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Providers: Please Submit Claims, Appeals, and Prior Authorizations Promptly
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Providers: Please Submit Claims, Appeals, and Prior Authorizations Promptly
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Providers: Please Submit Claims, Appeals, and Prior Authorizations Promptly
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Member FAQEmployer FAQAgent FAQProvider FAQ

When will annual tax documents be mailed? If there are questions, who does the agent contact?

Annual tax documents will be provided in accordance with applicable laws, which generally state 1099s must be sent by January 31. For questions regarding your annual tax documents please email Finance@UofMHealthPlan.org.

Member FAQ

Plan Closure

What’s happening at UM Health Plan?
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UM Health Plan is closing operations and will terminate all current health plan coverage as of Jan. 31, 2026. Some coverage may end before this date, so check the member ID card to verify the correct payer by dates of service. The members who are currently being served will transition to other payers between now and Feb. 1, 2026.

Plan Closure

Why is UM Health Plan closing?
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Like many health plans, UM Health Plan has experienced significant financial losses over the past few years. After a thorough business and financial assessment, UM Health has made the difficult decision to close UM Health Plan.

This announcement comes after a comprehensive evaluation of the plan’s financial sustainability, market trends, and the evolving needs of our members.

We recognize the importance of affordable and reliable health care, and this decision was not made lightly. Despite significant efforts to maintain the plan, the increasingly competitive health insurance landscape, and the Centers for Medicare & Medicaid Services (CMS) changes to Medicare Advantage plans have made it unsustainable to continue offering the high level of service our members deserve. We are deeply committed to our members, agents, employers, and providers, and will continue to serve all these groups and all members’ claims for services provided through the coverage period.

Plan Closure

Is UM Health Plan being acquired by another health plan or is it closing?
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UM Health Plan is closing. Member coverage will end in accordance with their current covered plan time frame.

Plan Closure

How does this decision to close UM Health Plan impact members’ current medical and pharmacy benefits?
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The decision to close UM Health Plan in 2025 for plan year 2026 does not impact members’ current medical or pharmacy benefits administered by UM Health Plan. New health plan coverage will need to be selected after UM Health Plan coverage ends.

Plan Closure

I just enrolled/reenrolled in a UM Health Plan-administered Medicare Advantage plan, individual/family plan, or group plan for plan year 2025. How does this impact members’ 2025 benefits?
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UM Health Plan will cover medically necessary services members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract, respectively.

Plan Closure

Will providers accept UM Health Plan through the termination date?
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Yes, UM Health Plan has a strong relationship with our contracted network of providers and do not anticipate any issues with our network or our providers' ability to continue being accessible and available to our members. UM Health Plan, together with our provider and hospital system partners across Michigan, share a commitment to helping people access the care they need, close to home and will continue to cover medically necessary services our members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract.

Plan Closure

If UM Health Plan is terminating coverage and a member receives services on their last covered day, will their claims be paid in 2026?
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Yes, claim(s) for covered services received during the coverage period will be paid in 2026, per the contract benefit.

Plan Closure

If a member is hospitalized at the end of Dec. 2025 and remains in the hospital on Jan. 1, 2026, will UM Health Plan pay the claims?
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Medicare members: Yes, claims for services incurred at any time in 2025 will be paid, including inpatient stays. CMS regulation 42 CFR 422.318 establishes special rules for coverage that begins or ends during an inpatient hospital stay. The regulation requires UM Health Plan to pay for your inpatient hospitalization services from the date of admission while a member of our plan, through the date of discharge, even if the member is effective on Original Medicare or another MA-PD plan.

‍Individual members: Coverage ends on the date of termination – Dec. 31, 2025 – even if a member is hospitalized or otherwise receiving medical treatment on that date.

‍Group members: UM Health Plan will cover medically necessary services members require through the term of the group’s contract.

Plan Closure

When will employers and members be notified that the health plan is terminating coverage? Is there a link on the website to the notification document? Was the member's provider notified?
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Individual and group members: Written notification about the plan ending will be mailed to Individual and Group members no later than Oct. 2, 2025.

Medicare members: Members’ written notifications of the plan ending will be mailed no later than Oct. 2, 2025.

Plan Closure

Who were discontinuation or non-renewal notices sent to? Will it be sent to group, individual, or Medicare members only?
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Individual and group members: Written notification about the plan ending will be mailed to Individual and Group members no later than October 2, 2025.

Medicare members: Written notifications of the plan ending will be mailed to members no later than Oct. 2, 2025.

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Plan Closure

How does a member find a new plan?
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Individual members: Individual members are being encouraged to use the Health Insurance Marketplace (HealthCare.gov) to find other Health Insurance Marketplace plans or contact an independent agent who can assist them in choosing a new plan.  

Group members: Group members should contact their employer for information on the new plan selections offered to them.

Medicare members: Medicare members can visit Medicare.gov to compare plans, see what fits their needs, and enroll online or talk with a licensed Medicare agent who can help explore options and answer questions specific to the member. Annual enrollment period is Oct. 15 through Dec. 7, 2025. If a member misses the annual enrollment period, they will have a special enrollment period (SEP) from Dec. 8, 2025 through Feb. 28, 2026.

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Plan Closure

When does coverage end?
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Individual members: Coverage ends for individual members on Dec. 31, 2025.

Group members: Group members’ coverage end dates vary dependent on each employer. Please contact your employer for 2026 plan options.

Medicare members: Coverage ends for Medicare members on Dec. 31, 2025.

Plan Closure

When will my current benefit card no longer work? Does my benefit card indicate the last covered day? Will a new benefit card be mailed?
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Your benefit card will no longer work once your benefits are no longer active. Members and providers can verify coverage dates by utilizing our Member portal and Provider portal. Benefit cards will no longer be mailed to members after Nov. 30, 2025; however, members can view their benefit card by accessing their account on the Member Portal.

Plan Closure

Do deductibles transfer to new plans?
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Whether to accept deductible transfers from UM Health Plan is up to the new plan. If the new plan wishes to receive this information, they can request a report by sending an email to Customer.Service@UofMHealthPlan.org, within 30 days of the group’s or member’s termination with UM Health Plan.

Plan Closure

Who do I speak to if I am enrolled in coverage through my employer?
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Group members should contact their employer for information on the new plan selections offered to them.

Plan Closure

What is the timeframe for direct member reimbursement requests? Is it different for medical and pharmacy? How are the requests submitted and what is the mailing address?
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If you pay for health care services, it is best that requests for reimbursement be submitted within 90 days of the date of service. If UM Health Plan does not receive a claim within one year of the date of service, the health care services may not be covered. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends.

If you are submitting a member reimbursement request for a pharmacy service after June 30, 2026, written notification of the claim must be given to the plan at the address below.

All medical reimbursements after Jan. 1, 2026, and pharmacy reimbursements after June 30, 2026, send to:

PO Box 30377
Lansing, MI  48909-7877

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Plan Closure

When will the Member Portal no longer be available?
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Medicare members: The member portal (MyMedicarePortal.org) is available through Mar. 31, 2026. After the portal is no longer available, a Medicare member can contact customer service at 844-529-3759.

Individual and group members: The portal is available through June 30, 2026. In order to access the portal through June 2026, your account must be created prior to the termination of your coverage.

Plan Closure

How does a member enroll in the member portal? What are the benefits of enrolling in the portal?
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Medicare members: Medicare beneficiaries can be enrolled into our plan through Dec. 1, 2025 effective dates. Agents can use the producer portal for submitting enrollments. UM Health Plan does not pay commissions for new enrollments in 2025. The Medicare producer portal is available through April 30, 2026, so agents/producers can access commission statement information.

Individual and group members: Member:  

The portal login page can be found here: https://www.uofmhealthplan.org/login

To create an account, you will need the policy numbers from your Member ID card.

Through your portal account you can order new ID cards, view and print claim information, such as Explanation of Benefits, and update your primary care provider (PCP) information.

Plan Closure

How long will customer service be available?
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Medicare members: The Medicare customer service call center will be available through May 31, 2027.

Individual and group members: The UM Health Plan Customer Service call center will be available through Aug. 31, 2026.

Plan Closure

Does UM Health Plan’s closure affect my benefits for 2025?
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No. The decision to close UM Health Plan does not impact your current medical or pharmacy benefits administered by UM Health Plan. UM Health Plan will continue to cover medically necessary services through Dec. 31, 2025, as stated in your plan documents.

Behavioral Health and Substance Abuse

Where can I find information regarding behavioral health services?
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Behavioral Health Services are managed by University of Michigan Health Plan (UM Health Plan). Call Customer Service at 517-364-8500.

