MyBlue Medigap℠ benefits

2014 plan information

Medigap basics

Blue Care Network of Michigan (BCN) offers MyBlue Medigap policies for Plans A, F 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 2014 CMS approved values and are subject to change in 2015. 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 copays.
  • Blood: First three pints of blood each year.
  • Hospice: Part A coinsurance.
Medigap Plans
How to read the chart:
If a check mark appears in a column of this chart, the Medigap policy covers 100% of the described benefit. If a row lists a percentage, the policy covers that percentage of the described benefit. If a row is blank, the policy doesn’t cover that benefit. Note: The Medigap policy covers coinsurance only after you have paid the deductible (unless the Medigap policy also covers the deductible).
Medigap Plans
Medigap benefits
A B C D F* G K L M N
Medicare Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Medicare Part B coinsurance or copayment 50% 75% ***
Blood (first three pints) 50% 75%
Part A hospice care coinsurance or copayment 50% 75%
Skilled nursing facility care coinsurance 50% 75%
Medicare Part A deductible 50% 75% 50%
Medicare Part B deductible
Medicare Part B excess charges
Foreign travel emergency (up to plan limits)
*Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible of $2,140 in 2014 before your Medigap plan pays anything. Out-of-pocket limit**
$4,940 $2,470
**After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($147 in 2014), the Medigap plan pays 100% of covered services for the rest of the calendar year.
***Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.
The deductible, coinsurance, and copay amounts listed in the charts above are based upon the 2014 CMS approved values and could change for 2015.

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, 2013 and Jan. 1, 2014. Policies sold for effective dates prior to Jan. 1, 2013 have different benefits and premiums.

Choose a MyBlue Medigap plan option that meets your needs

Please download the MyBlue Medigap plan brochure (PDF) for a detailed outline of coverage. You can 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 (PDF). 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 1-888-563-3307 (TTY users should call 711) or contact your Blue Care Network agent.

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. This request for information is insurance related and if you respond you may be contacted in an attempt to sell you insurance. MyBlue Medigap is not connected with or endorsed by the U.S. government or the federal Medicare program.

More information

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