Using participating providers' reduces out-of-pocket medical expenses for retirees with BCBS

University retirees who are eligible for Medicare and have BlueCross BlueShield (BCBS) should know the following information about their health care coverage:

Medicare Part A (Hospital Insurance) has a deductible and daily co-insurance provision for hospitalization and skilled nursing facilities. Blue Cross Blue Shield of Michigan will pay the deductible and daily co-insurance not paid by Medicare if the facility is considered a BCBS "participating provider." Services received from a non-participating hospital or skilled nursing facility do not have coverage for the deductible or daily co-insurance.

In-state or out-of-state: Ask if the provider "participates." In Michigan, all hospitals currently participate with Blue Cross Blue Shield. As for in-state skilled nursing facilities, some participate and some do not.

Hospitals or skilled nursing providers outside the state of Michigan would need to participate in the local Blue Cross plan in their area in order for the daily Medicare co-insurance to be a covered benefit.

The best way to verify benefits at a specific facility (in Michigan or elsewhere) is to contact that facility. If the facility does not participate with BCBS, the deductible and daily co-insurance is not covered.

Coordinating coverage: Medicare Part B (Medical Insurance) covers most doctor services and outpatient care and does not require the provider to participate with Medicare. The BCBS plan will pay the difference between the amount approved for a covered service and the amount paid by Medicare. If the billed amount is greater than the approved amount, a participating provider cannot bill for the difference. However, a non-participating provider would be able to send a bill for the balance. In this instance those who have United of Omaha major medical coverage may be able to submit a claim to lessen out-of-pocket expense. To see how Medicare, BCBS and United coordinate coverage, visit http://www.umich.edu/~benefits/forms/bcbsmunited.pdf.

The bottom line is, using preferred providers may save significant out-of-pocket expense. Those who are unsure should ask providers if they participate in BCBS.

Where to send claims: BCBS participating providers must bill claims through their local BCBS office. The provider must indicate the XYZ prefix and the retiree's contract number for the claim to be routed correctly.

Non-participating hospitals that agree to bill claims should send them to: Blue Cross Blue Shield of MI, P.O. Box 166, Detroit MI 48231.

Non-participating physicians and other non-hospital providers who agree to bill claims should send them to: Blue Cross Blue Shield of MI, P.O. Box 2500, Detroit MI 48231.

Retirees will need to submit their own claims only if they have paid the provider and are seeking reimbursement. Send the itemized statement, along with the paid receipt to: Payment-to-Subscriber Claims, Blue Cross Blue Shield of Michigan, 600 Lafayette East, B321, Detroit MI 48226. Do not send claims for services by participating providers to BCBS of Michigan. Participating providers must bill claims through their local BCBS office.

For more information, call (734) 763-1217.

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