Behavioral Health and Substance Abuse

How does UM Health Plan make sure that my benefit plan provides equal coverage for medical and behavioral health/substance use disorder services?
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UM Health Plan creates benefit plans in which your cost for a medical service, for instance an office visit, is equal to a similar service for behavioral health or substance abuse. This ensures the benefits are equal, and you don’t pay any more for behavioral health services than you would for the same type of medical service.

Bills or Explanation of Benefits (EOB)

What are deductibles, copayments and coinsurance?
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The deductible, copayment and coinsurance amounts are your responsibility to pay to your health care providers.

  • A deductible is the amount you pay for health care services before your insurance starts to pay.
  • A copayment is a fixed amount you must pay each time you receive certain covered health services.
  • Coinsurance is a percentage of the allowed cost for a covered services

Bills or Explanation of Benefits (EOB)

What is the difference between preventive services and diagnostic services?
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Preventive services are performed to screen for possible health issues when you do not have symptoms, and have not had a previous abnormal test result. An office visit, test, or procedure could all be considered preventive.

In order to be considered as preventive, services must be billed with specific preventive billing codes. Your provider’s biller will use industry standard coding guidelines to complete a claim for the service you received. UM Health Plan cannot change the coding to fit one type of benefit or another.

Diagnostic services are performed when you have symptoms, an abnormal test result, or a known health problem. An office visit, test, or procedure could all be considered diagnostic. The services may be performed to determine the cause of symptoms or to verify if a disease has returned or gotten worse.

Bills or Explanation of Benefits (EOB)

Why is my mammogram or colonoscopy not applying to my benefits as a preventive service?
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If you have family or personal history, abnormal test results, or known health problems associated with the procedure, the service will most likely be considered diagnostic. There is also a possibility that you have no history or symptoms, but during the procedure an issue is identified.

For questions regarding how your benefits applied to a service, contact Customer Service call center at the phone number on the back of your ID card.

Contact your provider's office for more details if your question pertains to why a procedure is being billed as a diagnostic service.

Bills or Explanation of Benefits (EOB)

Why was my hospital stay considered observation instead of inpatient?
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An Observation Stay is an outpatient hospital service in which an individual receives medical treatment to help the doctor decide whether they should be admitted to the hospital as an inpatient, or whether they should be discharged. Observation Stays may occur when patients go to the emergency department and have symptoms that require hospital providers to monitor them. Observation Stays can last as little as a few hours but may also last several days.

Your emergency room benefit will apply if you are kept for observation following services in the emergency department.

Bills or Explanation of Benefits (EOB)

Why was my doctor's visit billed as an outpatient clinic visit instead of a provider's office visit?
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A hospital-based outpatient clinic is a provider practice which is considered part of the hospital instead of a private provider office. These clinics may look like a regular doctors' office, but they are either in a partnership with a hospital or are a hospital-owned provider practice.

Hospital-based clinics are still considered part of the hospital even though they may be located miles away from the main hospital, across the street from the hospital, or inside of the hospital. Often, they are dependent upon the hospital for administrative services such as billing, staffing, and payroll, or equipment such as MRI, CT and laboratory.

To determine if your doctor is part of a hospital-based outpatient clinic or private office, ask your doctor how they will be billing services to your health insurance plan.

Bills or Explanation of Benefits (EOB)

What is an Explanation of Benefits?
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An Explanation of Benefits (EOB) is an explanation of how we processed a claim for you or a family member. An EOB is not a bill. EOBs are always addressed to the patient to protect patient confidentiality. An EOB shows the patient’s name, member number, claim number, name of provider and type of service, dates of service, billed charges, amounts not covered, deductible and copayments, and total patient cost. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.

Bills or Explanation of Benefits (EOB)

How can I get a copy of an Explanation of Benefits?
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Copies of your Explanation of Benefits (EOB) can be found by creating or logging into your member portal account. Access to your member portal account is found by visiting UofMHealthPlan.org and selecting Portal Login from the top navigation bar.

Please call Customer Service at 517-364-8500 if you have trouble creating an account or accessing your EOB.

Bills or Explanation of Benefits (EOB)

Can an out-of-network provider bill me for the balance not covered by insurance?
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Out-of-network services are from doctors, hospitals, and other health care professionals that do not have a contract with UM Health Plan. Out-of-network providers may set higher cost for services than providers who are in-network. Depending on the provider, the service could cost more or not be paid for at all.

  • Under the new legislation, if you or your representative are given and sign paperwork provided by an out-of-network provider that includes a disclosure form and a cost estimate at least 14 days in advance of your planned service (or within 14 days if your planned service is sooner), you agree to be balance billed by the out-of-network provider. You bear liability in this instance.
  • In a non-emergency situation at an in network facility, you may receive services from an out of network provider. If the out of network provider fails to give you the required disclosure before or within 14 days of your planned service, you cannot be balance billed. Only your applicable coinsurance, copayment or deductible should apply.
  • Emergency ground ambulance services are not covered under surprise billing. You should refer to your insurance policy and contract language for coverage details.
  • Check your EOB for applicable copays.

Bills or Explanation of Benefits (EOB)

Your Rights and Protections Against Surprise Medical Bills
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When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is surprise billing?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Some of the most common specialties that result in surprise bills include anesthesiologists, radiologists, pathologists, and emergency department providers.

You’re protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Note: surprise billing law does not apply to ground ambulance services. You should refer to your insurance policy and contract language for coverage details.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can no longer send you surprise bills without written disclosure and consent for planned services.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
  • Generally, your health plan must:
    • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

What do I need to know about state and federal regulation?‍

‍State protections for members Governor Whitmer signed into law Michigan's Surprise Billing legislation in October 2020. In non-emergency situations, out-of-network providers are now required to disclose the estimated cost of care to you at least 14 days in advance of your planned service (or within 14 days if your appointment is sooner). Your signature is required if you agree to pay the amount not covered by your health plan.

‍Provider's documentation must include:

  • A statement that your insurer may not cover all services
  • A "good-faith" estimate for services to be provided
  • A statement that you may request care from an in-network provider and can contact your health plan to discuss

Note: In emergency situations, or if an out-of-network provider fails to give you the required disclosure before your planned service, you cannot be balance billed.‍

‍Federal protections for members

‍The federal government also passed similar surprise billing legislation in December 2020. This went into effect on Jan. 1, 2022. Because the state of Michigan has its own surprise billing protections that supersede federal law, the federal Surprise Billing law is only applicable to air ambulance services, members in a self-funded group health plan, and members residing outside of the state of Michigan. In all situations where you are presented with paperwork by providers, we encourage you to read carefully before you sign.

‍If you think you’ve been wrongly billed

‍If you believe you’ve been wrongly billed, or you did not receive the required disclosure form, contact us at the number on the back of your Member ID card. Unresolved issues can be directed to the Michigan Department of Insurance and Financial Services (DIFS) Monday through Friday, 8:00 a.m. to 5:00 p.m. at 877-999-6442 or visit the DIFS website to file a complaint.

Unresolved issues related to air ambulance services, plan members of self-funded groups, or plan members residing outside of Michigan can contact the CMS/Centers for Medicare and Medicaid Services at 800-985-3059 or visit their website.

Care During an Emergent or Urgent Situation

What is an emergency? What is urgent care?
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A medical emergency is defined as a serious medical condition or symptom resulting from an accident, injury, sickness, or mental illness that arises suddenly and has severe symptoms, including severe pain. It is further defined as being a situation in which a reasonable person would believe that failure to get immediate care may result in:

  • Placing the patient’s health in serious danger
  • Serious harm to body functions
  • Serious harm to any body organ or part
  • Serious disfigurement
  • In case of a pregnant woman, serious jeopardy to the unborn child

Urgently needed health services are defined as health services that are required in order to prevent serious deterioration of a person’s health, and that are required as a result of an unforeseen sickness or injury. See the chart below for a few examples.

Emergency Conditions (Examples)
Choking
Unconsciousness
Convulsions
Severe Bleeding
Broken Bones
Heart Attack or Chest Pain
Severe Breathing Problem
Sudden Severe Headache
Nonemergency Conditions (Examples)
Cold or Flu
Sore Throat
Lower Back Pain
Immunizations
Upset Stomach
Minor Cuts or Bruises
Frequent Urination
Follow-up Care

Care During an Emergent or Urgent Situation

How do I get emergent or urgent care while away from home?
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UM Health Plan covers you at the network-benefit level for emergency and urgent conditions, even if you are traveling away from home. If you have an emergency, go to the nearest emergency room. If your situation is urgent, go to the nearest urgent care facility. We will also cover a non-network physician’s office visit for urgent care while traveling out of the area. Contact UM Health Plan as soon as possible after your treatment, so that follow-up care can be provided, and your medical record can be updated.

