PARTC

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C)
Insurance Provider
Blue Cross Blue Shield of Minnesota
CMS Rating
Plan Type
Cost
Annual Deductible
$0.00

What To Know About This Plan

  • This is a health coverage only plan

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
No
Out-Of-Pocket Spending Limit
$3,000 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
Not Applicable
Monthly Health Plan Premium
$74.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
$100 copay
Not Applicable
Inpatient Mental Health Care
$100 copay
Not Applicable
Skilled Nursing Facility (SNF)
$0
Not Applicable
Home Health Care
$0
Not Applicable
Doctor Office Visits
$15 maximum per visit
Not Applicable
Outpatient Services
$50 maximum per visit
Not Applicable
Ambulance Services
$25 maximum
Not Applicable
Emergency Care
$50 maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Kidney Disease and Conditions
$15 maximum per visit
Not Applicable
Specialist Office Visit
$15 maximum per visit
Not Applicable

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

Most drugs not covered.

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.


Drugs Covered under Medicare Part D

General

This plan does not offer prescription drug coverage.


Other Services

Inpatient Care

Doctor and Hospital Choice



In-Network

No referral required for network doctors, specialists, and hospitals.

In and Out-of-Network

You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share, you pay the Medicare Part B deductible and coinsurance.

Out of Service Area

Plan covers you when you travel in the U.S. or its territories.


Inpatient Hospital Care



In-Network

No limit to the number of days covered by the plan each hospital stay.

$100 copay for each Medicare-covered hospital stay

$0 copay for additional non-Medicare-covered hospital days


Outpatient Care

Inpatient Mental Health Care



In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

$100 copay for each Medicare-covered hospital stay.

Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.


Skilled Nursing Facility (SNF)



In-Network

Plan covers up to 100 days each benefit period

$0 copay for SNF services


Home Health Care



In-Network

$0 copay for Medicare-covered home health visits


Hospice



General

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


Doctor Office Visits



In-Network

$15 copay for each Medicare-covered primary care doctor visit.

$15 copay for each Medicare-covered specialist visit.


Outpatient Medical Services and Supplies

Chiropractic Services



In-Network

$15 copay for each Medicare-covered chiropractic visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).


Podiatry Services



In-Network

$15 copay for each Medicare-covered podiatry visit

Medicare-covered podiatry visits are for medically necessary foot care.


Outpatient Mental Health Care



In-Network

$15 copay for each Medicare-covered individual therapy visit

$15 copay for each Medicare-covered group therapy visit

$15 copay for each Medicare-covered individual therapy visit with a psychiatrist

$15 copay for each Medicare-covered group therapy visit with a psychiatrist

$15 copay for Medicare-covered partial hospitalization program services


Outpatient Substance Abuse Care



In-Network

$15 copay for Medicare-covered individual substance abuse outpatient treatment visits

$15 copay for Medicare-covered group substance abuse outpatient treatment visits


Outpatient Services



In-Network

$50 copay for each Medicare-covered ambulatory surgical center visit

$0 to $50 copay for each Medicare-covered outpatient hospital facility visit


Ambulance Services



In-Network

$25 copay for Medicare-covered ambulance benefits.


Emergency Care



General

$50 copay for Medicare-covered emergency room visits

Worldwide coverage.

If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.


Urgently Needed Care



General

$25 copay for Medicare-covered urgently-needed-care visits


Outpatient Rehabilitation Services



General

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

In-Network

$15 copay for Medicare-covered Occupational Therapy visits

$15 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits


Durable Medical Equipment



In-Network

20% of the cost for Medicare-covered durable medical equipment


Preventive Services

Prosthetic Devices



In-Network

20% of the cost for Medicare-covered prosthetic devices

20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices


Diabetes Programs and Supplies



In-Network

$0 copay for Medicare-covered Diabetes self-management training

20% of the cost for Medicare-covered Diabetes monitoring supplies

20% of the cost for Medicare-covered Therapeutic shoes or inserts


Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



In-Network

$0 copay for Medicare-covered:

  • lab services


  • diagnostic procedures and tests


  • X-rays


  • diagnostic radiology services (not including X-rays)


  • therapeutic radiology services



Cardiac and Pulmonary Rehabilitation Services



In-Network

$15 copay for Medicare-covered Cardiac Rehabilitation Services

$15 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$15 copay for Medicare-covered Pulmonary Rehabilitation Services


Additional Benefits

Preventive Services



General

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

In-Network

$0 copay for a supplemental annual physical exam


Kidney Disease and Conditions



General

Cost plan members pay Original Medicare cost sharing for out-of-area dialysis.

