2022 SUMMARY OF BENEFITS - FOR YOU. WITH YOU - BLUECARE PLUS CHOICE (HMO D-SNP)SM - BLUECARE PLUS DSNP
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For you.
With you.
BlueCare Plus Choice (HMO D-SNP)
SM
2022 Summary of Benefits
H3259_22SBF_M (08/21)Pre-Enrollment Checklist
Before making an enrollment decision, it is important that you
fully understand our benefits and rules. If you have any questions,
you can call and speak to a customer service representative
at 1-888-413-9637, TTY 711.
Understanding the Benefits
❒ Review the full list of benefits found in the Evidence of Coverage (EOC), especially
for those services for which you routinely see a doctor. Visit bluecareplus.bcbst.com
or call 1-888-413-9637, TTY 711 to view a copy of the EOC.
❒ Review the provider directory (or ask your doctor) to make sure the doctors you see
now are in the network. If they are not listed, it means you will likely have to select a
new doctor.
❒ Review the pharmacy directory to make sure the pharmacy you use for any prescription
medicine is in the network. If the pharmacy is not listed, you will likely have to select a
new pharmacy for your prescriptions.
Understanding Important Rules
❒ Benefits, premiums and/or copayments/co-insurance may change on January 1, 2023.
❒ Except in emergency or urgent situations, we do not cover services by out-of-network
providers (doctors who are not listed in the provider directory).
❒ This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be
based on verification that you are entitled to both Medicare and Medicaid and are
a BlueCare Choices 1, 2 or 3 member. The Medicaid categories we accept are QMB+,
SLMB+ and FBDE.
BlueCare Plus Tennessee, an Independent Licensee of the Blue Cross Blue Shield Association
H3259_22PECF_C (07/21)This is a summary of health and drug services
covered by BlueCare Plus Choice (HMO D-SNP)SM
health plan from Jan. 1, 2022 through Dec. 31, 2022.
BlueCare Plus Choice is an HMO Special Needs Plan (D-SNP) with a
Medicare contract and a contract with the Tennessee Medicaid program.
Enrollment in BlueCare Plus Choice depends on contract renewal.
The benefit information provided in the following chart is a summary
of what you pay for Medicare and Medicaid benefits covered under the
plan. It does not list every service covered under the plan or list every
limitation or exclusion. To get a complete list of services covered under
the plan, please request the "Evidence of Coverage" by contacting
Member Service or access it online by visiting bluecareplus.bcbst.com.
To join BlueCare Plus Choice, you must be enrolled in Medicare
Part A and Part B, receive Full Dual Medicaid assistance with BlueCare,
qualify for CHOICES Groups 1, 2 or 3, and live in our service area.
Our service area includes all Tennessee counties. Eligibility for full
Medicaid benefits means you are eligible to receive TennCare benefits
for the following Medicare Savings Program levels of eligibility (QMB+,
SLMB+ and FBDE).
TennCare is not responsible for payment for these benefits, except
for appropriate cost-sharing amounts such as premiums, deductibles
and copays. TennCare is not responsible for guaranteeing the availability
or quality of these benefits.
The BlueCare Plus Choice plan has a network of doctors, hospitals,
pharmacies and other providers. If you use providers who are not in
our network, the plan will not pay for these services, unless authorized
in advance. This plan does not require referrals to see specialists in the
BlueCare Plus Choice network.
Questions? Call 1-888-413-9637, TTY 711 | 1Summary of Medicare and Medicaid Benefits
for Contract H3259-002
Health Benefits BlueCare Plus Choice
Monthly Plan Premium
Our service area includes all counties $0. You pay nothing.
in the state of Tennessee.
Deductible $0. You pay nothing.
$7,550 annually. If you have Medicaid assistance,
Maximum Out-of-Pocket Responsibility all cost-sharing amounts will be sent to the
(does not include prescription drugs) Division of TennCare to process.
Requires prior authorization
$0 cost share
Inpatient Hospital Coverage
Our plan covers an unlimited number of days for an
inpatient hospital stay.
Outpatient Hospital Services
Ambulatory surgical center $0 cost share
Outpatient hospital $0 cost share
Doctor Visits
Primary Care Providers $0 cost share
Specialists $0 cost share
2 | Questions? Call 1-888-413-9637, TTY 711Health Benefits BlueCare Plus Choice
If CMS approves additional preventive services
under Original Medicare, these will be covered
Preventive Care under the plan from the date covered under
Original Medicare.