For Emergency Situations

If you have a serious injury or sudden illness with severe symptoms, call your primary care provider (PCP) and follow the instructions you are given. If you are unable to contact your doctor and have someone to transport you safely, go directly to the nearest hospital emergency department. If you don’t have enough time to contact your doctor and you need immediate assistance, call 911 and stay on the line until instructed to hang up. Emergency staff can get to you faster than you can get to the hospital. Contact UM Health Plan as soon as possible after your treatment, so that follow-up services can be provided.

Urgent Situations

Urgent care should be used in a situation that is not life-threatening but that requires care sooner than you can typically schedule an office visit. If you need urgent care during normal office hours, after doctor’s office hours or on the weekends, call your PCP for direction. Your PCP may direct you to obtain urgent care services at a network urgent care facility or may arrange to see you personally on an urgent basis.

Care During an Emergent or Urgent Situation

How do I obtain care after doctor's office hours?
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If you need urgent care after your doctor’s office hours or on the weekend, call your primary care provider’s office. Their after-hours recording may instruct you on how to obtain urgent care services. Go to the nearest urgent care facility or emergency department if you are unable to contact your PCP, and you have an injury or illness with symptoms that require immediate attention.

If your symptoms are severe, need immediate assistance, and you are unable to safely drive, call 911 and stay on the line until instructed to hang up. First responders can get to you faster than you can get to the hospital. As soon as possible after your treatment, contact your PCP so you can receive necessary follow-up services.

Claims

What is a claim?
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A claim is a request to an insurance company for payment of health care services. Usually, providers file claims with us on your behalf. If you received services from an out-of-network provider, and if that provider does not submit a claim to us, you can file the claim directly to UM Heath Plan up to 12 months from the date the services were rendered. Please contact Customer Service at 517-364-8500 to determine the specific time limit for submitting your claim.

Claims

What is prior authorization?
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Before you obtain certain medical services, UM Health Plan must review and approve them. This is called prior authorization or pre-service review. For example, any kind of inpatient hospital care (except maternity care) requires prior authorization. If you need a service that we must first approve, your doctor will call us for the authorization. If you do not receive prior authorization, you may have to pay up to the full amount of the charges. The number to call for prior authorization is included on the ID card you receive after you enroll. Please refer to the specific coverage information you receive after you enroll.

UM Health Plan typically decides on requests for prior authorization for medical services within 24-72 hours for urgent requests, depending upon the type of request, or within 7 days for non-urgent requests.

Claims

What information do I need to submit a claim to UM Health Plan?
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Medical Claims:

Please fill out the Medical Reimbursement Form, which can also be found on the Member Reference Desk Submit the completed form along with an itemized receipt showing the charges for the services you received, and the information outlined below.

If you are unable to print the form, submit an itemized receipt and the following information. Please include a brief description indicating that you are seeking reimbursement.

  • Provider name, address, phone number and Federal Tax ID number
  • Date of service
  • Place of service (e.g., urgent care, emergency department, etc.)
  • Diagnosis
  • Procedure and/or procedure code
  • Patient’s name and member ID number

Medical claims should be sent to:
University of Michigan Health Plan
P.O. Box 30377
Lansing, MI 48909-7877

Fax: 517-364-8411

Pharmacy Claims:

Members can request direct reimbursements through their ESI account at Express-Scripts.com. If you'd like to request reimbursement by mail, please fill out the Pharmacy Direct Reimbursement Form and submit an itemized receipt showing the charges for the services you received:

  • Member name
  • Pharmacy name
  • Drug name
  • National Drug Code (NDC)
  • Quantity dispensed
  • Day supply
  • Provider name
  • Date of service
  • Amount paid

Pharmacy claims should be sent to:‍

Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711

Fax: 517-364-8411

Claims

How do I check the status of a claim that was submitted to UM Health Plan by my doctor or me?
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Check the status of a medical or pharmacy claim by visiting logging into the member portal, or call Customer Service at 517-364-8500.

Claims

What does it mean if my claim is pended?
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If you are an individual member whose premium payment is past due, you are provided a grace period. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. For more information on grace periods, see the Premium Payments section below.

Enrollment and Other Membership Matters

I recently moved. Do I need to notify UM Health Plan of my new address and phone number?
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You may make changes to your mailing address on the member portal or by calling Customer Service at 517-364-8500. You should also notify your employer of any change in address.

Enrollment and Other Membership Matters

What should I do if I lose my ID card?
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To receive a new card, please request one online through the member portal or contact Customer Service at 517-364-8500. If you are concerned about the unauthorized use of your ID card or the information contained on it, please contact Customer Service at 517-364-8500.

Enrollment and Other Membership Matters

What should I do if my spouse or a dependent is no longer eligible to be on my policy?
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You should always notify your employer and UM Health Plan whenever someone is no longer eligible for coverage. Ex-spouses become ineligible on the date of divorce, and dependents become ineligible if they do not meet certain dependent requirements as specified by your policy. Please call Customer Service at 517-364-8500 whenever you have questions.

Enrollment and Other Membership Matters

How do I add my new spouse or my children to my policy?
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If you have coverage through your employer, contact your employer. Your employer will notify the plan of your changes.

If you have coverage through a UM Health Plan Off-Marketplace Individual/Family plan, fill out the change form and return to the plan.

If you have coverage through a UM Health Plan On-Marketplce Individual/Family plan, contact the Marketplace.

Enrollment and Other Membership Matters

How do I obtain health care services?
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Primary Care Physician (PCP):
You can make your own appointments with your network primary care physician as needed.
Specialist:
You can make your own appointment with a network specialist as needed; a referral is not required. However, some specialists may require that you get a referral from your PCP office.
Behavioral Health Doctor:
Some behavioral health services need to be approved by PHP. You may make your own initial appointment with a network doctor. Your doctor will contact PHP for authorization. If you are seeing a non-network doctor, it is a good idea to check with PHP before you start treatment to make sure the services you receive are covered under your non-network benefits.
Hospital:
Your doctor will coordinate your inpatient and outpatient hospital services. Please make sure your doctor has access (also referred to as “privileges”) to the hospital you choose; not all doctors are able to admit patients to all hospitals.

Enrollment and Other Membership Matters

How does UM Health Plan compensate the Broker/Agent that helped me with my Individual policy?
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UM Health Plan complies with the Consolidated Appropriations Act, 2021 – Broker Compensation Disclosure, and has outlined below the Individual Commission and Bonus Program offered to UM Health Plan’s broker/agent partners.

All individual members are billed the same premium regardless if they use a broker/agent to enroll, or if they enroll independently through UM Health Plan or Healthcare.gov.

  • Broker/Agents earn a 4% commission on all new and renewed individual premiums.
  • Broker/Agents are eligible for a one-time bonus for each newly enrolled subscriber.

UM Health Plan will continue to provide new or updated information as it becomes available.

Other Insurance

What is Coordination of Benefits (COB)?
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COB exists when you are covered by more than one health plan. The plans typically process Medical claims together, reducing your out-of-pocket expenses. COB rules tell each health plan who pays first (also referred to as the primary health plan). The primary plan provides full benefits as if there were no other plans involved. The other plan then becomes secondary. Further information about coordination of benefits can be found in your benefit booklet.

Outpatient Prescription Drug Product Benefits are not coordinated with those of any other health coverage plan. If you have primary health care coverage and this benefit plan is your secondary coverage, you must use your primary outpatient prescription drug coverage.

Other Insurance

Both my spouse and I have health coverage through our employers. Which policy should be billed first?

+

The policy you have through your employer, or the policy that lists you as the policy holder, will most likely be billed first, however there are exceptions that are based upon the type of policy. If you have any questions as to which policy should be billed first, call Customer Service at 517-364-8500.

Other Insurance

Do I need to notify UM Health Plan if I am involved in an auto, work-related or third-party accident?

+

Please call Customer Service at 517-364-8500 as soon as possible if you are involved in an accident and had medical services as a result of the accident. You may also receive a letter from a subrogation vendor on behalf of UM Health Plan asking for more information about certain injuries.

Other Insurance

How do I inform UM Health Plan about my other health coverage?