In-Network

$15 copay for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services


Dental Services



In-Network

In general, preventive dental benefits (such as cleaning) not covered.

$15 copay for Medicare-covered dental benefits


Hearing Services



In-Network

$0 copay for supplemental hearing aids.

$15 copay for Medicare-covered diagnostic hearing exams

$15 copay for up to 1 supplemental routine hearing exam(s) every year

$15 copay for up to 1 supplemental hearing aid fitting-evaluation(s) every year

$450 plan coverage limit for supplemental hearing aids every year.


Vision Services



In-Network

$0 to $15 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

$0 copay for up to 1 supplemental routine eye exam(s) every year

20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.

0% of the cost for eyeglasses (lenses and frames)

0% of the cost for contact lenses

$125 plan coverage limit for supplemental eyewear every year


CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Not Rated
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Not Rated
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions
Not Rated

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

Physician Finder

Physicians that accept Platinum Blue Choice (Cost) for Minnesota

/
DALY, PATRICK
651 ARCADE ST
SAINT PAUL, MN 55106
WHITE, MATTHEW
837 IVY AVE E
SAINT PAUL, MN 55106
DEVRIES, JASON
UFP PHALEN VILLAGE CLINIC
SAINT PAUL, MN 55106
LUNDSTEN, THOMAS
911 MARYLAND AVE E
SAINT PAUL, MN 55106
YANG, PAOKOU
1504 WHITE BEAR AVE N
SAINT PAUL, MN 55106
HATLESTAD, PRESTON
1414 MARYLAND AVE E
SAINT PAUL, MN 55106
NICHOLSON, WILL
1414 MARYLAND AVE E
SAINT PAUL, MN 55106
KARDELL, KATHERINE
911 MARYLAND AVE E
SAINT PAUL, MN 55106
WOOLNER, STANLEY
651 ARCADE ST
SAINT PAUL, MN 55106
AILABOUNI, ADAM
UFP - PHALEN VILLAGE CLINIC
SAINT PAUL, MN 55106
KELLY, TARA
911 MARYLAND AVE E
SAINT PAUL, MN 55106
RUDOLPH, SUSAN
825 NICOLLET MALL
MINNEAPOLIS, MN 55402
BARSANTI, JOHN
911 MARYLAND AVE E
SAINT PAUL, MN 55106
YANG, PETER
1504 WHITE BEAR AVE NORTH
SAINT PAUL, MN 55106
MATTSON, LOUISE
1414 MARYLAND AVE E
SAINT PAUL, MN 55106
BERENS, BRUCE
166 4TH ST E
SAINT PAUL, MN 55101
DAHIYA, RANJAN
640 JACKSON ST - MS 11102M
ST. PAUL, MN 55101
SMALLEY, STEVE
640 JACKSON ST - MS 11102M
ST. PAUL, MN 55101
TAYLOR, GREGORY
166 4TH ST E
SAINT PAUL, MN 55101
ASIS, MARTIN
166 4TH ST E
SAINT PAUL, MN 55101
BARAGA, JOSEPH
166 4TH ST E
SAINT PAUL, MN 55101
BLOCK, NATHAN
166 4TH ST E
SAINT PAUL, MN 55101
BRETZKE, CARL
166 4TH ST E
SAINT PAUL, MN 55101
CHUY, ADOLFO
166 4TH ST E
SAINT PAUL, MN 55101
COX, TED
166 4TH ST E
SAINT PAUL, MN 55101
Details
PATRICK DALY, M.B., B.S
Phone Number
(651) 793-3100
Office Locations
651 ARCADE ST
SAINT PAUL, MN 55106
651 ARCADE ST SAINT PAUL MN, 55106

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