FAQs

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.

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

‍

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.

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.

Previously, care received from an OON provider or facility, even unknowingly, could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health insurance paid. This is called “balance billing”. Balance billing most commonly occurs when a patient visits an in-network facility or provider for health care services and receives an unexpected medical bill from an out-of-network provider. An unexpected balance bill from an out-of-network provider is also referred to as a “surprise” medical bill.

Effective Jan. 1, 2022, The No Surprises Act, protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, and non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. The Act contains provisions that prohibit holding patients liable for these services beyond the patient’s in-network cost-sharing amount. PHP has made changes to comply with the No Surprises Act. If you have questions about a bill you have received, please call PHP Customer Service at 800.832.9186, 8:30 a.m. to 5:30 p.m., Monday-Friday, excluding holidays.

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.

Contact our award-winning customer service department at 517.364.8567 or 866.539.3342, Monday - Friday, 8:30 a.m. to 5:30 p.m. EST.

The amount of assistance you qualify for is determined by your income and family size. There are two types of health insurance financial assistance available through the Marketplace: the premium tax credit and the cost-share reduction.

Use this calculator to see if you qualify for assistance.

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.

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

Premium payments must be made by check to the address listed below:

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

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.

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.

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.

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

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.