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

2021 Medicare BlueBasic (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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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

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Deductible

$0

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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)

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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)

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Emergency care/Urgent Care

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

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Foot Care (podiatry services)

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

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Ground Ambulance

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

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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)

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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)

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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

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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

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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)

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MOOP

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

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

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

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Package #1

Deductible	$100.00
Monthly Premium	$39.00

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Preventive Care

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

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Preventive Dental

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

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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

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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

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Transportation

Not covered

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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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Medicare BlueBasic (PPO) H3335

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

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

Health Plan Customer Service Rating for Medicare BlueBasic (PPO)

Medicare BlueBasic (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
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.