2022 Medicare BlueBasic (PPO)


Medicare BlueBasic (PPO) H3335-043 is a 2022 Medicare Advantage Plan or Part-C by Excellus Health Plan, Inc available to residents in New York. This plan does not provide additional prescription drug (Part-D) coverage. The Medicare BlueBasic (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,500 out-of-pocket. This can be a extremely nice safety net.

Medicare BlueBasic (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Excellus Health Plan, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Medicare BlueBasic (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Excellus Health Plan, Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Excellus Health Plan, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Excellus Health Plan, Inc Medicare Advantage Plan Costs

Name:
Medicare BlueBasic (PPO)
Plan ID:
H3335-043
Provider:Excellus Health Plan, Inc
Year:2022
Type: Local PPO *
Monthly Premium C+D: $0
Part C Premium:
MOOP: $4,500
Similar Plan: H3335-044
New Plan: 2023 H3335-044




2021 Medicare BlueBasic (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics Not covered
Extractions Not covered
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered
Restorative services Not covered



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) 30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI) $150 copay
Diagnostic tests and procedures $15 copay
Diagnostic tests and procedures 30% coinsurance (Out-of-Network)
Lab services $15 copay
Lab services 30% coinsurance (Out-of-Network)
Outpatient x-rays $40 copay
Outpatient x-rays 30% coinsurance (Out-of-Network)



Doctor Visits


Primary $5 copay per visit
Primary 30% coinsurance per visit (Out-of-Network)
Specialist $40 copay per visit
Specialist 30% coinsurance per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $40 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment 30% coinsurance (Out-of-Network)
Foot exams and treatment $40 copay
Routine foot care Not covered



Ground Ambulance


$200 copay (Out-of-Network)
$200 copay



Hearing


Fitting/evaluation $75 copay (Out-of-Network)
Fitting/evaluation $0 copay
Hearing aids $699-999 copay (Out-of-Network)
Hearing aids $699-999 copay
Hearing exam $40 copay
Hearing exam 30% coinsurance (Out-of-Network)



Inpatient Hospital Coverage


$325 per day for days 1 through 5
$0 per day for days 6 through 90
30% per stay (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies 30% coinsurance per item (Out-of-Network)
Diabetes supplies $5 copay per item
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) 30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item



Medicare Part B Drugs


Chemotherapy 30% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 30% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $324 per day for days 1 through 5
$0 per day for days 6 through 90
Inpatient hospital - psychiatric 30% per stay (Out-of-Network)
Outpatient group therapy visit 20% coinsurance
Outpatient group therapy visit 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 20% coinsurance
Outpatient individual therapy visit 30% coinsurance (Out-of-Network)
Outpatient individual therapy visit 20% coinsurance
Outpatient individual therapy visit with a psychiatrist 20% coinsurance
Outpatient individual therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)



MOOP


$7,800 In and Out-of-network
$4,500 In-network



Option


No



Optional supplemental benefits


Yes



Outpatient Hospital Coverage


$300 copay per visit
30% coinsurance per visit (Out-of-Network)



Package #1


Deductible $100.00
Monthly Premium $39.00



Preventive Care


$0 copay
0-30% coinsurance (Out-of-Network)



Preventive Dental


Cleaning Not covered
Dental x-ray(s) Not covered
Fluoride treatment Not covered
Oral exam Not covered



Rehabilitation Services


Occupational therapy visit 30% coinsurance (Out-of-Network)
Occupational therapy visit $40 copay
Physical therapy and speech and language therapy visit 30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit $40 copay



Skilled Nursing Facility


30% per stay (Out-of-Network)
$0 per day for days 1 through 20
$184 per day for days 21 through 100



Transportation


Not covered



Vision


Contact lenses Not covered
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) Not covered
Other Not covered
Routine eye exam $0 copay
Routine eye exam 30% coinsurance (Out-of-Network)
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Medicare BlueBasic (PPO) H3335



2021 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


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Medicare BlueBasic (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Medicare BlueBasic (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Medicare BlueBasic (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST




Coverage Area for Medicare BlueBasic (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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