Our plan covers many preventive
services, including:
Abdominal aortic aneurysm screening
Alcohol misuse screenings and counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral
therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
» Multi-target stool DNA tests
» Screening barium enemas
» Screening colonoscopies
» Screening fecal occult blood tests $0 cost share
» Screening flexible sigmoidoscopies
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B Virus (HBV) infection
screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Questions? Call 1-888-413-9637, TTY 711 | 3Health Benefits BlueCare Plus Choice
If CMS approves additional preventive services
under Original Medicare, these will be covered
Preventive Care (continued) under the plan from the date covered under
Original Medicare.
Nutrition therapy services
Obesity screenings and counseling
One-time "Welcome to Medicare"
preventive visit
Prostate cancer screenings
Sexually transmitted infections screening
& counseling
Tobacco use cessation counseling
(counseling for people with no sign of $0 cost share
tobacco-related disease)
Vaccines:
» COVID-19
» Flu
» Hepatitis B
» Pneumococcal
Yearly “Wellness” visit
Emergency Care $0 cost share
Urgently Needed Services $0 cost share
Diagnostic Services/Labs/Imaging May require prior authorization
Advanced imaging services $0 cost share
(such as MRI, CT scans)
Lab services $0 cost share
Diagnostic tests and procedures $0 cost share
Outpatient X-rays $0 cost share
Therapeutic radiology services $0 cost share
(such as radiation treatment for cancer)
4 | Questions? Call 1-888-413-9637, TTY 711Health Benefits BlueCare Plus Choice
Hearing Services (Medicare-covered)
Hearing exam to diagnose and treat $0 cost share
hearing and balance issues
Hearing Services (Supplemental)
Hearing exam to diagnose and treat
hearing and balance issues
$0 cost share up to a $2,500 allowance
Routine hearing exam annual benefit
Hearing aid fitting/evaluation, hearing aid
and hearing aid repair/adjustment
Dental Services (Medicare-covered) May require prior authorization
Medicare-covered dental services are
those which are limited to surgery of
the jaw or related structures, setting
fractures of the jaw or facial bones, $0 cost share
extraction of teeth to prepare the jaw
for radiation treatments of neoplastic
cancer disease, or services that would
be covered when provided by a physician.
This list is not all-inclusive. Limitations and
Dental Services (Supplemental) advance determinations apply for certain services.
See the Evidence of Coverage (EOC) for full details.
Routine oral exams up to 2 per year
(1 standard exam per 6 month period)
Cleanings up to 2 per year
(1 cleaning per 6 month period)
Emergency exam
(1 emergency exam per 12 month period)
Dental x-ray up to 1 per year (1 bitewing $0 cost share up to a $5,000 allowance
per 12 month period) (1 panoramic or full annual benefit
mouth X-ray per 36 month period)
Fillings
Extractions
Dentures (Removable dentures; complete,
immediate, and partial limited to 1 in any
60-month period)
Questions? Call 1-888-413-9637, TTY 711 | 5Health Benefits BlueCare Plus Choice
Medicare-covered vision services for the
Vision Services (Medicare-covered) diagnosis and treatment of diseases and injuries
of the eye.
Eye exam (diagnostic) $0 cost share
Vision Services (Supplemental)
Eye exam (routine or diagnostic) - limit one $0 cost share
per year
Eyewear (frames, lenses, contact lenses) up to a $325 annual allowance benefit
May require prior authorization
Mental Health Services Our plan covers an unlimited number of days
for an inpatient mental health stay.
Inpatient visit
Outpatient group therapy visit $0 cost share
Outpatient individual therapy visit
Requires prior authorization
Our plan covers an unlimited number of days for
Skilled Nursing Facility (SNF) a Skilled Nursing Facility (SNF) stay.
$0 cost share
Physical Therapy Requires prior authorization
Occupational therapy visit $0 cost share
Physical therapy and speech and $0 cost share
language therapy visit
May require prior authorization for
non-emergency services
Ambulance
$0 cost share
6 | Questions? Call 1-888-413-9637, TTY 711Health Benefits BlueCare Plus Choice
May require prior authorization
Our plan covers up to 100 one-way trips to plan-
approved locations for dental, vision, hearing and
Transportation fitness visits and unlimited medical and pharmacy
trips.
