%PDF-1.7 % Blue Shield/Blue Shield Promise network referrals. <>/Filter/FlateDecode/ID[<640396EC155E3E4385DE44C7EB07AE63>]/Index[119 54]/Info 118 0 R/Length 102/Prev 42314/Root 120 0 R/Size 173/Type/XRef/W[1 2 1]>>stream 1-313-225-9000. California Physicians Service DBA Blue Shield of California is an independent member of the Blue Shield Association. OptumRx is the Pharmacy Benefit Manager for the State Health Plan PPOand will administer all retail, mail-order, and specialty prescription services for active employees and both Medicare-eligible and non-Medicare eligible retirees. Thank you for viewing. endstream endobj startxref This means you have the option to increase your payroll contributions so you can reach the maximum contribution amount earlier in the year. GradCare Member Reimbursement Form U-M Premier Care Member Reimbursement Form If you choose to do so, you will be responsible for both deductibles. Healthcare includes your Medical (ASR, BCBS, or HAP), Prescription (Navitus or HAP), Dental (Delta Dental), and Vision (NVA). Enrollment in the State HDHP will also provide access to an HSA, which is a tax-advantaged savings account that can be used to pay onlyeligiblehealth, prescription, dental, and vision-related expenses incurred for services not covered by insurance (e.g., deductibles, copays, and coinsurance). endobj View the eGuide to see the Ford resources available all year long. Please provide the following information about the policy holder of the other health coverage. For the HSA Plan, your deductible and out-of-pocket maximum amounts for in-network services are the same. www.bcbsm.com/som, State High Deductible HealthPlan (HDHP) withHealth Savings Account (HSA)- HDHP administered by Blue Cross Blue Shield of Michigan (BCBSM),HSA administered by HealthEquity. Both plans include a health savings account HSA. 0000010306 00000 n 172 0 obj 0000059887 00000 n 0000021457 00000 n 600 Lafayette East. You can use the money if you leave the company, change your plan, or retire. This is the amount taken from your pay each month. Individuals attempting unauthorized access will be prosecuted. Co-insurance is a percentage of the cost you share with the plan. The BlueCard Program links Blue plans across the United States and abroad through a single electronic network for claims processing and reimbursement. In order to understand if youll need information from Blue Cross to make an auto coverage decision, youll want to first talk to your auto insurer. 0000019432 00000 n 0000027316 00000 n 0000051836 00000 n Pontiac, MI 48341. An HDHP offers a lower biweekly premium in exchange for higher deductibles and out-of-pocket limits. 0000025213 00000 n .r~'J ms-oA&@i 9k2 J4T{Yt;cu6J_Fs"6r|(Z? %PDF-1.7 % 0000016284 00000 n (5 days ago) WebTo request a proof of qualified health coverage letter, contact Blue Cross' Customer Service department at 1-800-422-9146 from 8:30 a.m. to 5 p.m. Eastern time, Monday https://hwnr.bcbsm.com/content/dam/microsites/mpsers/2020/best-of-health-summer-nonmedicare.pdf Category: Health Show Health Filter Type: Treatment 0rtq]%g=z.#i0\*m(D2q;t2}$kX[-+G-0hdA9r*8!jcsfEdRyV0=bLzf']q[6F"h.wB)^wvDH =/OC; f'e$GVi]G}//xTw)9]y(kkxU*uXT) 0ajx[k jK`8P1(GU=. This plan provides health benefits using providers and facilities that are in-network, meaning the providers and facilities have agreed to accept a discounted fee from BCBSM in order to be in-network. For the best experience, use the latest version of Google Chrome or Microsoft Edge. You can log in to your online member account to see if you have a QHC letter to download. The Plan also covers most of your community-based care (office visits), as well as necessary medical equipment and supplies (crutches, hearing aids, etc.). [Narrator] Hello again, and welcome to Blue Cross Blue Shield of Michigan. 0000048207 00000 n 0000027945 00000 n In the HSA Plus Plan, you're also responsible for all medical and prescription costs until your deductible is met. They areresponsible for the deductible, then the hospital is reimbursed according to the plan design. See below. The rule provides protection against balance or "surprise" billing under certain circumstances, and phases in new transparency requirements on most group health plans and health insurers. 