Dependent Information for Tax Reporting
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: Under the Affordable Care Act, health coverage is not affected and will not be canceled if you do not provide a covered dependent's Social Security number. If not provided after multiple requests, the university will report to the IRS using your dependent's date of birth.
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 2021 SBCs.
2021 Summary of Benefits and Coverage
- BCBSM Community Blue PPO 2021 Summary of Benefits and Coverage
- BCBSM Community Blue PPO 2021 Summary of Benefits and Coverage - MNA (for members of the Michigan Nurses Association)
- CMM 2021 Summary of Benefits and Coverage
- CMM 2021 Summary of Benefits and Coverage - MNA (For members of the Michigan Nurses Association)
- GradCare 2021 Summary of Benefits and Coverage
- Michigan Care 2021 Summary of Benefits and Coverage
- Michigan Care 2021 Summary of Benefits and Coverage - MNA (For members of the Michigan Nurses Association)
- U-M Premier Care 2021 Summary of Benefits and Coverage
- U-M Premier Care 2021 Summary of Bemenfits and Coverage - MNA (for members of the Michigan Nurses Association)
Find a Participating Health Care Provider
Use these resources to find a physician or other health care provider that participates with your health plan.
- Community Blue PPO Provider Directory
- Comprehensive Major Medical Provider Directory
- GradCare Provider Directory
- U-M Premier Care Provider Directory
- Michigan Care provider directory - search the director to find out if your preferred providers are in the Michigan Care network. Use the "Find a Provider" link. No registration is required to search the provider directory. For coverage effective on or after January 1, 2021.
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.
- 2020 Health Plan Salary for Banding
- 2021 Health Plan Salary for Banding
- Application for Principally Supported Child
- Benefits Enrollment/Change Form for Faculty and Staff (GV)
- Benefits Enrollment/Change Form for Benefits-Eligible Fellowship or Medical Students (STV)
- Blue Cross Blue Shield Coordination of Benefits Form
- Certification of Other Medical Coverage
- Disabled Dependent Application for University of Michigan Health Plan
- Michigan Care Disabled Dependent Verification Form
- Group Health Insurance Application for Special Enrollment (HIPAA)
- Moving Out of a Managed Care Service Area
Use these forms to submit a claim to your health plan.
- BCBSM Community Blue PPO Plan Claim Form (Domestic claims)
- BCBSM CMM Plan Claim Form (Domestic claims)
- Blue Cross Blue Shield International Claim Form (Foreign Claims) - Download, complete and mail the claim form, or file an eClaim online.
To file an eClaim:
- Go to the Blue Cross Blue Shield Global website.
- Click to accept the terms and conditions.
- Enter the three letters of your "Enrollee ID" found on your Blue Cross Blue Shield member ID card, and then click Go.
- Select Claims on the menu bar.
- To file a Blue Cross Blue Shield Global Core eClaim online, log in with your username and password or register for access.
Graduate Student Forms
These forms are for use by graduate students enrolled in GradCare.
- 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 DocMgmtUL@bcbsm.com, 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)."
Retiree Forms and Documents
Information about your benefits in retirement.
These resources pertain to COBRA continuation of your 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
Plan Documents and Additional Resources
These resources provide additional information about your U-M health plan options.
- 2021 Michigan Care Plan Document
- 2021 Michigan Care Benefits-at-a-Glance
- 2021 Michigan Care Benefits-at-a-Glance MNA (for members of the Michigan Nurses Association)
- 2020 U-M Premier Care Benefits-at-a-Glance
- 2020 U-M Premier Care Benefits-at-a-Glance MNA (for members of the Michigan Nurses Association)
- 2020 U-M Premier Care Certificate of Coverage
- 2020 Comprehensive Major Coverage (CMM) Benefits-at-a-Glance
- 2020 GradCare Benefits-at-a-Glance
- 2020 GradCare Certificate of Coverage
- 2020 BCBSM Community Blue PPO Benefits-at-a-Glance
- 2020 BCBSM Community Blue PPO Benefits-at-a-Glance MNA (for members of the Michigan Nurses Association)
- Benefits for Gender-Affirming Services
- Infertility Coverage Fact Sheet (includes IVF and prescription drug coverage)
- University of Michigan HIPAA Notice of Privacy Practices