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Clarification and Reminders for Group Medicare Advantage Plans (HMO and ‘Open Access’)

Posted January 27, 2020

In our November 2019 Blue Review, we announced new names for some of our Medicare plans, including Medicare group plans, effective Jan. 1, 2020. These new names help identify our members who purchase their coverage through their employers or other groups. Related to this announcement, we’d like to clarify some important details and reminders.

Clarification: Blue Cross Group Medicare Advantage (HMO)SM
The Medicare group plans currently offered for Blue Cross and Blue Shield of Illinois (BCBSIL) members include Blue Cross Group Medicare Advantage (PPO)SM, Blue Cross Group Medicare Advantage Open Access (PPO)SM and Blue Cross Group MedicareRxSM. Our November 2019 notice also referenced Blue Cross Group Medicare Advantage (HMO)SM. Please note that no Illinois employer or other groups have selected the Group Medicare Advantage (HMO) plan yet for their retirees. While we may begin engaging provider partners on this new offering soon, at this time you will not see BCBSIL members with this plan name on their ID cards.

Reminders: Blue Cross Group Medicare Advantage Open Access (PPO)
Our Blue Cross Group Medicare Advantage Open Access (PPO) plan offers members ­access to care from any providers nationwide ­who accept Medicare assignment and are willing to bill BCBSIL. Members’ coverage levels are the same in- and out-of-network.

  • Pre-service reminders: For Blue Cross Group Medicare Advantage Open Access (PPO) members, referrals are not required for office visits, but benefit prior authorization may be required for certain Medicare-covered services. Always check eligibility and benefits first to confirm membership, coverage and other important information prior to rendering services.
  • “Out-of-network” providers: You do not need to have a government programs contract with BCBSIL to treat Blue Cross Group Medicare Advantage Open Access (PPO) members. Even if you are only contracted with BCBSIL for participation in our commercial networks, if you accept Medicare assignment, you may treat Blue Cross Group Medicare Advantage Open Access (PPO) members and bill BCBSIL as an out-of-network provider.*
  • Reimbursement: Out-of-network providers will be paid the Medicare allowed amount for covered services as defined by Medicare, less any member cost-sharing. In-network providers will be paid their contracted rate. 
  • For more information, such as a sample member ID card, refer to our Blue Cross Group Medicare Advantage Open Access (PPO) flyer.

*Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Group Medicare Advantage Open Access (PPO) members, except in emergency situations.

Checking eligibility and benefits and/or obtaining benefit prior authorization/pre-notification or predetermination of benefits is not a guarantee that benefits will be paid. Payment is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations and exclusions set forth in your patient’s policy certificate and/or benefits booklet and/or summary plan description. Regardless of any benefit determination, the final decision regarding any treatment or service is between you and your patient. If you have any questions, call the number on the member’s ID card.

PPO plans provided by BCBSIL, which refers to HCSC Insurance Services Company (HISC). PPO employer/union group plans provided by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). HCSC and HISC are Independent Licensees of the Blue Cross and Blue Shield Association. HCSC and HISC are Medicare Advantage organizations with a Medicare contract. Enrollment in these plans depends on contract renewal.