Medicare is the Federal government health care program designed for people ages 65 and over. Most U.S. citizens earn the right to enroll in Medicare by working and paying their taxes for a minimum of 10 years. Under certain circumstances, people under 65 may be eligible for Medicare. There are four parts of Medicare related to specific services: 

Part A — Hospital coverage.
Part B — Medical coverage.
Part C — Medicare Advantage Plans (private insurers like Blue Cross and Blue Shield of Texas that contract with the government to provide Medicare coverage through a variety of insurance products).
Part D — Prescription drug coverage.

Enrollment in Medicare Part A and Part B through the federal government is required for retirees to be eligible for any retiree Medicare plans, including this MAPD Open Access PPO. To have full coverage, you must sign up for Medicare Parts A & B and continue to pay your Part B premium. You can call the dedicated City of Austin enrollment support at 1-855-476-4149 to learn how your retiree plan will work with Medicare.

You can only be enrolled in one Medicare plan at a time. While Medicare usually cancels your previous Medicare Insurance plan coverage automatically when you enroll in a new plan, we recommend that you contact your current carrier to cancel your coverage. Be sure to continue coverage until the new plan’s effective date to avoid any gaps in coverage. We can offer support as you go through this change by calling 1-855-380-8542. 

Coverage is effective on the first day of the month following the date the application was processed or the Medicare Parts A & B effective date, whichever is later. When enrolling in this MAPD Open Access PPO Plan, you will need to provide your 11-character Medicare Beneficiary Identifier (MBI), located on your red, white and blue Medicare card along with your effective date. The earliest someone who is turning age 65 can sign up for Parts A & B is three months before the month they will turn age 65.

You have an Initial Enrollment Period (IEP) of 7 months to sign up: the 3 months leading up to the month you turn age 65, the month you turn 65, and 3 months following the month you turn 65. We strongly encourage you to start the enrollment process 3 months prior to turning age 65 so that there will be less chance of any gaps in coverage with your MAPD Open Access PPO.

Enrollment is done through the Social Security Administration (SSA). If you are already receiving Social Security benefits, you will be automatically enrolled in Medicare Part A at the start of your Initial Enrollment Period. However, you will need to contact SSA to sign up for Part B. Contact the Social Security Administration:

Visit SSA online at www.ssa.gov, or
Visit in person at your local SSA office, or                         
Call SSA at 1-800-772-1213 (TTY 1-800-325-0778)

Most people should enroll during the Initial Enrollment Period (IEP), and SSA will send you enrollment instructions at the beginning of your IEP. This is the period during which you can enroll in Medicare for the first time. It is a seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and runs for three months after the month you turned 65. For example, if you were born in June, your window to enroll is March 1 through September 30.

If you do not receive instructions from the SSA, please call 1-800-772-1213 (TTY 1-800-325-0778) or go to www.ssa.gov to enroll in Medicare. Because enrollment takes time to process, if you plan to retire at 65, we recommend enrolling three months prior to your 65th birthday.

IMPORTANT: If you plan to enroll in an employer-sponsored Medicare plan, you will need to enroll in both Parts A and B. And if you do not enroll in Medicare Parts A and  B when you are first eligible, you can be subject to late enrollment penalties.

Part A will not cost you anything if you or your spouse paid into Social Security for a minimum of 10 years. But signing up for Part A and/or Part B means you can no longer add funds to a health savings account. You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these: 

• Social Security.
• Railroad Retirement Board.
• Office of Personnel Management.

Non-payment of Part B and/or IRMAA premiums will result in termination of coverage.

The following web sites may be helpful:

•      www.medicare.gov
•      www.ssa.gov
•      www.cms.gov

Medicare Advantage plans are government-authorized plans offered by private health insurance companies like Blue Cross and Blue Shield of Texas that expand upon the benefits offered by Medicare Parts A and B. Also known as ‘Medicare Part C’ plans, they include some medical benefits not traditionally covered by Original Medicare Parts A and B. For example, this MAPD Open Access PPO includes non-Medicare covered benefits such as a hearing exam and hearing aid allowance, the SilverSneakers® fitness program, routine chiropractic services, a 24-hour nurse line, and virtual visits.

Retirees and their eligible dependents are enrolled in Medicare as individual members; however sponsored plans determine their own eligibility and enrollment policies. See below for enrollment information specific to the City of Austin MAPD Open Access PPO.

