2012 plan information
MyBlue Medigap℠ benefits
Medigap basics
Blue Care Network of Michigan (BCN) offers MyBlue Medigap policies for Plans A, F, M and N only. Other Michigan insurance carriers may offer other or additional plans, but Medigap plans can be sold in only 10 standard plans plus one high deductible plan (Plans A – D, F, G, K, L, M and N. Plans E, H, I, and J are no longer available for sale). The deductible, coinsurance, and copay amounts listed in the charts below are based upon 2012 CMS approved values and are subject to change in 2013. Every insurer must make Plan A available. Plan A covers basic benefits:
- Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
- Medical expenses: Part B coinsurance (20 percent of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require the insured to pay a portion of Part B coinsurance or copayments.
- Blood: First three pints of blood each year.
- Hospice: Part A coinsurance.
BASIC BENEFITS: For Plans A – D, F, G, K, L, M and N*
| Plan | A | B | C | D | F/F** | G |
|---|---|---|---|---|---|---|
| Basic Benefits (including 100% Part B coinsurance) | x | x | x | x | x | x |
| Skilled Nursing | x | x | x | x | ||
| Part A Deductible | x | x | x | x | x | |
| Part B Deductible | x | x | ||||
| Part B Excess | 100% | 100% | ||||
| Foreign Travel Emergency |
$250 ded. | $250 ded. | $250 ded. | $250 ded. |
*Deductibles are based on 2012 rates and are subject to change in 2013.
**Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year ($2,070 in 2012) deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed ($2,070 in 2012). Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
Basic Benefits for Plans K, L, M and N include similar services as plans A-D, F and G, but cost-sharing for the basic benefits is at different levels. The coinsurance and copay amounts listed in this chart are based upon the 2012 CMS approved values and could change for 2013.
| Plan | K | L | M | N |
|---|---|---|---|---|
| Part A hospitalization coinsurance and preventive care |
100% |
100% |
100% |
100% |
| Hospice cost-sharing | 50% |
75% | – |
– |
| Medicare-eligible expenses for the first three pints of blood |
50% | 75% | 100% | 100% |
| Part B | 50% Part B coinsurance | 75% Part B coinsurance | – |
Part B copays up to $20 for office visits and up to $50 for emergency room visits |
| Skilled Nursing Coinsurance |
50% | 75% | 100% | 100% |
| Part A Deductible | 50% | 75% | 50% | 100% |
| Part B Deductible | – |
– |
– |
– |
| Part B Excess | – |
– |
– |
– |
| Foreign Travel Emergency |
– |
– |
$250 deductible | $250 deductible |
| Out of pocket Annual Limit | $4,660** | $2,330** | – |
– |
**Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges." You will be responsible for paying excess charges. The out-of-pocket annual limit will increase each year for inflation. The value here is for plan year 2012. Deductible and copay amounts are subject to change in 2013.
This document is the MyBlue Medigap outline of coverage and the details and exceptions of MyBlue Medigap follow. This outline shows benefits and premiums of policies sold for effective dates on or after Jan. 1, 2012. Policies sold for effective dates prior to Jan. 1, 2012 have different benefits and premiums.
Choose a MyBlue Medigap plan option that meets your needs
Please download the MyBlue Medigap plan brochure for a detailed outline of coverage.
Download the MyBlue Medigap plan brochure to compare benefits and premiums among policies, certificates of coverage and contracts and premiums offered by BCN. Visit the Premiums page for more information about plan premiums.
The outline of coverage does not give all the details of Medicare coverage. For information about your Medicare Part A and Part B coverage, contact your local Social Security office or consult Medicare & You. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
Note: The MyBlue Medigap plan may not fully cover all of your medical costs. When you receive covered services from a provider that does not accept Medicare assignment, you are responsible for the difference between the provider’s charge and the Medicare-approved amount, plus any deductible or coinsurance amounts required by the MyBlue Medigap plan you select.
Once enrolled in MyBlue Medigap, we’ll send you a member ID card and plan handbook that provides comprehensive details about your coverage. The certificate of coverage is your contract with BCN. The following is only an outline describing the most important features of BCN’s certificate of coverage. You must read the certificate to understand all of the rights and duties of both you and BCN. For more information about MyBlue Medigap coverage, call 1-877-469-2583, or contact your Blue Care Network agent. TTY users should call 1-800-481-8704.
Like Medicare, MyBlue Medigap coverage is accepted nationwide and the plan is easy to use. There are no provider networks or referrals: Just use any health care provider that accepts Medicare. Simply present your MyBlue Medigap ID card along with your red, white and blue Medicare health insurance card whenever you receive health care services. We’ll coordinate payment with Medicare and your health care providers. In most cases, you’ll never have to bother with claim filing or paperwork.
MyBlue Medigap offers access to any hospital, doctor or other health care provider in the U.S. or its territories that accepts Medicare assignment. The plan does not require members to use a specified provider network. MyBlue Medigap is a Medigap plan administered by Blue Care Network. Certain factors may affect the monthly premium cost: geographic location of the applicant’s residence, age, gender, height, weight and whether the applicant uses tobacco. Neither Blue Care Network nor agents authorized to sell Blue Care Network policies are connected with Medicare.
page modified 12/08/2011