+

You may receive a notice from us asking you to tell us about any other medical coverage that you or your dependents have. Please follow the directions on the notice so that we have the most up-to-date information and can pay your medical claims correctly. Information regarding other health coverage can be provided at any time by logging into your member portal or by calling Customer Service at 517-364-8500. If you do not provide us with your other insurance information, we may deny or delay paying your claims.

Pharmacy Benefits

What are tiers and how do they affect my copayment?

+

Outpatient pharmacy benefits are categorized within six tiers – Tier 1A, Tier 1B, Tier 2, Tier 3, Tier 4 and Tier 5. The higher the tier, the higher your copay. Refer to your benefit plan for more information about your copays.

Pharmacy Benefits

What is the Prescription Drug List (PDL)/Formulary?

+

Prescription drug lists , also known as formularies, are chosen by your employer for your benefit plan. Pharmacy benefits are provided by Express Scripts, Inc. (ESI). You can verify the drug coverage you have by contacting Customer Service at 800-832-9186, or by visiting Express-Scripts.com. If you are a first-time user of ESI, you will need to register with your subscriber number.

These lists are subject to change.

Pharmacy Benefits

What if my prescribed medicine is not on the Prescription Drug List (PDL) and it’s after business hours?

+

Call Customer Service at 517-364-8500. If it is urgent, we will contact an on-call nurse to assist you.

Pharmacy Benefits

What if my provider prescribes a drug that requires prior approval?

+

If your provider prescribes a prescription drug in a classification or tier that is not available to you, we conduct, at you or your provider’s request, a review to determine if the drug is medically appropriate in your specific circumstances. We notify you and your provider of our coverage decision within 7 calendar days of receipt for a standard request. If your situation is urgent, we make our decision and notify your provider within 72 hours of receiving an expedited request.

You may initiate a request for exception by asking UM Health Plan for a prior approval via email or phone. You may submit your request via email -- using the secure Contact Us Form on our website -- or phone by calling Customer Service at 517-364-8567 or 866-539-3342. You must submit:

  • Your name
  • Your member ID number
  • The name of the prescribing provider(s) coordinating your treatment
  • The drug in question

We will contact your provider to get your medical information. In most cases, your provider will submit the request on your behalf. The Medication Prior Authorization Form should be used for any exception requests. The completed form and supporting information from either you or your provider can be faxed to Pharmacy  at 877-999-6442.

Pharmacy Benefits

What if my provider prescribes a drug that is excluded from coverage?

+

A standard request for a non-formulary and excluded medication will receive notification of a coverage decision, sent to both you and your provider, within 72 hours of receipt. If your situation is urgent, we make our decision and notify you and your provider within 24 hours of receiving an expedited request.

If your request is denied for a non-formulary and/or excluded medication, alternative drug choices may be suggested. You, a personal representative, or prescribing provider also can ask for an independent review of your request via phone, mail or fax. The independent review must be completed within the same time-period as the original request (72 hours for a standard request or 24 hours for an expedited request.)

To accommodate the needs of new members, we may, upon clinical review, cover a non-formulary drug for a limited period of time.

You may initiate a request for exception by asking for a prior approval via email or phone. You may submit your request via email -using the secure Contact Us Form on our website,  phone - by calling  Customer Service at 517-364-8567 or 866-539-3342, or mail - PO Box 30377, Lansing, Michigan 48909-7877. You must submit your name, member ID number, the name of the prescribing provider(s) coordinating your treatment and the drug in question. We will contact your provider to get your medical information. In most cases, your provider will submit the request on your behalf. The Medication Prior Authorization Form should be used for any exception requests. The completed form and supporting information from either you or your provider can be faxed to Pharmacy at 517-364-8413.

Pharmacy Benefits

How can I make sure that I am getting the greatest value from my outpatient drug benefit?

+

Discuss the use of generic drugs with your provider. Generic drugs must have the identical active ingredients as the brand name drug. The differences can be color, shape, fillers and flavor. If you or your provider have questions, please call Customer Service at 517-364-8500.

Premium Payments

How do I make a premium payment for my individually purchased coverage?

+

Premium payments can be made online with a credit card, debit card or bank withdrawal by using our Online Payment Form. Payments can be made using our 24-hour automated payment system at 877-233-7488, or you can pay by check to the address listed below.

University of Michigan Health Plan
P.O. Box 74008122
Chicago, IL 60674-8122

Premium Payments

I am trying to make a payment, but the system cannot locate my account.

+

When using the “Make A Payment” option for online payments, please be sure you are using the Account Number, which is on your invoice and in your online account. This is the number that starts with the number “1” and has 10 digits. If you do not have this number, please use the option to find your account using your social security number.. If you have questions or are still unable to find your account, contact Customer Service at 517-364-8567.

Premium Payments

Do I have a grace period for premium payment?

+

You are required to pay your monthly premium by the scheduled due date, which is indicated on your premium invoice. The premium due date is the last day of the preceding month. Your coverage could be cancelled if you fail to make your payment by the due date.

For policies not receiving a Premium Tax Credit:

If you do not pay your monthly premium on time you will receive a 30-day grace period, ending on the last day of the month your premium was due. A grace period is a time period when your coverage will not terminate even though you did not pay your monthly premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full. If you do not pay your delinquent premium by the end of the 30-day grace period, your coverage will be terminated retroactively to the last paid month. If you pay your full outstanding premium before the end of the grace period, UM Health Plan will pay all properly submitted claims for covered services you received during the grace period.

For policies receiving a Premium Tax Credit:

If you do not pay your monthly premium on time you will receive a 3-month grace period. UM Health Plan will pay all properly submitted claims for covered services during the first month of the grace period. During the second and third months of that grace period, any claims you incur will be pended. If you pay your full outstanding premium before the end of the 3-month grace period, we will pay all claims for covered services that are submitted properly for the second and third months of the grace period. If you do not pay all of your outstanding premium by the end of the 3-month grace period, your coverage will terminate, and UM Health Plan will not pay for any pended claims submitted for you during the second and third months of the grace period. Your coverage will be retroactively terminated back to the end of the first month of your grace period. Your provider may balance bill you for services incurred during the second and third months of your grace period.

Premium Payments

What happens if my coverage is retroactively terminated and I received treatment after my date of coverage?

+

A retroactive termination of coverage is the reversal of coverage for months in which your premiums were not paid. A retroactive claim denial is the reversal of a claim we have already paid but is now after your coverage has ended. If we retroactively deny a claim we have already paid for you, you will be responsible for payment. You can avoid retroactive denials by paying your premiums on time, and in full.

Premium Payments

How can I obtain a refund if I have overpaid my monthly premium?

+

If you believe you have paid too much for your premium and should receive a refund, please call Customer Service at 517-364-8567.

Premium Payments

How long should I expect for a refund to be issued?

+

Refunds in the exact amount of your credit card, debit card or automatic bank withdrawal payment, made no more than 6 months ago, can be refunded directly to the method of payment. This refund should be reflected in the payment account within 7-10 business days. If your refund was made by check or money order, or was made more than 6 months ago, the refund will be issued by check. This refund check will be mailed by UM Health Plan within 4-6 weeks. Please allow mailing time for the payment to reach you.

Providers

How can I find a doctor or hospital in my network?

+

Visit the Finding a Doctor page for information about doctors and hospitals in-network for the plan type you have. Customer Service staff is also available to help you with answers to your important provider-related questions:

  • Will the doctor accept new patients?
  • What are the office hours and where is the doctor located?
  • Is the provider board certified?
  • Is the hospital accredited?
  • What hospitals can the doctor work with?
  • Where did the doctor go to school?
  • Does the provider speak your language?

Providers

What should I do if my provider does not participate with UM Health Plan?

+

If you are a new member or if your provider leaves the UM Health Plan network, you must pick an in-network doctor. You may be able to see your current provider for up to 90 days, depending on the care you are currently receiving. If you are pregnant, special case-by-case consideration may be given. To learn more, contact Medical Resource Management at 517-364-8560.

Referrals and Prior Authorizations

What is the difference between a referral and a prior authorization?

+

A referral is a recommendation from one doctor to another, commonly from your primary care provider to a specialist. UM Health Plan does not require a referral, but the specialist you want to see may require the information.

A prior authorization is approval for a health care service. Not all health care services require UM Health Plan prior authorization. You or your doctor should submit the request for prior authorization before you receive the service using the authorization request form. Non-urgent requests are reviewed within 7 days. Urgent requests are reviewed in 72 hours. The request may be approved or denied. We will send you and your provider a letter with the decision.

Referrals and Prior Authorizations

How do I get a referral to see a specialist?

