Q. What are the CMU medical plan options through Blue Cross Blue Blue Shield and what do they cover?
A. PPO 1 is a Preferred Provider Organization plan which utilizes the Community Blue PPO network through Blue Cross Blue Shield. Preventative services, such as an annual physical exam and well baby care, are covered only by going to PPO participating physicians. The copay for routine doctor visits is $10 with a PPO participating physician. In-network hospital services are covered at 100% of reasonable and customary charges and there is no deductible for in-network services. There is a deductible of $250 per person/$500 per family per year for out-of network services plus a 20% copay. Emergency room visits have a $50 copay, but the copay is waived if the patient is admitted to the hospital or if it was an accidental injury. More details can be found on the medical comparison grid at: PPO Medical Comparison. To compare costs of the various plans, please use the plan cost calculator at: Plan Cost Calculator.
PPO 2 is also a Preferred Provider Organization plan which utilizes the Community Blue PPO network through Blue Cross Blue Shield. Preventative services, such as an annual physical exam and well baby care, are covered only by going to PPO participating physicians. The copay for routine doctor visits is $10 with a PPO participating physician. There is a deductible of $250 per person/$500 per family for in-network hospital services plus a 20% copay. The deductible of for out-of-network services $500 per person/$1000 per family per year plus a 40% copay. Emergency room visits have a $50 copay, but the copay is waived if the patient is admitted to the hospital or if it was an accidental injury. More details can be found on the medical comparison grid at: PPO Medical Comparison. To compare costs of the various plans, please use the plan cost calculator at: Plan Cost Calculator.
Q. What is a PPO?
A. PPO means Preferred Provider Organization. One of the most important benefits of Community Blue PPO is its quality control process to screen and continually monitor potential and existing providers. The result is that members have convenient access to a network of qualified physicians and hospitals throughout the state.
Q. What is Community Blue PPO?
A. Community Blue PPO is a program designed by Blue Cross Blue Shield of Michigan to meet the needs of employees/employers by offering the best features of traditional plans, built-in preventative and wellness care, open access to a large, established network of providers, and no claim forms for members.
Q. On a PPO plan, when do I need a referral, and who do I get it from?
A. In either of the PPO plans, you need a referral if you are going out of network for benefit coverage. You must obtain the referral from a participating PPO provider.
For your out-of-network provider, it is not required that you be referred to a traditional BCBS participating provider. Your doctor may want you to go to a non-participating doctor or specialist. In that case, it is important to be aware that additional out-of pocket costs can be involved when you are referred to a non-participating BCBS physician. Non-participating physicians can charge you the difference between BCBS approved amount and their charge.
If you are referred to an out-of-network provider who participates with BCBS you will be billed as if they are a PPO doctor ($10.00 office visit co-pay).
Q. Can I get a referral for the PPO preventative services?
A. No, you cannot get a referral for preventative services in either of the PPO plans. An in-network participating provider must provide preventative services on either of the PPO plans.
Q. Why do some urgent care clinics participate with a PPO and some do not?
A. BCBS contracts with the physician and not the clinic. You will need to check to make sure that the physician staffing the urgent care clinic is a participating PPO provider, then you will only have a $10 co-pay. If the physician does not participate you will be responsible for a 20% co-pay on the PPO 1 plan and a 40% copay on the PPO 2 plan. You may also be responsible for difference between the BCBS approved amount and the amount charged by the non-participating physician. Certain PPO hospital-based and hospital affiliated urgent care facilities also accept the $10 co-payment instead of the $50 emergency co-payment, check the BCBS website for a list or contact BCBS customer service at 1-877-354-2583.
Q. Is allergy serum covered under the PPO plans?
A. Allergy serum is covered as part of the allergy testing/therapy benefit. The physician prepares most serum. If the serum must be ordered through a pharmacy and delivered to the physician for injection, the serum would not be covered through the Community Blue PPO program.
Q. How can I determine which doctors are BCBS participating providers?
A. Visit BCBS website at http://www.bcbsm.com to check out the directory of participating providers.
You can call and ask your current physician if he or she is a participating provider; or you can call the BCBS customer service representatives at 1-877-354-2583.
Q. What happens if I am on the PPO and an emergency situation occurs either at home or when I am away from home, such as on vacation or traveling?