You cannot be refused coverage because of a pre-existing condition. Your coverage cannot be canceled and your claims for covered services cannot be denied because of a pre-existing condition. 

As a rule, group Medicare plans have better benefits than individual plans. And, because many employers or unions offer a defined contribution plan or subsidy (paying part of the cost you would pay wholly on your own with an individual plan), the cost is likely less as well.

This plan is a Part C Medicare Advantage plan, not to be confused with a Medicare Supplement Insurance plan. Unlike a Medicare Supplement Insurance plan, this plan has additional benefits that Medicare does not cover.

This MAPD Open Access PPO covers all the services that Medicare Parts A and B cover and includes additional benefits not covered by Original Medicare (Parts A and B). Plan specifics and details are covered in enrollment materials. Please call customer service at 1-855-380-8542 for help understanding how the plans compare.

Yes. Spouses and/or dependents who are eligible for Medicare are eligible for this plan. They must join this Medicare Advantage Open Access PPO if the primary policyholder joins the plan. If the primary policyholder elects to enroll in a different plan, the spouse and/or dependent can choose either that plan or this Medicare Advantage Open Access PPO.

If a spouse and/or dependent are not Medicare-eligible, they have the option to remain on the City’s active coverage.

The Blue Cross and Blue Shield Global Core program gives members traveling outside of the United States and its territories access to urgent and emergency medical assistance services and doctors and hospitals in more than 200 countries around the world. If you have questions about what medical care is covered when you travel, please call the member services at 1-855-380-8542 or access information at www.bcbsglobalcore.com.

This plan is available to retirees who live in the United States and its territories. If you reside full time outside of the country, you are not eligible for this Medicare Advantage Open Access PPO. Your coverage may be continued through the current City of Austin active health care plan.

This MAPD Open Access PPO was designed to match or provide better benefits than your current plan. Based on the specific procedure or service, there could be some differences, but those are rare. In many cases, the MAPD Open Access PPO has additional benefits outside of what Medicare allows. Please see the plan overview and summary of benefits for coverage details. You can also call the pre-enrollment help line at 1-855-380-8542.

Some examples of higher cost services are diagnostic procedures such as MRI, MRA, CT scans and PET scans (Advanced Imaging). Prior Authorization (PA) is also needed for:

• Musculoskeletal – Pain/Joint/Spine
• Outpatient Medical Oncology
• Outpatient Radiation Therapy
• Outpatient Sleep Study
• Outpatient Specialty Drugs
• Lab Management Solutions – Molecular and Genomic Lab Testing

Services that are performed as part of an inpatient stay, 23-hour observation or emergency room visit do not need PA.

Your provider will work with MAPD Open Access PPO to get any PA you may need and may talk with you about other options if necessary. If you have a PA in place when you enroll in the MAPD Open Access PPO, that PA continues for the first three months of coverage.

To enroll, view your existing coverages or make changes follow these steps:

• Go to: https://www.benselect.com/coa.
• Enter your username: Your unique username (printed on your Open enrollment packet from City of Austin)
• Enter your PIN: Your PIN is the last 4 digits of your Social Security  Number and the 2-digit year of your birth. For example, if the last 4 digits of your SSN are 3214 and you were born on September 21, 1968, your PIN would be “321468.”
• Click Log in.
• You will be prompted to create a new PIN.
• Login using your newly created User ID and Password.
• You can begin enrollment by clicking NEXT in the top or bottom right-hand corner of the welcome page.

Coverage for retirees new to this plan is effective January 1, 2025. Or, if newly eligible for the plan after January 1, 2025, due to age or retirement, the plan is effective once CMS approves your coverage.

Most likely, yes. Under the MAPD Open Access PPO which is an ‘open access’ or ‘passive’ PPO, you can go to any providers who: 1) accept Medicare; 2) agree to see you as a patient; and 3) agree to submit claims to Blue Cross and Blue Shield of Texas. They do not need to be part of any Blue Cross and Blue Shield network.

Please inform your providers that your plan has changed when you call for an appointment and when you arrive for your visit. As a MAPD Open Access PPO member, you have a new member number and ID card. Be sure to show your new card to your providers or their office staff. Remind them that your old ID is no longer valid. If your provider does not use your new number, care may be delayed. Your enrollment and welcome kits will also have a notice to bring with you when you see your provider.