+

UM Health Plan does not require referrals to in-network specialists. However, some specialists may still require a referral from your primary care provider (PCP). If your specialist still wants a referral from your PCP, call your PCP and tell them that your specialist is asking for a referral.

Employer FAQ

Plan Closure

What’s happening at UM Health Plan?

+

UM Health Plan is closing operations and will terminate all current health plan coverage as of Jan. 31, 2026. Some coverage may end before this date, so check the member ID card to verify the correct payer by dates of service. The members who are currently being served will transition to other payers between now and Feb. 1, 2026.

Plan Closure

Why is UM Health Plan closing?

+

Like many health plans, UM Health Plan has experienced significant financial losses over the past few years. After a thorough business and financial assessment, UM Health has made the difficult decision to close UM Health Plan.

This announcement comes after a comprehensive evaluation of the plan’s financial sustainability, market trends, and the evolving needs of our members.

We recognize the importance of affordable and reliable health care, and this decision was not made lightly. Despite significant efforts to maintain the plan, the increasingly competitive health insurance landscape, and the Centers for Medicare & Medicaid Services (CMS) changes to Medicare Advantage plans have made it unsustainable to continue offering the high level of service our members deserve. We are deeply committed to our members, agents, employers, and providers, and will continue to serve all these groups and all members’ claims for services provided through the coverage period.

Plan Closure

Is UM Health Plan being acquired by another health plan or is it closing?

+

UM Health Plan is closing. Member coverage will end in accordance with their current covered plan time frame.

Plan Closure

How does this decision to close UM Health Plan impact members’ current medical and pharmacy benefits?

+

The decision to close UM Health Plan in 2025 for plan year 2026 does not impact members’ current medical or pharmacy benefits administered by UM Health Plan. New health plan coverage will need to be selected after UM Health Plan coverage ends.

Plan Closure

I just enrolled/reenrolled in a UM Health Plan-administered Medicare Advantage plan, individual/family plan, or group plan for plan year 2025. How does this impact members’ 2025 benefits?

+

UM Health Plan will cover medically necessary services members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract, respectively.

Plan Closure

Will providers accept UM Health Plan through the termination date?

+

Yes, UM Health Plan has a strong relationship with our contracted network of providers and do not anticipate any issues with our network or our providers' ability to continue being accessible and available to our members. UM Health Plan, together with our provider and hospital system partners across Michigan, share a commitment to helping people access the care they need, close to home and will continue to cover medically necessary services our members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract.

Plan Closure

If UM Health Plan is terminating coverage and a member receives services on their last covered day, will their claims be paid in 2026?

+

Yes, claim(s) for covered services received during the coverage period will be paid in 2026, per the contract benefit.

Plan Closure

If a member is hospitalized at the end of Dec. 2025 and remains in the hospital on Jan. 1, 2026, will UM Health Plan pay the claims?

+

Medicare members: Yes, claims for services incurred at any time in 2025 will be paid, including inpatient stays. CMS regulation 42 CFR 422.318 establishes special rules for coverage that begins or ends during an inpatient hospital stay. The regulation requires UM Health Plan to pay for your inpatient hospitalization services from the date of admission while a member of our plan, through the date of discharge, even if the member is effective on Original Medicare or another MA-PD plan.

‍Individual members: Coverage ends on the date of termination – Dec. 31, 2025 – even if a member is hospitalized or otherwise receiving medical treatment on that date.

‍Group members: UM Health Plan will cover medically necessary services members require through the term of the group’s contract.

Plan Closure

When does coverage end?

+

Individual members: Coverage ends for individual members on Dec. 31, 2025.

Group members: Group members’ coverage end dates vary dependent on each employer. Please contact your employer for 2026 plan options.

Medicare members: Coverage ends for Medicare members on Dec. 31, 2025.

Plan Closure

When will my current benefit card no longer work? Does my benefit card indicate the last covered day? Will a new benefit card be mailed?

+

Your benefit card will no longer work once your benefits are no longer active. Members and providers can verify coverage dates by utilizing our Member portal and Provider portal. Benefit cards will no longer be mailed to members after Nov. 30, 2025; however, members can view their benefit card by accessing their account on the Member Portal.

Plan Closure

Do deductibles transfer to new plans?

+

Whether to accept deductible transfers from UM Health Plan is up to the new plan. If the new plan wishes to receive this information, they can request a report by sending an email to Customer.Service@UofMHealthPlan.org, within 30 days of the group’s or member’s termination with UM Health Plan.

Plan Closure

What is the timeframe for direct member reimbursement requests? Is it different for medical and pharmacy? How are the requests submitted and what is the mailing address?

+

If you pay for health care services, it is best that requests for reimbursement be submitted within 90 days of the date of service. If UM Health Plan does not receive a claim within one year of the date of service, the health care services may not be covered. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends.

If you are submitting a member reimbursement request for a pharmacy service after June 30, 2026, written notification of the claim must be given to the plan at the address below.

All medical reimbursements after Jan. 1, 2026, and pharmacy reimbursements after June 30, 2026, send to:

PO Box 30377
Lansing, MI  48909-7877

‍

Plan Closure

How long will customer service be available?

+

Medicare members: The Medicare customer service call center will be available through May 31, 2027.

Individual and group members: The UM Health Plan Customer Service call center will be available through Aug. 31, 2026.

Frequently Asked Questions

Where can I find benefit summaries for quotes or groups?

+

Please contact Sales at Sales@UofMHealthPlan.org for information for quotes or groups.

Frequently Asked Questions

Can I make enrollment and eligibility changes online?

+

Contact Sales at Sales@UofMHealthPlan.org to request enrollment and eligibility changes.

Frequently Asked Questions

How can I find participating providers accepting new patients or with extended weekday or weekend office hours?

+

To find a participating doctor, visit the Provider Directory.

Frequently Asked Questions

Can employer groups pay their premiums online?

+

At this time, groups cannot pay their premiums online. Employer groups can send checks to the following address:

For HMO Plans:

University of Michigan Health Plan

PO Box 776180

Chicago, IL 60677-6180

For PPO Plans:

University of Michigan Health Plan

PO Box 776178

Chicago, IL 60677-6178

Frequently Asked Questions

Can employer groups have their premiums automatically deducted from their bank account each month?

+

Groups are able to set up ACH payments to UM Health Plan. Employer groups must initiate the payment through their financial institution.

For more information contact Finance at 888-892-0009.

Frequently Asked Questions

Do the maximum-out-of-pocket (MOOP) amounts shown on quotes include the deductibles?

+

Yes - the maximum-out-of-pocket (MOOP) amounts include the deductibles.

Frequently Asked Questions

What if I have employees residing outside of the UM Health Plan service area?

+

In order for your group to take part in an HMO plan or a POS plan through UM Health Plan, your employees must live or work within our service area. HMO or POS members who live or work outside of the service area must agree to receive services from in-network providers.

If your group offers a PPO plan, and you have a new enrollee who lives outside of the service area, please notify your account manager so that the new enrollee can be placed in the appropriate network class to receive in-network benefits.

Frequently Asked Questions

What if a member needs to seek services while traveling out of the area?

+

UM Health Plan offers a statewide network of providers and facilities. A member who has an urgent or emergency situation when traveling outside the service area should visit the nearest urgent care center or emergency department, regardless of whether it is in the network. Urgent Care and Emergency services are always covered under a member's in-network benefit, in all 50 states and worldwide.

Frequently Asked Questions

What is the prescription drug list?

+

It is a list of prescription drugs covered by a particular drug benefit plan. UM Health Plan, in conjunction with its pharmacy benefit manager, Express Scripts, Inc. (ESI), reviews its Prescription Drug Lists on a regular basis to ensure that they are up-to-date.

Frequently Asked Questions

Are there pre-existing condition clauses in your policies?

+

There are no pre-existing clauses under any UM Health Plan policies.

Frequently Asked Questions

How do I enroll a member, make a change or check the status of an enrollment or change?

+

You can make enrollment changes in a number of ways:

  • Make changes in the Employer Portal
  • Submit the necessary forms to Enrollment at Enrollment@UofMHealthPlan.org
  • Call your account manager.

Changes may take up to 48 hours to be effective.

Frequently Asked Questions

What if a member needs Case Management services?

+

Please fill out and return the Case Management Referral Form to CaseManagement@UofMHealthPlan.org.

Agent FAQ

Plan Closure

What’s happening at UM Health Plan?

