Blue Cross Medicare Advantage Freedom Blue (PPO) 2024 Benefit Details for Plan H5959-018-0 in Freeborn County, MN
Blue Cross Medicare Advantage Freedom Blue is a 2024 PPO Medicare Advantage plan {with_without_pdp} prescription drug plan benefits (Part D).
This Blue Cross and Blue Shield of Minnesota option offers the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may also include additional, valuable benefits not covered by Part A or Part B.
See more Medicare Advantage Plans in Freeborn County, Minnesota.
Plan Basics | |
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Plan ID: | H5959 018 0 |
Plan Type: | Local PPO |
Plan Year: | 2024 |
Premium: | $0.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $4,200/yr |
Part B Reduction: | $100.00/mo |
Drug Plan Benefit: | Not Included |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Freeborn County, MN |
Insured By: | Blue Cross and Blue Shield of Minnesota |
Summary of Benefits |
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Health Plan Cost Sharing
This Blue Cross and Blue Shield of Minnesota Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $20 Copay |
Specialist: | $30 Copay Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $30 Copay Authorization Required |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay Authorization Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $90 Copay |
Urgent care: | $35 Copay |
Ground ambulance: | $200 Copay |
Inpatient hospital coverage: | $200.00 per stay |
Outpatient hospital coverage: | $100 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $30 Copay |
Outpatient group therapy visit with a psychiatrist: | $30 Copay |
Inpatient hospital - psychiatric: | $200.00 per stay |
Outpatient group therapy visit: | $30 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $30 Copay Authorization Required |
Occupational therapy visit: | $30 Copay Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $70 Copay Authorization Required |
Lab services: | $0 |
Outpatient x-rays: | $0 |
Diagnostic tests and procedures: | $20 Copay Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Blue Cross Medicare Advantage Freedom Blue Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Blue Cross and Blue Shield of Minnesota includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay |
Vision | Maximum vision benefit: | $250.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | Covered Limits may apply |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
2024 CMS Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent CMS ratings for Blue Cross Medicare Advantage Freedom Blue.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- Blue Cross Medicare Advantage Complete
- Blue Cross Medicare Advantage Complete
- Blue Cross Medicare Advantage Choice
- Blue Cross Medicare Advantage Choice
- Blue Cross Medicare Advantage Comfort
Contact Blue Cross and Blue Shield of Minnesota
Plan Website: | http://www.bluecrossmnonline.com |
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Formulary Information: | http://www.myprime.com |
Pharmacy Information: | Blue Cross and Blue Shield of Minnesota Pharmacy Page |
Prospective Members: | (855)579-7658 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Blue Cross and Blue Shield of Minnesota, http://www.bluecrossmnonline.com, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H5959-018-0 Plan Detail Page
The data on this Blue Cross Medicare Advantage Freedom Blue plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Blue Cross and Blue Shield of Minnesota to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Blue Cross and Blue Shield of Minnesota, at (855)579-7658, prior to enrollment.