Blue Medicare HMO Essential is a Medicare Advantage HMO plan with 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) and a standalone Part D plan. The private health plan includes benefits not provided by Original Medicare.
What's the Benefit of a HMO Plan from Blue Cross and Blue Shield of North Carolina?
The advantage of a HMO plan, like this one, is lower out-of-pocket costs (e.g., premium, co-payments and co-insurance). However, the cost reduction does come with restrictions. Specifically, you must use in-network providers (unless you have an emergency).
CRITICAL: The Medicare Part D plan that's included with Blue Medicare HMO Essential has a deductible and co-pays. If you take medications, take the time to verify that your prescriptions are covered at a good price before joining this plan.
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 it's more restrictive than Original Medicare, this Blue Cross and Blue Shield of North Carolina plan 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
We recommend evaluating these five components of this plan before making an enrollment decision:
- Premium: This is what you pay each month to be a plan member. The Medicare Advantage premium is not inclusive of your Medicare Part B premium, which you must continue to pay.
- Co-payment & Co-insurance: When you use most healthcare services you pay a portion of the cost out-of-pocket. It's important to understand what these shared costs will be before you join.
- Maximum-Out-Of-Pocket (MOOP): Medicare Advantage limits your annual shared costs. A plan's MOOP is the most you'll pay in a plan year before the plan pays 100%.
- Prescription Coverage: Prescriptions are costly. For this reason, it's important to evaluate how this plan will covers your medications (e.g., what you'll pay at the pharmacy).
- CMS 5-Star Ratings: Medicare evaluates all plans in 9 major areas. Have a good look, because it will help you understand how the plan will care for you.
Premiums and Deductibles
This plan's premium is $76.00 per month. The premium is inclusive of the Medicare Part D component for your prescriptions. Most healthcare services, except preventive care, also include shared costs (e.g., co-payments or co-insurances). Review the H3449-023 Summary of Benefits for details.
Be aware that the Medicare Part C component of this plan does not have a deductible, but the Part D component, for your prescriptions, does. The Part D deductible is $355.00 per year. That means you pay 100% of your prescription costs until you've spent $355.00, then the plan will begin paying it's share.
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 Essential is right for you.
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:||$10 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 Essential includes Medicare Part D coverage for prescriptions. If you have regular prescriptions, be sure to look up your medications in the plan's formulary.
In addition to the monthly premium and deductible, the Part D component of this plan has shared costs. You'll pay these when you pickup your medications at the pharmacy. Here are the plan's tiered shared costs:
|6||Select Care Drugs||$3|
|6||Select Care Drugs||$3|
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 Essential MOOP is $6,700 . 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 Essential 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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