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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

Check the status of a medical or pharmacy claim by visiting logging into the member portal, or call Customer Service at 517-364-8500.

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.

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.

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.

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.

UM Health Plan is closing. Member coverage has ended.

Individual and group members: Written notification about the plan was ending was mailed to Individual and Group members prior to Oct. 2, 2025.

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Individual and group members: Written notification about the plan ending was mailed to Individual and Group members prior to October 2, 2025.

Medicare members: Written notification of the plan ending was mailed to members prior to Oct. 2, 2025.

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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.

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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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.

UM Health Plan is closing operations and terminated all health plan coverage.