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  • Learn More
    • Intro to Medicare
      • Introduction
      • Eligibility and Enrollment
      • Frequently Asked Questions
      • Your Coverage Choices
      • Original Medicare
      • Medicare Advantage
      • Prescription Drug Coverage
      • Plan that’s Right for you
      • Sign-Up for a Guide Book and Email
      • Medicare Basics Video Series
    • Are You Eligible For Medicare?
    • Are Your Drugs Covered?
    • Attend a Seminar
    • About Medicare
      • Health Plan Basics
      • Important Dates
    • Request a Call
  • Health & Wellness
    • Finding Care
      • 24-Hour Nurse Line
      • Care Management
      • ER Alternatives
      • Find a Doctor
      • Member Support & Assistance Program
        • In-home Care from Landmark Health
        • In-home Health Assessments with Signify Health®´
        • Personalized Support for Disease Management
        • Quality Optimizer
        • Additional Programs
      • Mental Health
      • Supporting Caregivers
    • Manage Your Health
      • Managing Diabetes
      • Preventive Care
      • Flu Prevention
      • Chronic Care
      • Fall Prevention
      • Urinary Incontinence
      • Meals and Nutrition
  • Member Resources
    • Plan Information
      • Plan Documents
      • Quality Assurance
      • National Coverage Determination
      • Ending Membership
    • Pharmacy Benefits
      • Drug Benefits
        • Home Delivery
        • Formulary Overview
        • Coverage Requirements
        • Formulary Changes
      • Medicare Advantage Pharmacy Network
      • Plan Drug Transition Policy
      • Medication Therapy Management
      • Prescription Drug Utilization Review
    • Learn to Live
    • Get More With MyBlue
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Health Plan Basics

Reviewing these key health care terms will help you choose the right Medicare plan. For detailed definitions, refer to our Glossary.

Common Terms
Deductible

The fixed amount you pay for covered services in a plan year. Most preventive care is fully covered even before you pay your deductible.

Copayment

The fixed amount you pay for covered services after you’ve paid your deductible.

Co-insurance

The percentage of costs you pay for covered services after you’ve paid your deductible.

Out-of-Pocket Maximum

The most you have to pay for covered services in a plan year. This limit doesn’t include your monthly premiums or services your plan doesn’t cover.

HMO versus PPO – What’s the difference?

Health Plan Basis HMO

You must get your health care from doctors and hospitals that are part of the plan's network. You also need to choose a primary care doctor who will manage your care and give you referrals to specialists. If you receive care outside of your plan's network, the costs won't be covered, except for emergency care.

Health Plan Basis PPO

You can choose to see any doctor or go to any hospital. However, a PPO plan has a preferred network of doctors and hospitals. If you get care from the plan's network, your costs are usually lower. If you choose out-of-network doctors and hospitals, they may cost more. You don't need to choose a primary care doctor or get referrals.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities that have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

You can file a complaint if you feel that you received inaccurate, misleading or inappropriate information. Please call Member Service at 1-800-200-4255 (TTY users call: 711). If your complaint involves a broker or agent, be sure to include the name of the broker/agent when filing your complaint.

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Last Updated: 01/01/2023

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