Healthy Blue Choices POS: Member and Service Information

The member's out-of-pocket costs vary depending on whether they're getting care from an in-network or out-of-network provider:

• Healthy Blue Choices in-network providers are providers contracted with BCN HMO and non-Michigan providers who participate with a BlueCard Traditional plan. Members pay less out of pocket when they're seen by these providers.
• Healthy Blue Choices out-of-network providers are:
• Michigan providers who are not contracted with BCN
• Non-Michigan providers who do not participate with a BlueCard Traditional plan. Members may get care from out-of-network providers for covered services, but they'll pay more.

Members may get care from out-of-network providers for most covered services, but they'll pay more. See the section Some services are covered only from in-network providers for a list of services that require an in-network provider.

When a dependent is enrolled in Healthy Blue Choices with a non-Michigan address and receives care through an office visit with a "PCP-like" BlueCard Traditional-participating provider outside of Michigan, they'll pay either the PCP copay or the specialist copay; this depends on the member's enrolled address and the provider's location. PCP-like providers are BlueCard-Traditional participating family medicine, general practice, pediatrics and internal medicine providers outside of Michigan that also include nurse practitioners for adult health, family, gerontology, pediatrics and primary care.

See the table below for some examples of the out-of-pocket costs a member will pay:

Some services are covered only when received from an in-network provider (see the A list for examples). But there are also preventive services that members can receive from in- or out-of-network providers (see the B list for examples). Be sure to check each member's benefits through our provider portal (availity.com) or by contacting Provider Inquiry,

A. Examples of services covered from in-network providers only

• Some preventive services
• Office visits
• Routine prenatal care — For members with active employee coverage (subscriber ID prefix XYS)
• Colonoscopy — For members with retiree coverage (subscriber ID prefix XYD)
• Durable medical equipment
• Prosthetics and orthotics
• Diabetic supplies
• Outpatient rehabilitation (physical therapy, occupational therapy, speech therapy)
• Hearing aids

B. Examples of preventive services covered in and out of network

• Colonoscopy — For members with active employee coverage (subscriber ID prefix XYS)
• Shingrix and Zostavax^® immunizations
• Mammography
• Voluntary female sterilization
• Routine postnatal visits

You can access a list of preventive service procedure codes that comply with the Affordable Care Act and are effective for Healthy Blue Choices members with active employee coverage (subscriber ID prefix XYS). Follow these steps:

1. Log in to our provider portal (availity.com).
2. Click Payer Spaces on the Availity menu bar.
3. Click the BCBSM and BCN logo.
4. Click Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Click Preventive Benefits on the Member Care tab.

Some services are handled through specific vendors not associated with Blue Care Network.

• Behavioral health services — For dates of service through Dec. 31, 2024: Contact Carelon Behavioral Health at 1-800-346-7651 for retroactive requests.
  
  Exception — The following services are covered through Blue Care Network:
• Certain services for patients with an autism diagnosis. Specifically:
• Occupational, speech and language and physical therapy performed by a licensed, certified therapist for PT, OT, ST
• Nutritional therapy
• Genetic testing
• Claims with a medical primary diagnosis code
• Developmental screening
• Emergency services, ambulance, outpatient radiology, outpatient rehabilitation and outpatient laboratory services with a behavioral health primary diagnosis
• Neuropsychological exams and ancillary services such as evaluations and interviews
• Psychiatric diagnostic evaluations