BlueCHiP for Medicare Core (HMO)
H4152 - 004 - 0
(4.5 / 5)
BlueCHiP for Medicare Core (HMO) is a Medicare Advantage (Part C) Plan by Blue Cross & Blue Shield of Rhode Island.
This page features plan details for 2024 BlueCHiP for Medicare Core (HMO) H4152 – 004 – 0 available in State of Rhode Island.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
BlueCHiP for Medicare Core (HMO) is offered in the following locations.
Plan Overview
BlueCHiP for Medicare Core (HMO) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross & Blue Shield of Rhode Island |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,500 In-network |
| Drugs Covered: | No |
Ready to sign up for BlueCHiP for Medicare Core (HMO) ?
Premium Breakdown
BlueCHiP for Medicare Core (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
BlueCHiP for Medicare Core (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,500 In-network |
| No |
| In-network | No |
| $0-150 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0-5 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $25 copay per visit (Authorization is not required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $130 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $200-1,675 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $15 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $15 copay (Authorization is required.) (Referral is not required.) |
| $150 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | $25 copay (There are no limits.) (Authorization is not required.) (Referral is required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Diabetes supplies | $0 copay per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is not required.) (Not applicable.) |
| $180 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $180 per day for days 1 through 4 $0 per day for days 5 through 90 $0 per day for days 90 and beyond (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $130 per day for days 21 through 45 $0 per day for days 46 through 100 (Authorization is required.) (Referral is not required.) |
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Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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