$0 cost share
Medicare Part B Drugs Requires prior authorization
Chemotherapy drugs $0 cost share
Other Part B drugs $0 cost share
Chiropractic Care Subluxation of the spine
Manipulation of the spine to correct a
subluxation (when 1 or more of the bones $0 cost share
of your spine move out of position).
Diabetes Self-Management Training $0 cost share
Foot Care (podiatry services)
Routine Care
Foot exams and treatment $0 cost share
Requires prior authorization
Home Health Care
$0 cost share
Requires notification
Our plan covers 14 meals following discharge
from an acute inpatient hospital or skilled
Meals nursing facility stay to a home setting.
$0 cost share
Questions? Call 1-888-413-9637, TTY 711 | 7Health Benefits BlueCare Plus Choice
Medical Equipment/Supplies May require prior authorization
Durable Medical Equipment $0 cost share
(such as wheelchairs, oxygen)
Prosthetics $0 cost share
(such as braces, artificial limbs)
Diabetes monitoring supplies $0 cost share
Therapeutic shoes or inserts $0 cost share
(for diabetes)
Outpatient Substance Abuse
Group therapy visit $0 cost share
Individual therapy visit $0 cost share
Outpatient Rehabilitation Requires prior authorization
Cardiac (heart) rehab services for a
maximum of 2 one-hour sessions per
day for up to 36 sessions
Pulmonary (lung) rehab services for a $0 cost share
maximum of 2 one-hour sessions per
day for up to 36 sessions
Supervised Exercise Therapy for
Peripheral Artery Disease (SET for PAD)
8 | Questions? Call 1-888-413-9637, TTY 711Health Benefits BlueCare Plus Choice
$100 each month
Any unused amount will expire at the end
of each month.
You can use your debit card at select network
retail stores or place an order online, over the
Health & Wellness Product/Over-the- phone or by mail through your Health & Wellness
Counter (OTC) Products Card Products Catalog that will be sent to you.
The catalog includes items such as vitamins,
cough, cold and allergy medicine, dental
products, blood pressure monitors and skin
Healthy Food Benefit Card* care items.
*(available to eligible members) *If you're eligible, you may use the monthly
amount to buy healthy food items such as
vegetables, fruit, grains, milk, meats and more
at select locations near you.
See Evidence of Coverage chapter 4 Benefits
Chart for more details.
Renal Dialysis $0 cost share
Members are required to use the defined
telehealth network.
Telehealth
$0 cost share
Wellness Programs This plan includes a fitness membership.
Fitness membership $0 cost share
Questions? Call 1-888-413-9637, TTY 711 | 9Medicare Part D Prescription Drug Benefits
Outpatient Prescription Drugs BlueCare Plus Choice
What you pay for a 30- or 90-day supply
of Retail & Mail Order Drugs
Initial Coverage Stage Your copay will depend on your level of Low
Income Subsidy. Some medications may
require prior authorization, please see the
formulary (drug list).
For generic drugs (including brand drugs
treated as generic), from retail or mail $0 copay, or $1.35 copay, or $3.95 copay
order pharmacies, either
For all other drugs, either $0 copay, or $4 copay, or $9.85 copay
After your yearly out-of-pocket drug costs
(including drugs purchased through your
Catastrophic Coverage Stage retail pharmacy and through mail order)
reach $7,050, you pay nothing for all drugs.
If you want to know more about the coverage and costs of Original Medicare, look in
your current "Medicare & You" handbook. View it online at medicare.gov or get a copy
by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.
This document is available in other formats.
10 | Questions? Call 1-888-413-9637, TTY 711CHOICES Benefits
The following chart explains how Medicare, Medicaid
and Choices work together to provide you benefits.
Your services are paid first by Medicare and then by
Medicaid or Choices. If a benefit is exhausted or not
covered by Medicare, then Medicaid or Choices may
provide coverage, depending on your type of Medicaid
and Choices coverage.
Coverage of benefits listed in the following chart
depend on your level of Medicaid and Choices eligibility.
If you have questions about your Medicaid and Choices
eligibility and what benefits you are entitled to, call
Division of TennCare, 1-800-342-3145.
