page was last reviewed and updated on .
This page is a brief summary of the plan benefits, not a complete description and is not intended to be a substitute for professional legal, health, or financial advice. Limitations, co-payments and/or co-insurance, and restrictions may apply. For complete details contact the plan at (800)665-8037 or (800)922-3140 for TTY users.
Medicare Requirements: You must live in the service area and have both Medicare Part A and Medicare Part B in order to enroll in a Medicare Advantage plan, and you must continue to pay your Medicare Part B premium.
Enrollment Period: Members may enroll in a Medicare plan only during specific times of the year, or around specific events or changes in individual circumstances as defined by Medicare. Co-payment, service area, and benefit limitations may apply.
HMO Provider Network: If you enroll in a plan with a closed provider network you must use the plan's providers, except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers, you are responsible for the costs.
PPO Out-of-Network and Non-Contract Providers: Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. For a decision about whether a PPO plan will cover an out-of-network service, ask for a pre-service organization determination before you receive the service.
Medicare Advantage PPO, Cost, and Point of Sale plans: If you enroll in a plan that has a network, but allows you to see providers outside that network, services may cost more, with the exception of emergencies or urgent care.
Pharmacy Network: For any plan that includes Part D benefits, you must use network pharmacies to access drug benefit, except in non-routine circumstances. Restrictions may apply.
Annual Plan Changes: Benefits, formulary, pharmacy network, premium, and/or co-payments/co-insurance may change January 1, of each year.
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