0000048916 00000 n 0000017479 00000 n You may look up HMOs in your residential area using the zip code tool. And for the HSA Plus Plan, it's $1,020. Health insurance plans may contain auto exclusions (meaning they don't provide coverage for car accident-related injuries); may fail to cover the treatment, care and services needed by car accident victims; may limit such treatment, care and services in ways that No-Fault does not; and/or may involve managed care or HMOs which require `+DO>|5%Nqdws=0y';L a66[OIe,%EqtRS&54Qvw"E$iu3:G+x+II^ UTT"9W!4XuYS6Ly}l&!2 0000010545 00000 n View the Telemedicine Benefit Summary to see your State-sponsored health insurance carrier's telemedicine coverage. For more information about the State of Michigan's eligibility requirements for employee health insurance coverage, . 0000007258 00000 n Claims | Benefits | Member eligibility | How to use Provider Connection | Contracts | Credentialing | 0000006145 00000 n After the deductible and coinsurance are applied for the HSA Plus Plan, James will be responsible for $3,480. You may enroll in an authorized HMO plan serving your residential area. 0000049102 00000 n endstream endobj 141 0 obj <>/Metadata 11 0 R/Pages 138 0 R/StructTreeRoot 21 0 R/Type/Catalog/ViewerPreferences 160 0 R>> endobj 142 0 obj <>/MediaBox[0 0 612 792]/Parent 138 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 143 0 obj <>stream 0000012476 00000 n We're sorry, but the attestation service is temporarily unavailable. Later in the year, that same person needs an MRI and chooses an out-of-network provider. "Qualified Health Coverage" means your health coverage: Does not exclude or limit coverage for motor vehicle accidents; and Has an annual deductible of $6,000.00 or less per covered individual. 0000027006 00000 n View detailed plan information in this document. }v".VrTAmk$NJ+ y{i-Y#gds7D <> A plan is considered QHC if coverage for motor vehicle accidents is not excluded and the annual deductible is $6,000 or less per covered individual. Follow the instructions on the page to have your letter created. The State Health Plan PPO provides reimbursement for medical care expenses when you need treatment for an illness, injury, or disease. %%EOF Other costs to use the HSA Plan will vary depending on whether you select plan coverage for you or for your family. And with the HSA Plus Plan, Ford will also contribute to your HSA. If you're asked to provide your auto insurer with a QHC letter, you will either need to contact your health plan (like Blue Cross) or your employer to request the letter. When you combine Mary's cost to have and use the HSA Plus Plan, her total cost is $5,306. Reviewplan materialscarefully to understand the advantages and risks associated with the plan. 0 0000009647 00000 n 0000032777 00000 n If your auto insurance is requesting a QHC letter to issue or renew a policy, you may request a QHC letter by contacting yourhealth carrier. SECTION 2 OTHER HEALTH COVERAGE INFORMATION . Now let's look at what a single person with relatively few healthcare needs might experience. 0000004500 00000 n 0000024311 00000 n Select Claims on the menu bar. Learnyour requirements, deadline dates and more about your coverage. How to Recognize Signs and Ease the Burden, PEARS Increases Early Autism Identification in Toddlers with Play-Based, Rapid Interactive Screening System, Its My Duty: How Doctors are Working to Reduce Health Disparities Among Black Patients, Does not exclude or limit coverage for injuries related to motor vehicle accident and has an annual deductible of $6,000 or less per individual, Or if your coverage is Medicare Parts A & B. *Blue Shield of California member plans only. Identified standard preventive services are covered at 100%, but most other services have a 20% in-network coinsurance after meeting the deductible. Member logins offer many on-line tools, such as access to claims information, viewing Explanation of Benefits, printing replacement ID cards, etc. 0000039800 00000 n When an out-of-area Blue plan member seeks medical care from your office, use our tools to simplify claims submission to Blue Shield of California. 