Questions? Call 1-888-413-9637, TTY 711 | 11CHOICES Program Services by Group
Service and Group 1 Group 2 Group 3
Benefit Limit
Short-term only Short-term only
Nursing facility care X (up to 90 days) (up to 90 days)
(Specified CBRA
Community-based residential services and levels
X of reimbursement
alternatives (CBRA)
only. See below)1
Personal care visits
(up to 2 visits per day at
intervals of no less than 4 hours X X
between visits)
Attendant care (up to 1080
hours per calendar year; up to
1400 hours per full calendar
year only for persons who
X X
require covered assistance
with household chores or
errands in addition to hands-on
assistance with self-care tasks)
Home-delivered meals
X X
(up to 1 meal per day)
Personal Emergency Response
Systems (PERS) X X
Adult day care (up to 2080
X X
hours per calendar year)
1
CBRAs for which Group 3 members are eligible include only: Assisted Care Living Facility services,
Community Living Supports 1 (CLS1), and Community Living Supports-Family Model 1 (CLS-FM1)
12 | Questions? Call 1-888-413-9637, TTY 711CHOICES Program Services by Group
Service and Group 1 Group 2 Group 3
Benefit Limit
In-home respite care (up to
216 hours per calendar year) X X
In-patient respite care (up to
X X
9 days per calendar year)
Assistive technology (up to
$900 per calendar year) X X
Minor home modifications (up
to $6,000 per project; $10,000
per calendar year; and $20,000 X X
per lifetime)
Pest Control (up to 9 units per X X
calendar year)
1
CBRAs for which Group 3 members are eligible include only: Assisted Care Living Facility services,
Community Living Supports 1 (CLS1), and Community Living Supports-Family Model 1 (CLS-FM1)
Questions? Call 1-888-413-9637, TTY 711 | 13Nondiscrimination Notice
BlueCross BlueShield of Tennessee (BlueCross), including its subsidiaries SecurityCare
of Tennessee, Inc. and Volunteer State Health Plan, Inc. also doing business as BlueCare
Tennessee, complies with applicable Federal civil rights laws and does not discriminate on
the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude
people or treat them differently because of race, color, national origin, age, disability or sex.
BlueCross:
Provides free aids and services to people with disabilities to communicate
effectively with us, such as: (1) qualified interpreters and (2) written information
in other formats, such as large print, audio and accessible electronic formats.
Provides free language services to people whose primary language is not English,
such as: (1) qualified interpreters and (2) written information in other languages.
If you need these services, contact Member Service at the number on the back of your
Member ID card or call 1-800-332-5762, TTY 711. From Oct. 1 to March 31, you can call
us 7 days a week from 8 a.m. to 9 p.m. ET. From April 1 to Sept. 30, you can call us Monday
through Friday from 8 a.m. to 9 p.m. ET. Our automated phone system may answer your
call outside of these hours and during holidays.
If you believe that BlueCross has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability or sex, you can file
a grievance (“Nondiscrimination Grievance”). For help with preparing and submitting your
Nondiscrimination Grievance, contact Member Service at the number on the back of your
Member ID card or call 1-800-332-5762, TTY 711. They can provide you with the appropriate
form to use in submitting a Nondiscrimination Grievance. You can file a Nondiscrimination
Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievance to:
Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits
Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019;
(423) 591-9208 (fax); Nondiscrimination_OfficeGM@bcbst.com (email).
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room
509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD), 8:30 a.m.
to 8 p.m. ET. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
H3259_21NDMLI_C (08/20)
14 | Questions? Call 1-888-413-9637, TTY 711Multi Language Services
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-332-5762, TTY 711.
Questions? Call 1-888-413-9637, TTY 711 | 15Notes: 16 | Questions? Call 1-888-413-9637, TTY 711
Questions?
Give the team a call.
1-888-413-9637, TTY 711
bluecareplus.bcbst.com
1 Cameron Hill Circle | Chattanooga, TN 37402
From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 9 p.m. ET. From April 1 to Sept. 30, you can call
us Monday through Friday from 8 a.m. to 9 p.m. ET. If you call us outside these hours or on a holiday, our automated system will
answer your call. You can leave a message for us, and we will call you back as the next business day. Premium, copayments,
co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
BlueCare Plus Tennessee, an Independent Licensee of the Blue Cross Blue Shield AssociationYou can also read