Yes. In fact, we simplified the claims process for providers. Instead of submitting claims to Medicare, providers can now submit directly to Blue Cross and Blue Shield of Texas. We take care of any interactions with Medicare on behalf of the provider and you.

98% of providers across the country accept Medicare. Open Access PPO plans cover everything covered by Medicare Part A and B. For most MAPD Open Access PPO patients, providers will file claims with their local BCBS plan and are familiar with this process. If your providers accept Medicare, we’ve made it easy for them to submit claims for your care.

This is an Open Access PPO plan. Any provider who accepts Medicare assignment and agrees to bill BCBS, will be paid. Providers who have contracted to be in the BCBS network will be paid their contracted rate. Providers who are not in the BCBS network will be paid the Medicare allowable rate for your care. You can see providers inside and outside of the BCBS network who agree to the rules stated above. Providers outside of Texas can file claims with their local BCBS plan and are familiar with this process.

There is no difference in the submission of claims for providers accepting assignment and willing to submit claims to BCBS. With this process there will be no member intervention needed. Providers will not need to submit claims directly to Medicare. The claims will process seamlessly according to benefits allowed and based on medical necessity. Providers outside of Texas can file claims with their local BCBS plan and should be familiar with this process.

This is an Open Access PPO plan. Any provider who accepts Medicare assignment and agrees to bill BCBS will be paid. Providers who have contracted to be in the BCBS network will be paid their contracted rate. Providers who are not in the BCBS network will be paid the Medicare allowable rate for your care. Providers outside of Texas can file claims with their local BCBS plan and are familiar with this process.

This is an Open Access PPO plan. Any provider who accepts Medicare assignment and agrees to bill BCBS will be paid. Providers who are not in the BCBS network will be paid the Medicare allowable rate for your care.

You will receive a notice in both your enrollment and welcome kits to share with your provider. Providers outside of Texas can file claims with their local BCBS plan and are familiar with this process. The customer service number listed on the back of your member ID card is for you or your provider to call with any questions.

This is an Open Access PPO plan. You can see any out-of-state provider who accepts Medicare assignment and agrees to bill BCBS.

If you require medical treatment while out of the country, you are only covered in an emergency or urgent situation. The Blue Cross and Blue Shield Global Core program gives members traveling outside of the United States and its territories access to urgent and emergency medical assistance services and doctors and hospitals in more than two hundred countries around the world. If you have questions about what medical care is covered when you travel, please call customer service or access information at www.bcbsglobalcore.com.

Claim Forms for care received abroad can be obtained at www.bcbsglobalcore.com or by calling

800-810-BLUE.

Submit claims to:

BCBS Global Core Service Center
P.O Box 2048
Southeastern, PA 19399

To request an appeal, you, your representative, or your doctor can mail or fax a written request as well as contact customer service. Appeals must be submitted within 60 days of receiving your Explanation of Benefits (EOB) for the visit in question.

If you submit a written request for appeal, you must include the following information:

Your name, member number, address, reasons for appealing, and any evidence you want us to review such as medical records, doctor’s letters or other information that explains why you need the item or service.

Requests can be mailed to:

Blue Cross Medicare Advantage    
Attention: Appeals Department
P.O. Box 663099
Dallas, TX 75266

For a standard appeal we will provide a written decision within 60 days.

Yes. If a member goes to a provider who does NOT accept Medicare assignment and is not in the national BCBS Medicare Advantage PPO network, the member may be expected to pay the billed amount directly to the provider at the time of service. The member can submit the claim to BCBSTX. We would then pay the claim to the member at the Medicare limiting charge of 115% of the Medicare fee schedule for professional providers. If the provider has charged more than the 115% limiting charge, the member would not be reimbursed the difference of the billed amount they paid to the provider for services and 115% Medicare rates paid. The member would need to pursue a refund from the provider directly.

Example: Robert sees Dr. Smith, a non-participating provider and pays him $200 after the visit. The Medicare allowed amount for the visit is $80. Because Medicare limits what the provider can charge for covered services to 115% of the allowed amount for the service, Robert will be reimbursed $92. The remaining $108 will not be reimbursed.