0000059656 00000 n Your email address will not be published. 0000048472 00000 n NO - YES - Please complete entire form, sign at the bottom and return sign at the bottom and return . 0000021696 00000 n Please keep in mind that PIP coverage pays for some items that health insurance doesnt, such as attendant care, lost wages and vehicle or housing modifications. endstream Respond promptly to the carrier to complete the final phase of the enrollment process. What does PIP cover? Standard Qualification Form If you have a Blue Cross Blue Shield of Michigan plan other than Healthy Blue Achieve that requires a qualification form, please use the form below. K4[WYV5pL@=>QBuD 0000036168 00000 n Visit myfordbenefits.com and make your plan selection for 2023. State Health Plan PPO - Administered by Blue Cross Blue Shield of Michigan (BCBSM). 0000048409 00000 n The maximum deductible for two or more covered persons in your family was limited to 1 months of your basic salary. #G:&#WeKo]b287X]4 fd!n>X3jG[)GW%0.{1,JqA]Vf,fyf#Ji+OvDUpe!K|\"e2{g3ePW?/p Submit and confirm authorizations and approval of medical and pharmacy services prior to services being rendered. hb``a`` -mY8PE!u[dCC#W6,j.Fvtl,s fb`p;CT3j 0000049042 00000 n When an out-of-area Blue plan member seeks medical care from your office, use our tools to simplify claims submission to BlueShield of California. 0000023941 00000 n 140 0 obj <> endobj XYQ This product provides comprehensive PPO coverage with costsharing features. b|=b}#Aif3TRD0;@NHkQ#`VEQxD Let's start with Mary who selected a plan to cover her family. startxref 0000031798 00000 n With the total of all her family services and prescriptions, the HSA Plan costs $3,030 to use. 0000014991 00000 n startxref 0000019892 00000 n 0000005858 00000 n It has more than 20,000 physicians, including specialists, and more than 140 all acute care hospitals in Michigan. 0000004937 00000 n To file a Blue Cross Blue Shield Global Core eClaim online, log in with your username and password or register for access. 0000026320 00000 n Be sure to turn off pop-up blocker and private browsing prior to opening your Auto Health verification letter. %%EOF For example: a single person chooses an in-network hospital for surgery. 0000033229 00000 n Contact your auto insurance agent with questions and to learn more about your options. In 2021, you'll have a choice between two HSA eligible medical plans, HSA Plan and HSA Plus Plan. IS IBCQ-]97T5dUa{ugdcg`\o'.Nu }n|7G|ZXXMf9I\RTt K{d\H3$]S^-}h C6PDI^7|[N$G3y\80-~/T2;D->>DRUw_ F=(8#l9o&.fy66tK~yUR~YZOa.y=jYh8MfH3eXg]s#2H`pw$]Nx8p&`1l)v1]\Ib`wO6+1OLn@{hE +vA3LSY+o(*_6]o. The deductible is the amount you pay before your plan contributes to your costs. 0000004148 00000 n 0000008905 00000 n You keep what you dont spend on medical expenses, even if you retire or leave state employment. Visit Federal No Surprises Act (michigan.gov)for more information. Per state and federal law, providers and facilities must attest to accuracy of directory information to stay visible in find a Doctor. Qualified Health Coverage Documents DIFS Bulletin 2020-01-INS advises health plans should develop a document that indicates whether a person's coverage is "qualified health coverage" or QHC for purposes of the new no-fault law. The plan covers inpatient hospital care, as well as other outpatient services received at a hospital including emergency room care. To quickly and easily find out if you, the provider, or a provider referral, participate in the member's plan network*, either log in or register for Provider Connection. An important note regarding the State Health Plan PPO deductibles: You have the freedom to see both in-network and out-of-network providers. 