MyBlue Medigap℠ benefits
2013 plan information
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 2013 CMS approved values and are subject to change in 2014. 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.
| Medigap Plans | |||||||||||
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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). |
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| 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 |  |
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| Medicare Part B coinsurance or copayment | |
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50% | 75% | |
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| Blood (first three pints) | |
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50% | 75% | |
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| Part A hospice care coinsurance or copayment | |
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50% | 75% | |
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| Skilled nursing facility care coinsurance | |
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50% | 75% | |
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| Medicare Part A deductible | |
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50% | 75% | 50% | |
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| Medicare Part B deductible | |
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| Medicare Part B excess charges | |
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| Foreign travel emergency (up to plan limits) | |
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| *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 $2,110 in 2013 before your Medigap pays anything. | Out-of-pocket limit** | ||||||||||
| $4,800 | $2,400 | ||||||||||
| **After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($147 in 2013), 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 2013 CMS approved values and are subject to change in 2014. | |||||||||||
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. 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 1-877-469-2583, or contact your Blue Care Network agent. TTY users should call 1-800-481-8704.
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.
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