$  80    Medicare allowed amount for the service
$  92    115% of the allowed amount

$200    Robert pays Dr. Smith
$  92    Robert is reimbursed this amount by BCBS
$108    Robert would need to seek this refund from the provider on his own

Less than 2% of providers opt out of Medicare. Providers who have opted out are unable to be reimbursed for services rendered. A member may see a provider who has opted out of Medicare; however, the visit will not be paid for by the plan or Medicare. A listing of providers that have opted out of Medicare can be found here on the CMS website.

If the provider does not accept Medicare assignment and refuses to bill BCBS, the member may need to pay the billed amount of the services directly to the provider at the time of service and submit the bill to BCBSTX for reimbursement. There is no reimbursement form to complete, however you can submit a claim for reimbursement in writing to:

Blue Cross Medicare Advantage (Claims)
PO Box 4195
Scranton, PA 18505

Please include the following documentation:

• Copy of receipt showing payment was made
• Member name and ID number including the alpha prefix listed on ID card, and
• An invoice showing services rendered OR another form of documentation that includes:
  • Diagnosis (or DX codes if available)
  • Procedure (or CPT codes if available)
  • Name and address of servicing provider

Yes, your plan includes Medicare Part D coverage for 30-, 60-, and 90-day retail and mail order prescriptions.

Before you enroll, you can search your medicines online at www.myprime.com:

• Select ‘Medicines,’ then ‘Find a Medicine,’ followed by ‘Continue  without sign in.’
• Under ‘Select Your Health Plan,’ select ‘BCBS Texas,’ then answer ‘Yes,’ select ‘Blue Cross Group Medicare Advantage (PPO) 3T Complete (your plan’s formulary),’ and click ‘continue.’ 
• Type your medicine and dosage. Review the drug tier requirements. Refer to the Summary of Benefits for your costs.

Post enrollment, use your Blue Access for Members (BAM) account or visit www.myprime.com.

MyPrime.com is a pharmacy benefit website owned and operated by Prime Therapeutics LLC, a separate company providing pharmacy benefit management services for your plan.

If you are transitioning from another plan, you are eligible for a one-time 30-day supply of non-formulary drugs or drugs with utilization management requirements during the first 90 days of enrollment. You should then talk to your doctor to decide if there is another option available on the formulary. You can also call us to find out if we cover another drug that is used to treat your condition. Or you or your doctor may ask for an exception. We will work with your doctor to help make sure you are getting the right medicine to meet your needs.

The MAPD Open Access PPO covers a routine hearing exam, a hearing aid allowance of $5,000 (for 2024 plans) or $2,500 (for 2025 plans) for both ears over 36 months, and routine chiropractic care and acupuncture.

Routine chiropractic visits are covered at a $0 copay (20 visits per year).

Your supplemental benefits include:

• Hearing Care
• Wellness Solutions
• SilverSneakers® Fitness Program*
• 24/7 Nurseline 
• Virtual Visits
• Post-Hospital Discharge Meals
• Routine Chiropractic Care
• Non-Emergency Transportation
• Chronic Disease Prevention and Support
• Hypertension and Diabetes Programs 
• Musculoskeletal and Chronic Pain Programs 
• Weight Management Program
• Over the Counter Discount Program
• Routine Acupuncture

Please check your summary of benefits for coverage levels.

* Classes and amenities vary by location.

You can still participate but you will not be eligible for free medication.

ID cards for effective date 1/1/2025 will be mailed in December. Retirees who enroll throughout the year receive their cards 10-14 days after Medicare confirms their enrollment.

Here are the items you can expect, in order. You will receive an acknowledgment letter, followed by a confirmation letter and then your new member ID card (mid-December for 1/1/2025 effective date). You may use your confirmation letter as proof of insurance until your card arrives. Your MAPD Open Access PPO card is for use with hospital and medical providers and pharmacies.

As an MAPD Open Access PPO, you have a new member number and ID card. Be sure to show your new card to your providers or their office staff. Remind them that your old ID is no longer valid. If the provider does not use your new number, your benefits cannot be confirmed and there may be delays processing your claims. 

If you enroll in the MAPD Open Access PPO, you will receive your Explanation of Benefits (EOB) from Blue Cross and Blue Shield of Texas. How often you receive it depends on how often you see your provider. This statement is not a bill. It simply details what you have paid and indicates the level of benefits you have used.