Flex and Open Access for Medicare Patients and Providers

September 8, 2022

If you’re a Medicare provider, you may treat Blue Cross Medicare Advantage Flex (PPO)^SM and Blue Cross Group Medicare Advantage Open Access (PPO)^SM members, regardless of your contract or network status with Blue Cross and Blue Shield of Montana (BCBSMT). That means you don’t need to participate in BCBSMT Medicare Advantage networks or in any other BCBSMT networks to see these members. The only requirement is that you accept Medicare assignment and will submit the claims to BCBSMT.

Flex and open access advantage

Individual members may join the Flex plan. The Group Open Access plan is available to retirees of employer groups.

These plans cover the same benefits as Medicare Advantage Parts A and B plus additional benefits per plan. Members’ coverage levels are the same inside and outside their plan service area nationwide for covered benefits.

• The Flex plan includes medical coverage and prescription drug coverage. It doesn’t require member cost share.
• The Open Access plan includes medical coverage and may include prescription drug coverage. Plan members may have to pay deductibles, copays and coinsurance, depending on their benefit plan. Call the number on the member ID card for details.

Referrals aren’t required for office visits. Prior authorization may be required for certain services from Medicare Advantage-contracted providers with BCBSMT. Before providing care to our members, always check eligibility and benefits first.

For reimbursement

Follow the billing instructions on the member’s ID card. When you see these members, you’ll submit the claims to BCBSMT and not Medicare.

• If you’re a Medicare Advantage-contracted provider with any Blue Cross and Blue Shield (BCBS) plan, you’ll be paid your contracted rate. You’re required to follow utilization management review requirements and guidelines.
• If you’re a Medicare provider who isn’t contracted for Medicare Advantage with any BCBS plan, you’ll be paid the Medicare-allowed amount for covered services. You may not balance bill the member for any difference in your charge and the allowed amount.* You aren’t required to follow utilization management guidelines. However, you may request a review to confirm medical necessity.

Flex plan members

You can identify Flex plan members by their member ID card. Look for the Flex plan name on the front. If you have questions, call 877-774-8592

*Group Open Access members may be responsible for cost share for supplemental dental services from non-contracted Medicare providers.

Out-of-network/non-contracted providers are under no obligation to treat Blue Cross Medicare Advantage Flex (PPO) or Blue Cross Group Medicare Advantage Open Access (PPO) members, except in emergency situations.

Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.

HMO and PPO plans provided by Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HMO plans available for employer/union groups only. HCSC is a Medicare Advantage organization with a Medicare contract. Enrollment in HCSC's plans depends on contract renewal.