+

UM Health Plan is closing operations and will terminate all current health plan coverage as of Jan. 31, 2026. Some coverage may end before this date, so check the member ID card to verify the correct payer by dates of service. The members who are currently being served will transition to other payers between now and Feb. 1, 2026.

Plan Closure

Why is UM Health Plan closing?

+

Like many health plans, UM Health Plan has experienced significant financial losses over the past few years. After a thorough business and financial assessment, UM Health has made the difficult decision to close UM Health Plan.

This announcement comes after a comprehensive evaluation of the plan’s financial sustainability, market trends, and the evolving needs of our members.

We recognize the importance of affordable and reliable health care, and this decision was not made lightly. Despite significant efforts to maintain the plan, the increasingly competitive health insurance landscape, and the Centers for Medicare & Medicaid Services (CMS) changes to Medicare Advantage plans have made it unsustainable to continue offering the high level of service our members deserve. We are deeply committed to our members, agents, employers, and providers, and will continue to serve all these groups and all members’ claims for services provided through the coverage period.

Plan Closure

Is UM Health Plan being acquired by another health plan or is it closing?

+

UM Health Plan is closing. Member coverage will end in accordance with their current covered plan time frame.

Plan Closure

How does this decision to close UM Health Plan impact members’ current medical and pharmacy benefits?

+

The decision to close UM Health Plan in 2025 for plan year 2026 does not impact members’ current medical or pharmacy benefits administered by UM Health Plan. New health plan coverage will need to be selected after UM Health Plan coverage ends.

Plan Closure

I just enrolled/reenrolled in a UM Health Plan-administered Medicare Advantage plan, individual/family plan, or group plan for plan year 2025. How does this impact members’ 2025 benefits?

+

UM Health Plan will cover medically necessary services members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract, respectively.

Plan Closure

Will providers accept UM Health Plan through the termination date?

+

Yes, UM Health Plan has a strong relationship with our contracted network of providers and do not anticipate any issues with our network or our providers' ability to continue being accessible and available to our members. UM Health Plan, together with our provider and hospital system partners across Michigan, share a commitment to helping people access the care they need, close to home and will continue to cover medically necessary services our members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract.

Plan Closure

If UM Health Plan is terminating coverage and a member receives services on their last covered day, will their claims be paid in 2026?

+

Yes, claim(s) for covered services received during the coverage period will be paid in 2026, per the contract benefit.

Plan Closure

If a member is hospitalized at the end of Dec. 2025 and remains in the hospital on Jan. 1, 2026, will UM Health Plan pay the claims?

+

Medicare members: Yes, claims for services incurred at any time in 2025 will be paid, including inpatient stays. CMS regulation 42 CFR 422.318 establishes special rules for coverage that begins or ends during an inpatient hospital stay. The regulation requires UM Health Plan to pay for your inpatient hospitalization services from the date of admission while a member of our plan, through the date of discharge, even if the member is effective on Original Medicare or another MA-PD plan.

‍Individual members: Coverage ends on the date of termination – Dec. 31, 2025 – even if a member is hospitalized or otherwise receiving medical treatment on that date.

‍Group members: UM Health Plan will cover medically necessary services members require through the term of the group’s contract.

Plan Closure

When will employers and members be notified that the health plan is terminating coverage? Is there a link on the website to the notification document? Was the member's provider notified?

+

Individual and group members: Written notification about the plan ending will be mailed to Individual and Group members no later than Oct. 2, 2025.

Medicare members: Members’ written notifications of the plan ending will be mailed no later than Oct. 2, 2025.

Plan Closure

Who were discontinuation or non-renewal notices sent to? Will it be sent to group, individual, or Medicare members only?

+

Individual and group members: Written notification about the plan ending will be mailed to Individual and Group members no later than October 2, 2025.

Medicare members: Written notifications of the plan ending will be mailed to members no later than Oct. 2, 2025.

‍

Plan Closure

How does a member find a new plan?

+

Individual members: Individual members are being encouraged to use the Health Insurance Marketplace (HealthCare.gov) to find other Health Insurance Marketplace plans or contact an independent agent who can assist them in choosing a new plan.  

Group members: Group members should contact their employer for information on the new plan selections offered to them.

Medicare members: Medicare members can visit Medicare.gov to compare plans, see what fits their needs, and enroll online or talk with a licensed Medicare agent who can help explore options and answer questions specific to the member. Annual enrollment period is Oct. 15 through Dec. 7, 2025. If a member misses the annual enrollment period, they will have a special enrollment period (SEP) from Dec. 8, 2025 through Feb. 28, 2026.

‍

Plan Closure

When does coverage end?

+

Individual members: Coverage ends for individual members on Dec. 31, 2025.

Group members: Group members’ coverage end dates vary dependent on each employer. Please contact your employer for 2026 plan options.

Medicare members: Coverage ends for Medicare members on Dec. 31, 2025.

Plan Closure

When will my current benefit card no longer work? Does my benefit card indicate the last covered day? Will a new benefit card be mailed?

+

Your benefit card will no longer work once your benefits are no longer active. Members and providers can verify coverage dates by utilizing our Member portal and Provider portal. Benefit cards will no longer be mailed to members after Nov. 30, 2025; however, members can view their benefit card by accessing their account on the Member Portal.

Plan Closure

Do deductibles transfer to new plans?

+

Whether to accept deductible transfers from UM Health Plan is up to the new plan. If the new plan wishes to receive this information, they can request a report by sending an email to Customer.Service@UofMHealthPlan.org, within 30 days of the group’s or member’s termination with UM Health Plan.

Plan Closure

Who do I speak to if I am enrolled in coverage through my employer?

+

Group members should contact their employer for information on the new plan selections offered to them.

Plan Closure

What is the timeframe for direct member reimbursement requests? Is it different for medical and pharmacy? How are the requests submitted and what is the mailing address?

+

If you pay for health care services, it is best that requests for reimbursement be submitted within 90 days of the date of service. If UM Health Plan does not receive a claim within one year of the date of service, the health care services may not be covered. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends.

If you are submitting a member reimbursement request for a pharmacy service after June 30, 2026, written notification of the claim must be given to the plan at the address below.

All medical reimbursements after Jan. 1, 2026, and pharmacy reimbursements after June 30, 2026, send to:

PO Box 30377
Lansing, MI  48909-7877

‍

Plan Closure

How does a member enroll in the member portal? What are the benefits of enrolling in the portal?

+

Medicare members: Medicare beneficiaries can be enrolled into our plan through Dec. 1, 2025 effective dates. Agents can use the producer portal for submitting enrollments. UM Health Plan does not pay commissions for new enrollments in 2025. The Medicare producer portal is available through April 30, 2026, so agents/producers can access commission statement information.

Individual and group members: Member:  

The portal login page can be found here: https://www.uofmhealthplan.org/login

To create an account, you will need the policy numbers from your Member ID card.

Through your portal account you can order new ID cards, view and print claim information, such as Explanation of Benefits, and update your primary care provider (PCP) information.

Plan Closure

When will annual tax documents be mailed? If there are questions, who does the agent contact?

+

Annual tax documents will be provided in accordance with applicable laws, which generally state 1099s must be sent by January 31. For questions regarding your annual tax documents please email Finance@UofMHealthPlan.org.

Plan Closure

How long will customer service be available?

+

Medicare members: The Medicare customer service call center will be available through May 31, 2027.

Individual and group members: The UM Health Plan Customer Service call center will be available through Aug. 31, 2026.

Frequently Asked Questions

Where can I find benefit summaries for quotes or groups?

+

Please contact Sales at Sales@UofMHealthPlan.org for information for quotes or groups.

Frequently Asked Questions

Can I make enrollment and eligibility changes online?

+

Contact Sales at Sales@UofMHealthPlan.org to request enrollment and eligibility changes.

Frequently Asked Questions

How can I find participating providers accepting new patients or with extended weekday or weekend office hours?

+

To find a participating doctor, visit the Provider Directory.

Frequently Asked Questions

Can employer groups pay their premiums online?

+

At this time, groups cannot pay their premiums online. Employer groups can send checks to the following address:

For HMO Plans:

University of Michigan Health Plan

PO Box 776180

Chicago, IL 60677-6180

For PPO Plans:

University of Michigan Health Plan

PO Box 776178

Chicago, IL 60677-6178

Frequently Asked Questions

Can employer groups have their premiums automatically deducted from their bank account each month?

+

Groups are able to set up ACH payments to UM Health Plan. Employer groups must initiate the payment through their financial institution.

For more information contact Finance at 888-892-0009.

Frequently Asked Questions

Do the maximum-out-of-pocket (MOOP) amounts shown on quotes include the deductibles?

