What Is Medicare Plus Blue?
Medicare Plus Blue (MPB) is a privately administered Medicare Advantage (Part C) plan offered by WellMed Medical Management. It combines the traditional Medicare benefits (Part A & B) with additional services, prescription drug coverage (Part D), and a range of costsaving options.
The Enhanced Benefits tier adds extra clinical services, wellness programs, and broader provider networks. These benefits are bundled into a single monthly premium, but the plan also follows a detailed fee schedule for specific services that are not covered under the bundled amount or for providers who bill outside the network.
Key Enhanced Benefits
- Comprehensive prescription drug coverage with tiered copay tiers.
- Wellness and preventive services, including fitness memberships and nutrition counseling.
- Specialist visits without prior authorization (subject to fee schedule).
- Telehealth visits and remote patient monitoring.
- Dental, vision, and hearing services at discounted rates.
- Transportation to and from medical appointments.
Members can also access a 24hour nurse line and personalized care coordination.
Enhanced Benefits Fee Schedule
The fee schedule outlines the amounts that Medicare Plus Blue will reimburse for services performed by outofnetwork providers or for services that exceed the bundled payment limit. The schedule varies by service type, geographic area, and whether the member is in a Medicare Advantage or dualeligible (Medicare/Medicaid) group.
Typical Fee Schedule Categories
| Service Category | Typical Medicare Allowed Amount | MPB Enhanced Reimbursement | Member Cost-Sharing |
|---|---|---|---|
| Primary Care Visit (InNetwork) | $85 | $75 | $0 copay |
| Primary Care Visit (OutofNetwork) | $85 | $65 | $10 copay |
| Specialist Visit (InNetwork) | $160 | $130 | $10$15 copay |
| Specialist Visit (OutofNetwork) | $160 | $110 | $20 copay |
| Emergency Room (ER) Visit | $300 | $250 | $0 copay |
| Inpatient Hospital Stay (per day) | $1,300 | $1,150 | $0 deductible |
| Diagnostic Imaging (e.g., MRI) | $1,200 | $950 | $50 copay |
| Physical Therapy (30minute session) | $100 | $80 | $0 copay (up to 20 visits/yr) |
| Prescription Drug (Tier 1) | $5 | $0 | $0 copay |
| Prescription Drug (Tier 3) | $45 | $30 | $5$10 copay |
*Amounts shown are illustrative averages for the 2024 calendar year. Actual fees may differ based on zip code, provider contracts, and annual updates to the Medicare fee schedule.
How the Fee Schedule Works for Members
- InNetwork Care: When you see an innetwork provider, the plan applies the bundled allowance; most services have $0 or low copays.
- OutofNetwork Care: If you choose an outofnetwork provider, the plan reimburses based on the OutofNetwork column in the fee schedule. You are responsible for any balancebilling beyond that amount.
- Prior Authorization: Certain highcost services (e.g., MRI, specialty drugs) may still require prior authorization even under the enhanced tier.
- Annual OutofPocket Maximum: The MPB Enhanced Benefits plan caps outofpocket expenses at $2,800 for individual members and $5,600 for families. Costs incurred after reaching the cap are covered in full.
- Billing Process: Providers submit claims using the usual Medicare billing codes. The plan applies the fee schedule automatically and generates an Explanation of Benefits (EOB) for the member.
Frequently Asked Questions
1. Do I need to pay a separate premium for the Enhanced Benefits?
Yes. The Enhanced Benefits tier adds a modest monthly premium (typically $25$35) on top of the base Medicare Plus Blue premium. This premium covers the added services and the broader fee schedule.
2. What happens if a provider bills more than the fee schedule amount?
The plan will pay the amount listed in the fee schedule. Any excess amount is considered balance billing, and the member is responsible for that balance unless they have supplemental coverage that addresses it.
3. Can I switch back to a standard Medicare Advantage plan?
Yes. During the annual Open Enrollment Period (October15December7) you may switch plans without penalty. You can also change plans during a Special Enrollment Period if you qualify (e.g., relocation, loss of other coverage).
4. Are there limits on the number of specialist visits?
There are no hard caps on specialist visits, but each visit is subject to the fee schedule and the applicable copay. Excessive use may trigger a utilization review.
5. How do I find innetwork providers?
Use the Find a Doctor tool on the Medicare Plus Blue website or call the member services line (1800555MPB). The tool lets you search by specialty, location, and language preference.
