2013 Individual plan coverage

Plans, premiums, coverage and copayments

Understanding Medicare

Premiums

Premiums vary by the county in which you permanently reside. Rates are based on the use and cost of health care services in each regional segment.

Low-income subsidy

Medicare beneficiaries can receive extra help with paying for their prescription drug benefits if they have limited income and resources. Those who qualify pay no or reduced premiums.

Premium for Service Area (by County) Elements Basic Classic Prestige Focus
Monthly Premium (in addition to
monthly Medicare Part B Premium)
Region 1
Allegan, Barry, Ionia, Kalamazoo, Kent, Muskegon, Newaygo, Oceana, Ottawa		 $20 $0 $75 $203 N/A
Region 2
Calhoun, Eaton, Gratiot, Ingham, Jackson, Monroe, Montcalm, Van Buren		 $28 $0 $88 $218 N/A
Region 3
Bay, Clare, Crawford, Gladwin, Huron, Kalkaska, Roscommon, Saginaw, Sanilac, Shiawassee, Tuscola		 $33 $0 $96 $213 N/A
Region 4
Clinton, Genesee, Grand Traverse, Isabella, Lapeer, Livingston, Mecosta, Midland, Missaukee, St. Clair		 $20 $0 $78 $200 N/A
Region 5
Macomb, Oakland, Washtenaw		 $39 $0 $113 $218 N/A
Wayne county only $39 $0 $113 $218 $58

Your cost as a member of the plan

Annual Deductible Elements Basic Classic Prestige Focus
Annual Medical Deductible $160 $300 $125 $0 $0

Summary of services

This is a summary of most-often-sought services that BCN Advantage covers and how much you will pay for each service. For additional information, see your Evidence of Coverage booklet.

Medical Coverage Elements Basic Classic Prestige Focus
Inpatient hospital care

Days 1-5:
$180 copay per day

Days 6+:
$0 copay

Days 1-5:
$200 copay per day

Days 6+:
$0 copay

Days 1-5:
$130 copay per day

Days 6+:
$0 copay

Days 1-5:
$90 copay per day

Days 6+:
$0 copay

$400 per Medicare covered stay
Skilled nursing facility (in a Medicare-certified nursing facility)

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day
Outpatient services $0 to $125 copay $0 to $125 copay $0 to $100 copay $0 to $75 copay $0 to $100 copay
Office visits: primary care physicians $20 copay $25 copay $15 copay $10 copay $15 copay
Office visits: specialists $40 copay $45 copay $35 copay $25 copay $35 copay
Outpatient surgery

Ambulatory copay: $75

Hospital copay: $125

Doctor office copay: $50

Ambulatory copay: $75

Hospital copay: $125

Doctor office copay: $50

Ambulatory copay: $60

Hospital copay: $100

Doctor office copay: $40

Ambulatory copay: $45

Hospital copay: $75

Doctor office copay: $30

Ambulatory copay: $60

Hospital copay: $100

Doctor office copay: $40
Ambulance services $50 copay $50 copay $50 copay $50 copay $75 copay
Urgent care — worldwide $35 copay $35 copay $35 copay $35 copay $35 copay
Emergency medical care — worldwide $65 copay $65 copay $65 copay $65 copay $65 copay
Durable medical equipment 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance
Preventive services $0 copay $0 copay $0 copay $0 copay $0 copay
Preventive services, such as Welcome to Medicare exam, Personalized Prevention Plan Services, bone mass measurement, colorectal screening, glaucoma screening, immunizations (including flu, pneumonia and Hepatitis B vaccines), mammograms, Pap smears, and prostate screening.
New preventive benefits include: screening and behavioral counseling interventions to reduce alcohol misuse, screening for depression in adults, screening for sexually transmitted infections (STIs) and behavioral counseling to prevent (STIs), behavioral therapy for cardiovascular disease, and behavioral therapy for obesity.
Other physical exams $20 copay $25 copay $15 copay $10 copay $15 copay
Chiropractic $20 copay $20 copay $20 copay $20 copay $20 copay
Podiatry $40 copay $45 copay $35 copay $25 copay $35 copay
Outpatient psychotherapy services $40 copay $40 copay $35 copay $25 copay $35 copay

Out-of-pocket maximum and annual deductibles

To protect your financial health, your annual out-of-pocket costs are capped. Once the deductible, coinsurance and copayments you pay for medical services reach the values indicated below, we pay 100% of your covered services for the remainder of the calendar year.

Annual Out-of-Pocket Maximum Elements Basic Classic Prestige Focus
Out-of-pocket maximum for Medicare-covered
medical services (excluding durable medical equipment)		 $3,600 $4,200 $3,400 $3,200 $3,400
The plan covers 100% after the out-of-pocket maximums are reached

H5883_BCNAdvantageWebR5.4 Pending CMS Approval

Important Plan and Benefit Information

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