Retirees with Medicare  (revised 2-18-03)

 

 

 

 

Preventive Services

BENEFITS

 

Health Maintenance Exam

Covered – 100%, one per calendar year, includes select lab and diagnostic procedures *

 

Annual Gynecological Exam

Covered – 100%, one per calendar year *

 

Pap Smear Screening – laboratory services only

Covered – 100%, one per calendar year *

 

 

 

 

Well-Baby and Child Care

Covered – 100% *

•   6 visits per year through age 1

•   2 visits per year, age 2 through age 3

•   1 visit per year, age 4 through 15

 

Immunizations

Covered – 100%, NO age limitation

 

 

 

Fecal Occult Blood Screening

Complete Blood Count

Chemical Profile

Flexible Sigmoidoscopy

Prostate Specific Antigen (PSA)

Covered – 100%, one per calendar year *

 

Chest X-ray

Covered – 100%, one per calendar year

 

Colonoscopy

Covered – 100%, one per calendar year

 

EKG

Covered – 100%, one per calendar year

 

 

Unlimited Preventive Care Benefits, no dollar benefit maximum

 

 

Mammography

 

 

Mammography Screening

Covered –100%

 

 

 

 

 

Physician Office Services

 

 

Office Visits

Covered $10 copay

 

Outpatient and Home Visits

 Covered $10 copay

 

Office Consultations

Covered $10 copay

 

Urgent Care

Covered $10 co-pay

 

 

 

 

 

Emergency Medical Care

 

 

Hospital Emergency Room – approved diagnosis

Covered – $50 co-pay, waived if admitted or for an accidental injury  (standard benefit)

 

 

Physician’s Office – approved diagnosis

Covered – 100%

 

Ambulance Services – medically necessary

Covered –90%, after deductible

 

 

Maternity Services Provided by a Physician

 

Pre-Natal and Post-Natal Care

 

 

Delivery and Nursery Care

 

 

Certified Nurse Midwife

Covered – 100%

 

 

Covered –100%

 

 

Covered

 

Abortions (Medically necessary)

Covered- 100%

 

 

 

 

 

Diagnostic Services

 

 

 

Laboratory and Pathology Tests

Covered –100%

 

Diagnostic Tests and X-rays

Covered –100%

 

Radiation Therapy

Covered – 100%

 

 

 

 

 

Hospital Care

 

 

 

Semi-Private Room, Inpatient Physician Care, General Nursing

Covered – 100%

 

Care, Hospital Services and Supplies

Unlimited days

 

Inpatient Consultations

Covered –100%

 

hemotherapy

Covered –100%

 

 

 

 

 

Alternatives to Hospital Care

 

 

 

Skilled Nursing Care

Covered –100%

 

 

365 days per calendar year,

 

Hospice Care

Covered – 100%

 

 

Limited to the lifetime dollar maximum

which is adjusted annually by the state

$16,650.85 lifetime maximum, of which $1,137.73 is a physician maximum

 

Home Health Care

Covered –100%

 

 

Unlimited visits

 

Ambulatory Surgical Facilities

(must be participating with BCBSM.

Covered –100%

 

 

 

 

 

Surgical Services

 

 

 

Surgery, including all related surgical services

Covered –100%

 

 

 

 

 

Human Organ Transplants

 

 

 

Specified Organ Transplants – in designated facilities

Covered – 100%

 

 

Up to $1 million maximum per transplant

 

Bone Marrow

Covered – 100%

 

Kidney, Cornea and Skin

Covered – 100%

 

 

 

 

 

 

 

Inpatient Mental Health Care and Substance Abuse Care

Covered – 100%

 

 

45 days Combined

 

Outpatient Mental Health Care

Covered $10 copay per visit

100 visits per calendar year

 

Cover MSWs, CSWs & LLPs

Covered - $10 copay, processed by Exception Processing (tied into the 100 outpatient Mental Health Visit maximum above. 

 

Outpatient Substance Abuse Care

Covered – 100%

 

 

Up to the state-dollar amount which is adjusted annually

 

 

 

 

 

Other Services

 

 

Allergy Testing and Therapy

Covered – 100%

 

Chiropractic Spinal Manipulation

Covered – 90%, after deductible

 

 

Up to 60 visits per calendar year

 

Outpatient Physical, Speech and

Occupational Therapy

Covered –100%

 

 

Up to 80 visits per calendar year

 

Durable Medical Equipment

Covered –90%, after deductible

 

Hearing Care Benefit

Covered 100%

 

Prosthetic and Orthotic Appliances

Covered- 90%, after deductible

 

Private Duty Nursing

Covered – 50%, after deductible

 

Certified Nurse Practitioner

Covered Rider CNP

$10 copay for office visits

 

Individual Case Management

Covered (ICMP Rider)

 

Deductible, Co-pays and Dollar Maximums

 

 

Deductible

$50 per member / $100 family

 

Co-pays

 

- Fixed

 

 

 

 

 

 

 

 

 

- Percent

 

 

$50 for emergency room visits.

 

Fixed $10 copay  for office visits & urgent care centers.

 

$10 copay for each Outpatient Mental Health visits.

 

No general copay, a copay only on select benefits noted below.

 

10% copay for Ambulance, Chiropractic Spinal Manipulation, Durable Medical Equipment, Prosthetic and Orthotic Equipment.

 

50% for private duty nursing.

 

Co-pay Dollar Maximums

Applies to ambulance, chiropractic spinal manipulation, Durable Medical Equipment and Prosthetic & Orthotic Appliances

$500 per member, $1000 family

 

Dollar Maximums

$5 million lifetime per member for all covered services

and as noted for individual services

 

 

 

 

 

Drug Program

-Retail

$10 copay for Generic drugs and $20 for Brand Drugs.

-University Health Center

            $5 copay for Generic drugs and $10 for Brand Drugs.

-Oral Contraceptives covered

 

Return to NMU Human Resources Benefits Page