+

Yes - the maximum-out-of-pocket (MOOP) amounts include the deductibles.

Frequently Asked Questions

What if I have employees residing outside of the UM Health Plan service area?
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In order for your group to take part in an HMO plan or a POS plan through UM Health Plan, your employees must live or work within our service area. HMO or POS members who live or work outside of the service area must agree to receive services from in-network providers.

If your group offers a PPO plan, and you have a new enrollee who lives outside of the service area, please notify your account manager so that the new enrollee can be placed in the appropriate network class to receive in-network benefits.

Frequently Asked Questions

What if a member needs to seek services while traveling out of the area?
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UM Health Plan offers a statewide network of providers and facilities. A member who has an urgent or emergency situation when traveling outside the service area should visit the nearest urgent care center or emergency department, regardless of whether it is in the network. Urgent Care and Emergency services are always covered under a member's in-network benefit, in all 50 states and worldwide.

Frequently Asked Questions

What is the prescription drug list?
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It is a list of prescription drugs covered by a particular drug benefit plan. UM Health Plan, in conjunction with its pharmacy benefit manager, Express Scripts, Inc. (ESI), reviews its Prescription Drug Lists on a regular basis to ensure that they are up-to-date.

Frequently Asked Questions

Are there pre-existing condition clauses in your policies?
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There are no pre-existing clauses under any UM Health Plan policies.

Frequently Asked Questions

How do I enroll a member, make a change or check the status of an enrollment or change?
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You can make enrollment changes in a number of ways:

  • Make changes in the Employer Portal
  • Submit the necessary forms to Enrollment at Enrollment@UofMHealthPlan.org
  • Call your account manager.

Changes may take up to 48 hours to be effective.

Frequently Asked Questions

What if a member needs Case Management services?
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Please fill out and return the Case Management Referral Form to CaseManagement@UofMHealthPlan.org.

Provider FAQ

Plan Closure

What’s happening at UM Health Plan?
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UM Health Plan is closing operations and will terminate all current health plan coverage as of Jan. 31, 2026. Some coverage may end before this date, so check the member ID card to verify the correct payer by dates of service. The members who are currently being served will transition to other payers between now and Feb. 1, 2026.

Plan Closure

Why is UM Health Plan closing?
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Like many health plans, UM Health Plan has experienced significant financial losses over the past few years. After a thorough business and financial assessment, UM Health has made the difficult decision to close UM Health Plan.

This announcement comes after a comprehensive evaluation of the plan’s financial sustainability, market trends, and the evolving needs of our members.

We recognize the importance of affordable and reliable health care, and this decision was not made lightly. Despite significant efforts to maintain the plan, the increasingly competitive health insurance landscape, and the Centers for Medicare & Medicaid Services (CMS) changes to Medicare Advantage plans have made it unsustainable to continue offering the high level of service our members deserve. We are deeply committed to our members, agents, employers, and providers, and will continue to serve all these groups and all members’ claims for services provided through the coverage period.

Plan Closure

Is UM Health Plan being acquired by another health plan or is it closing?
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UM Health Plan is closing. Member coverage will end in accordance with their current covered plan time frame.

Plan Closure

How does this decision to close UM Health Plan impact members’ current medical and pharmacy benefits?
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The decision to close UM Health Plan in 2025 for plan year 2026 does not impact members’ current medical or pharmacy benefits administered by UM Health Plan. New health plan coverage will need to be selected after UM Health Plan coverage ends.

Plan Closure

I just enrolled/reenrolled in a UM Health Plan-administered Medicare Advantage plan, individual/family plan, or group plan for plan year 2025. How does this impact members’ 2025 benefits?
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UM Health Plan will cover medically necessary services members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract, respectively.

Plan Closure

Will providers accept UM Health Plan through the termination date?
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Yes, UM Health Plan has a strong relationship with our contracted network of providers and do not anticipate any issues with our network or our providers' ability to continue being accessible and available to our members. UM Health Plan, together with our provider and hospital system partners across Michigan, share a commitment to helping people access the care they need, close to home and will continue to cover medically necessary services our members require through the term of the Medicare Advantage beneficiary’s, individual's, or group’s contract.

Plan Closure

If UM Health Plan is terminating coverage and a member receives services on their last covered day, will their claims be paid in 2026?
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Yes, claim(s) for covered services received during the coverage period will be paid in 2026, per the contract benefit.

Plan Closure

If a member is hospitalized at the end of Dec. 2025 and remains in the hospital on Jan. 1, 2026, will UM Health Plan pay the claims?
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Medicare members: Yes, claims for services incurred at any time in 2025 will be paid, including inpatient stays. CMS regulation 42 CFR 422.318 establishes special rules for coverage that begins or ends during an inpatient hospital stay. The regulation requires UM Health Plan to pay for your inpatient hospitalization services from the date of admission while a member of our plan, through the date of discharge, even if the member is effective on Original Medicare or another MA-PD plan.

‍Individual members: Coverage ends on the date of termination – Dec. 31, 2025 – even if a member is hospitalized or otherwise receiving medical treatment on that date.

‍Group members: UM Health Plan will cover medically necessary services members require through the term of the group’s contract.

Plan Closure

When were providers notified the health plan is closing?
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Providers were originally notified in Nov. 2024 of the decision to wind down the plan. Communications are also posted on the UM Health Plan website and provider portal. Ongoing communications will occur throughout the remainder of the year regarding closure and winddown activities.

Plan Closure

When does coverage end?
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Individual members: Coverage ends for individual members on Dec. 31, 2025.

Group members: Group members’ coverage end dates vary dependent on each employer. Please contact your employer for 2026 plan options.

Medicare members: Coverage ends for Medicare members on Dec. 31, 2025.

Plan Closure

When will my current benefit card no longer work? Does my benefit card indicate the last covered day? Will a new benefit card be mailed?
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Your benefit card will no longer work once your benefits are no longer active. Members and providers can verify coverage dates by utilizing our Member portal and Provider portal. Benefit cards will no longer be mailed to members after Nov. 30, 2025; however, members can view their benefit card by accessing their account on the Member Portal.

Plan Closure

Do deductibles transfer to new plans?
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Whether to accept deductible transfers from UM Health Plan is up to the new plan. If the new plan wishes to receive this information, they can request a report by sending an email to Customer.Service@UofMHealthPlan.org, within 30 days of the group’s or member’s termination with UM Health Plan.

Plan Closure

How do I confirm coverage for a patient?
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Providers can utilize the provider portal to verify member eligibility. They can also contact our Customer Service team for benefit coverage and eligibility information. It is the responsibility of the provider to verify member eligibility at the time of each visit to ensure active coverage for that date of service, as some groups have disenrolled throughout 2025 plan year.

Plan Closure

How long are electronic claims accepted by UM Health Plan?
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Individual and group members: UM Health Plan will accept claims for processing as outlined in the providers participation manual and provider agreement. Electronic claims will be accepted through July 31, 2026.

Medicare members: UM Health Plan will accept in-network provider claims through June 30, 2026. Out-of-network provider claims can be submitted through Dec. 31, 2026.

In Network Payer ID

Commercial: 37330

Medicare: 83276

Out of Network Payer ID

Commercial: 07689  

Medicare: 83276

‍

Plan Closure

How long are paper claims accepted by UM Health Plan?
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All paper claims submitted must be received as outlined in the provider manual. We expect all claims to be received and processed by Dec. 31, 2026.

Plan Closure

How does a provider submit a paper claim and what is the mailing address?
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Commercial paper claims can be sent to:    

In Network

P.O. Box 313, Glen Burnie, MD 21060-0313

Out of Network

P.O. Box 247, Alpharetta, GA 30009-0247

‍

Medicare paper claims can be sent to:  

P.O. Box 7119, Troy, MI 48007

 

After July 31, 2026 – All commercial paper claims should be submitted to:

P.O Box 30377, Lansing, MI 48909-7877

‍

We encourage all providers to submit claims promptly to ensure prompt payment and processing. Claims not submitted within the terms of the participation agreement may be denied or rejected.

Plan Closure

What is the timeframe for direct member reimbursement requests? Is it different for medical and pharmacy? How are the requests submitted and what is the mailing address?
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If you pay for health care services, it is best that requests for reimbursement be submitted within 90 days of the date of service. If UM Health Plan does not receive a claim within one year of the date of service, the health care services may not be covered. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends.

If you are submitting a member reimbursement request for a pharmacy service after June 30, 2026, written notification of the claim must be given to the plan at the address below.

