Health Plan Forms and Documents

Summary of Benefits and Coverage

Use these Summary of Benefits Coverage (SBC) documents for quick reference about your health plan coverage or to easily compare your health plan options. 

View the Uniform Glossary of Health Coverage and Medical Terms for help understanding the information included in the SBCs.

Summary of Benefits and Coverage and Benefits-at-a-Glance

BCBSM Community Blue PPO

2026

Comprehensive Major Medical

2026

Consumer-Directed Health Plan

2026

GradCare

2026 

U-M Premier Care

2026

Find a Participating Health Care Provider

Use these resources to find a physician or other health care provider that participates with your health plan.

Enrollment/Change Forms

Most enrollment and/or benefit changes are completed in Wolverine Access.  However, certain changes may be completed by submitting a paper form. Additional forms are available on the Benefit Plan Forms and Documents page.

Dependent Information for Tax Reporting

Dependent Information Form

The Affordable Care Act requires large employers like the university to report Social Security numbers for individuals and their covered dependents on Form 1095, a tax form that reports information about health coverage. If you received a notice from the university because a Social Security number is not on file for one or more your dependents covered by your University of Michigan health plan, please complete the Dependent Information Form and return it as instructed on the form. 

IMPORTANT INFORMATION: The federal Mandatory Insurer Reporting Law requires group health plans to report to Medicare the Social Security numbers of adults covered under a group health plan. To comply with this law, you will be asked to provide this information for your spouse or OQA. If your spouse or OQA is not eligible for a Social Security number, you will be asked to provide the reason. Under the Affordable Care Act, the university is also required to request the Social Security number of each person enrolled under a U-M health plan, including children. If you do not provide your dependents’ Social Security numbers at the time of enrollment, you may receive requests from U-M to allow the university to comply with federal legislation.

Health Plan Member Reimbursement Forms

Use these forms to submit a claim to your health plan. You can also submit an eClaim by logging into your health plan portal or mobile app.

To file an eClaim:

  1. Go to the Blue Cross Blue Shield Global website.
  2. Click to accept the terms and conditions.
  3. Enter the three letters of your "Enrollee ID" found on your Blue Cross Blue Shield member ID card, and then click Go.
  4. Select Claims on the menu bar.

Graduate Student Forms

These forms are for use by graduate students enrolled in GradCare.

Retiree Forms and Documents

Information about your benefits in retirement.

COBRA Forms

These resources pertain to COBRA continuation of your benefits.

Health Plan Machine-readable Files

H.R. 2471, the Consolidated Appropriations Act, 2021 introduced new federal regulations for health care price transparency. It aims to assist consumers by increasing the availability and transparency of health care price information. The goal is for this transparency to enhance market competition and lower health care costs.

As a group health plan sponsor, U-M is required to post the following health care information monthly on a public website:

Access Blue Cross Blue Shield of Michigan’s machine-readable files to download the table of contents that contains web addresses for the .Json format files with in-network negotiated rates and out-of-network allowed amounts and historical billed charges. You will need to copy the URLs in the table of contents and paste in your browser to download the machine-readable files.

Important Notes

Plan Documents and Additional Resources

  • Benefits Enrollment Change Form (for benefit-eligible fellowship holders and medical students)
  • GradCare Off-Site Registration Form (required for Level 2 care) 
    The department administrators can email the completed form to BCN at [email protected], however, they should be aware that the form must include the specific program date span (begin date mm/dd/yyyy, end date mm/dd/yyyy) and the department head signature. If the department head is unable to sign, the department administrator should include in the body of the email that the form is "an approved off-site registration for (name and ID)." 
  • Agreement for Preauthorized Benefit Premium Payments
  • Your Retirement Benefits
  • COBRA Notification of Other Coverage, Medicare Entitlement, or Cessation of Disability
  • Notice of COBRA Qualifying Event
  • Notice of COBRA Second Qualifying Event
  • Notice of Disability
  • In-network provider rates for covered items and services
  • Out-of-network allowed amounts and billed charges for covered items and services, if 20 or more claims in the 90-day period are included in the file
  • The information contained in this machine-readable file may be difficult to access without certain technology.
  • These files may be large and require a computer that can download at least up to 1TB (terabyte) of data. Most modern hard drives store half of this amount of data. Based on your computer’s storage and hard drive, attempting to open or download large files may cause instabilities in Windows, cause performance issues resulting in downloads that could take hours, days or weeks depending on the file size and hard drive combination. For reference: 1TB = 243 high-definition streaming movies (average 2 hours per movie).
  • This mandate is a building block for future customer-facing mandates, including a Price Transparency Tool and an Advanced Explanation of Benefits.
  • The data in the files may not be useful for the average consumer. For example, facilities that are paid based on a percent of charge will not have a dollar amount representing the amount paid for a service.
  • The machine-readable files will be updated monthly to ensure accuracy of the data and reflect changes in pricing and regulatory requirements.