A. Emergency situations are always covered as in-network benefits. The $50 co-payment on either of the PPO plans is waived if the emergency is an accidental injury or if you are admitted to the hospital. For a list of participating Community Blue PPO providers call 1.800.810.BLUE (2583) or check BCBS website http://www.bcbsm.com.
Q. What happens if I am on one of the PPO plans and I need care other than emergency when I am out-of-state or out of the country?
A. BlueCard is a national BCBS Association program that links all Blue plans. This provides CMU employees and their dependents with access to more than 85% of all hospitals and doctors throughout the US.
To find a Community Blue PPO provider in the area you are in call 1-800.810.BLUE (2583). You will find this number on the back of your ID card.
If you live or are traveling out of the country and you can access a participating hospital in that country, they will bill us direct. If you cannot you may need to pay them and send us the itemized bill for payment. The bill needs to be in English.
Q. What is the difference between Blue Cross and Blue Shield?
A. Blue Cross covers hospital services and Blue Shield covers medical, surgical services, x-rays and lab tests.
Q. I'm having a problem with a BCBS claim being paid, is there anything I can do?
A. Yes, you can call the BCBS toll free telephone number 1-877-354-2583. When using the 800 number ask the customer service representative for his/her name.
Always have your contract number ready. Collect relevant information such as explanation of benefits forms, itemized bills, name of doctor, and any other relevant information.
Q. Can you switch medical plan coverage when electing COBRA? When can changes be made?
A. Flexible benefits program participants are eligible for COBRA rights with respect to the medical benefits elected for the plan year. For example, if you elected PPO 1 under CMU Choices, you cannot change to PPO 2 under COBRA until open enrollment. Changing to a new plan can be made only during the annual open enrollment period.
Q. What happens if I become ineligible, or eligible, for other medical coverage during the year? May I change my enrollment?
A. Yes. If you experience a Status Change, as defined in the List of Status Change Events, you have 30 DAYS from the time of the status change to change your election.
Q. If I choose, for example, the PPO 1 plan, and my spouse, who is now covered under his or her employer, loses coverage and needs to be covered under my medical insurance during the year, may I file a status change to cover us both under a different plan?
A. Certain status change events may allow you to switch plans provided you complete the status change paperwork within 30 days of the event. We encourage you contact the Benefits and Wellness office at 989-774-3661 as soon as possible regarding a qualifying status change so that we can help determine what benefit changes are allowed. More information on status change events can be found on our web page at: Status Changes.
Q. If my spouse's employer's medical or dental plan requires a larger employee contribution during the year, and we need to pay more for coverage, does that constitute a "family status change"?
A. No. This does not qualify as a "family status change" since the plan is still being offered by the other employer.
Q. If my spouse is self-employed, is he or she required to provide his or her own insurance?
A. No, your spouse may be covered by the medical option you elect in CMU CHOICES if the alternative is that your spouse would have to purchase medical insurance entirely on his or her own.
Q. If my spouse works only part-time and if there is insurance available through his or her employer, does he or she have to be covered there?
A. Yes. A spouse must sign up for insurance at his or her place of employment as long as the employer makes any contribution toward the coverage.
Q. Currently my spouse is eligible for medical insurance via his or her employer's plan but he or she is not enrolled. What happens?
A. If your spouse's employer provides insurance but does not fund any of it, your spouse can be insured under your plan and DOES NOT have to take coverage with his/her employer.
If he or she has not taken an available employer funded plan (even if only partially funded), CMU CHOICES will continue to cover your spouse, as the primary insurance plan, through this transition period until your spouse's next open enrollment period. At that time, your spouse must enroll in his or her employer's plan. If your spouse does not have an open enrollment period, CMU will work with you on an individual basis until your spouse can get insurance through their employer.
Q. When do I contact BCBS Customer service at 1-877-354-2583, and when do I contact CMU's Benefits Office regarding questions, changes, etc.,?
A. Call or stop by the Benefits Office (989-774-3661) for a name change or a change in your family medical coverage needs because of a change in family status. There are forms that need to be filled out and signed. Whenever you have questions regarding a claim, participating providers’ facilities, and information regarding medical benefits, call BCBS at customer service 1-877-354-2583 directly; or check out BCBS’s website at http://bcbsm.com for a directory listing, other services, and claims filing such as coordination of benefits.