All medical reimbursements after Jan. 1, 2026, and pharmacy reimbursements after June 30, 2026, send to:

PO Box 30377
Lansing, MI  48909-7877

‍

Plan Closure

When will the Provider Portal no longer be available?
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Medicare members: The provider portal is available through Mar. 31, 2026. After the portal is no longer available, a provider with Medicare inquiries can contact customer service at 844-529-3759.

Individual and group members: The portal is available through June 30, 2026. After the portal is no longer available, a provider can contact customer service for assistance at 800-832-9186.

Plan Closure

When will the UM Health Plan no longer accept retro-authorizations? Is there a different process for medical and pharmacy submissions? How does a provider submit a retro-auth? What are acceptable reasons for submitting a retro auth?
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Effective Jan. 31, 2026, UM Health Plan will no longer accept untimely requests or notifications once the member’s eligibility and benefits have terminated.  

Please note that requests submitted through EZ Auth/Referrals, fax, email, phone, or the online exception process with not be accessible after Jan. 31, 2026.

Providers seeking a claim review for services, procedures, or items without a prior authorization must follow the standard claim submission process and include all necessary documentation.  

For medical, untimely request/notifications will no longer be accepted by UM Health Plan after the member’s eligibility and benefits terminate with the health plan. The provider can follow the claim submission process with applicable documentation for a claim review if an authorization was not obtained prior to services, procedures, or items being provided. EZ Auth/Referrals and requests received by fax and through the online exception process will not be accessible after Jan. 31, 2026.

Plan Closure

Is there a transition or continuity of care plan for members? Will the plan(s) be shared with providers?
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The provider and member must coordinate with the new health plan to reauthorize services, procedures, and items. They will need to follow the new plan’s policy for transition and continuity of care.

The provider and member will work with the member’s new health plan to determine which services, procedures, and items will require a new authorization and/or follow policy guidelines for transition and continuity of care needs.

Plan Closure

How does a provider update information, for example Tax ID, address, etc. for payment purposes?
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It is important to keep UM Health Plan up to date on all provider information during the duration of time we are processing claims and for year-end tax purposes. The form for all updates and changes can be obtained on the UM Health Plan website, under Providers/Forms. You can send via email, fax, or mail at the locations indicated on the website.

Plan Closure

When will 1099 reports be mailed? If a provider has questions, who do they contact?
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1099s will be provided in accordance with applicable laws, which generally state 1099s must be sent by Jan. 31. For questions regarding your 1099s please email Finance@UofMHealthPlan.org.

Plan Closure

How long will customer service be available?
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Medicare members: The Medicare customer service call center will be available through May 31, 2027.

Individual and group members: The UM Health Plan Customer Service call center will be available through Aug. 31, 2026.

Plan Closure

Since UM Health Plan is ending coverage, why are you still asking for medical records from our office?
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UM Health Plan is required to comply with all audit and regulatory requirements for any coverage year under contract. This will include audits of prior year(s) activity, which will require medical record validation. CMS has announced intent to complete Medicare Advantage RADV audits for coverage years 2018-2024, which will require UM Health Plan to obtain medical records from participating offices to support these CMS audit activities.    

Copies of the requested medical records must be received within 14 days of the request. Records may be provided in the following ways:

‍

Physical Mail

UM Health Plan Medical Record Request Team

P.O Box 30377

Lansing, MI 48909-7877

‍

Fax

517-364-8408

Attn: RADV Audit

Alternative Fax: 517-364-8460

 

Secure/Encrypted Email

QualityDepartment@UofMHealthPlan.org

 

Electronic

For flash drive or CD, please email pass codes to QualityDepartment@UofMHealthPlan.org

 

Onsite Review or Pick Up

Call or email to schedule

Plan Closure

As UM Health Plan is winding down, is a provider required to comply with a request for records from UM Health Plan?
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Providers are required to comply with all terms of their participation agreement with UM Health Plan that were in force at the time of the rendered service. As outlined in the providers participation agreement, payor shall have access to all records related to the obligations and health services being audited for ten (10) years following termination.  Copies of medical records must be sent within fourteen (14) days from the date the request is made.

Plan Closure

Where do I send medical records requested?
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Medical records should be sent as outlined in the medical request communication or as outlined below:  

Physical Mail

UM Health Plan Medical Record Request Team

P.O Box 30377

Lansing, MI 48909-7877

 

Fax

517-364-8408

Attn: RADV Audit

Alternative Fax: 517-364-8460

 

Secure/Encrypted Email

QualityDepartment@UofMHealthPlan.org

 

Electronic

For flash drive or CD, please email pass codes to QualityDepartment@UofMHealthPlan.org

 

Onsite Review or Pick Up

Call or email to schedule

Plan Closure

Will I receive reimbursement for my time in collecting records, and be able to charge a retrieval and copying fee?
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In accordance with most provider participation agreements, the agreement specifies, “Provider will maintain adequate medical, ...administrative records related to Health Services rendered by Provider under this Agreement. Payor, .....upon reasonable notice and demand in writing or in person, shall have access to and the right to audit all information and records, and to make copies of such records at no charge, related to all of Provider and Participating Providers’ obligations and Health Services rendered by Participating Providers under this Agreement.”

Refer to your UM Health Plan participation agreement to determine if reimbursement for record retrieval is defined or if it may be charged to UM Health Plan. If your office utilizes a third-party service to retrieve, copy, and send records, you need to ensure your service provider is aware of the limits of the fee.

Plan Closure

Who do I contact after UM Health Plan has closed for any questions?
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Individual and group: The UM Health Plan Customer Service team will be available through Aug. 31, 2026.  You can contact them at 800-832-9186.

Medicare: The Medicare provider service number is 844-529-3757. Medicare customer service call center is available through May 31, 2027.

Plan Closure

Will any authorizations that extend beyond UM Heath Plan’s closure be passed on to the new carrier?
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Active authorization will terminate when a member’s eligibility and benefit plan with UM Health Plan ends.  

Active authorizations will end when the member’s eligibility and benefit plan terminates with UM Health Plan. Authorizations will not extend past non-active membership.

Plan Closure

Will UM Health Plan still request medical records, conduct audits, overpayments and recoupments after the end of UM Health Plan coverage?
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UM Health Plan will continue to conduct audits and process claims, recoupments, overpayments, and adjustments throughout 2026 for services incurred during the coverage period.

Plan Closure

Will Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) continue through UM Health Plan’s usual process?
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ERA and EFT will continue through the Health Plans usual process through Aug. 31, 2026. After Aug. 31, 2026, all payment/processing will be completed via paper remittance and check.

Plan Closure

How long will providers have to appeal a claim?
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Providers will have 60 days from the date a claim is processed to submit an appeal. All providers should submit claims promptly to ensure prompt payment and processing. Claims not submitted within the terms of the participation agreement may be denied or rejected.

Plan Closure

When will a provider know that all obligations are complete and final. Will a final notification from UM Health Plan confirming all obligations are closed/ended be sent to providers?
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UM Health Plan will send notice of final contract termination in accordance with the terms outlined in providers’ participation agreements. Providers are required to comply with all terms of their participation agreement with UM Health Plan that were in force at the time of the rendered service.

Plan Closure

When can I expect to receive my 2025 Primary Care Management Program (PIP) payment?
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Primary care providers eligible for the incentive payment can expect reports and payment by Dec. 31, 2025.

Frequently Asked Questions

What services/procedures require prior authorization?
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Please refer to the Notification/Prior Authorization Table

Frequently Asked Questions

How do I check eligibility and claim status?
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Providers can check eligibility and claim status within the Provider Portal.

Frequently Asked Questions

I am a non-network provider. Where do I send claims?
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Submit your claims to the following address:

Global-Care
‍
PO Box 247
Alpharetta, GA 30009-0247

Or submit your claim electronically by using the following information:

Payor ID: 07689
Payor Name: UM Health Plan

Frequently Asked Questions

Where can I find the most recent provider directory?
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Please review the Provider Directory or contact Customer Service at 800-832-9186 for commercial members or 800-661-8299 for UM Health-Sparrow members.

Frequently Asked Questions

What do I need to do if I need to change our office address, name, phone number, etc.?
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Your office will need to submit a Provider Information Update Form.

Frequently Asked Questions

Does UM Health Plan release fees?
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UM Health Plan does release fees, but we ask that you please contact your provider relations coordinator directly at ProviderRelations@UofMHealthPlan.org.

Frequently Asked Questions

Does UM Health Plan have a provider manual?

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Review the latest Provider Manual.

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