0000011580 00000 n 0 0000032096 00000 n 0000031415 00000 n It has more than 20,000 physicians, including specialists, and more than 140 all acute care hospitals in Michigan. 0000008243 00000 n If you absolutely need to call, please try again at a later date. 0000003382 00000 n Government Human Resources Benefits Health Benefit Plans. Under the State Health Plan PPO, members choose their in-network providers from the BCBSM Community Blue/Blue Preferred PPO Network. The HSA Plan is still the less costly option for Mary because the total cost to have and use the plan is lower in the HSA Plan. An HMO provides necessary hospital and medical treatment when you are sick or injured, prescription medicine services, substance abuse treatment, short-term mental health care, and routine preventive health maintenance services such as immunizations. You can now file disputes, attach supporting documents, and retrieve letters for submitted disputes online! And he pay $2,280 annually to have the HSA Plus Plan. Members should direct specific questions about PIP coverage to their auto insurer. 0000007100 00000 n Log in to continue with member verification. 310 0 obj <>/Filter/FlateDecode/ID[<4C51D19B138643B1A2CB07133610D1D7>]/Index[258 116]/Info 257 0 R/Length 203/Prev 1461330/Root 259 0 R/Size 374/Type/XRef/W[1 3 1]>>stream 0000059211 00000 n Simply . bcbsm.com. Oakland County's Qualified Health Coverage Letter for Retiree Notice of Qualified Health Coverage for Purposes of Michigan No-Fault Auto Law Medical Health Plans ASR Plan Documents ASR PPO 1 Plan Document ASR PPO 3 Plan Document Summary of Benefits and Coverage 2023 PPO 1 Summary of Benefits and Coverage 2023 PPO 3 Summary of Benefits and Coverage 1996-2023 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 0000025504 00000 n Health Insurance Marketplace Check out information about the Marketplace, especially if you are not eligible for coverage through LCC. There are several ways you can request a QHC letter. You must be in pay status to receive this payment. i' *eW This copay is waived if Mary or her family member is admitted as a result of the ER visit. 0000044573 00000 n 0000009279 00000 n 0000045752 00000 n The only providers permitted to submit a signed "Hospital Coverage Letter" for hospital privileges' requirement, are the following provider specialties/types: Adolescent Medicine, Child & Adolescent Psychiatry, Developmental-Behavioral Pediatrics, Family Practice, General Practice, Geriatric Medicine, Internal Medicine, Pediatrics, Physical %PDF-1.6 % endstream endobj 14 0 obj <. SM. This provides cost and other information related to your plan options. 0000029757 00000 n 0000011210 00000 n To get reimbursed for a flu or pneumonia shot, you'll need to fill out our Member Flu and Pneumonia Shots Reimbursement Form (PDF). Fax: 248-524-2752, https://dev.michigan.local/som/json?sc_device=json, State Health Plan Preferred Provider Organization (PPO), State High Deductible Health Plan (HDHP) with Health Savings Account (HSA), Catastrophic Benefits (Effective January 1, 2023 this plan is no longer available to employees and their dependents), OptumRx is the Pharmacy Benefit Manager for the State Health Plan PPOand will administer all retail, mail-order, and specialty, State High Deductible HealthPlan (HDHP) with, dministered by Blue Cross Blue Shield of Michigan (BCBSM),HSA a, The federal government issued the "transparency in coverage" final rule under the Federal No Surprises Act. You're now aware you have a choice between two HSA eligible medical plans in 2021. 866-503-3158 0000011869 00000 n 0000015623 00000 n If you are new to an HMO, that HMO may ask you to select your primary care physician. This copay does not apply to the out of pocket maximum for the HSA Plan, so Mary will be responsible for this copay each time she or a family member visits the ER, after the deductible is met. The State High Deductible Health Plan (HDHP) with Health Savings Account (HSA) provides a different way for employees to cover health care costs while still being able to access the entire BCBSM PPO network.
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