The U-M Plans

Why is it so important for U-M to have my physical address and not my P.O. box?

The Centers for Medicare and Medicaid Services (CMS) validates enrollment for individuals moving into a Medicare Advantage plan. The validation process requires that we have the physical residency for each participant. For this reason, please make sure your home address is up-to-date in Wolverine Access.

Where can I get more information about Open Enrollment and U-M Medicare Advantage Plans?

Check the Open Enrollment and Medicare-Enrolled Retirees, Survivors and LTD Participants web pages; the Open Enrollment booklet you'll receive each September; and your U-M email account. 

Are U-M’s Medicare Advantage plans the same as the publicly available Medicare Advantage plans I’ve read about in articles, such as in The New York Times, or have seen advertised?

No. U-M’s Medicare Advantage plans are not the same as publicly offered plans. They are intentionally distinct, with lower out-of-pocket costs, from the consumer plans available to the general public.

The U-M MA plans were custom-designed by the university with the involvement of faculty experts and Michigan Medicine leadership to provide more benefits and lower out-of-pocket costs than the publicly available plans. To be eligible to enroll in U-M’s MA plans, you must be a benefits-eligible retiree from the University of Michigan and enrolled in Medicare Parts A and B. The general public is not eligible for U-M’s MA plans.

Do U-M Medicare Advantage plans require members to pay a deductible?

No. There are no deductibles for any U-M Medicare Advantage plan.

What are U-M Medicare Advantage plan copays?

All office visit copays for U-M Medicare Advantage plans are $10 per visit, including for your primary care provider (PCP), specialist, mental health, chiropractic, and physical, occupational and speech therapy care. Copays for emergency room visits are $65 (waived if admitted).

Do I have an out-of-pocket maximum with U-M Medicare Advantage plans?

The out-of-pocket maximum for all Medicare Advantage plans is $3,000. Fixed copays for select services are stated in the benefit summaries. These copays are tracked; when you have paid $3,000 in copays, you will not have further copays for the rest of the year. This out-of-pocket maximum has been in place since 2014.

When I switch to Medicare Advantage, can I continue to see my primary care physician (PCP)?

It depends on whether the provider is a participating provider in your selected Medicare Advantage plan.

The U-M Premier Care Advantage plan requires a PCP selection; the Medicare Advantage PPO plan does not. If you are enrolled in one of the HMO plans, contact the health plan to confirm your PCP selection. If a member in a HMO plan has not selected a PCP, one will be selected for them. The member will receive a letter stating the selected PCP. You may still change your PCP by contacting the health plan.

Are there changes in prior authorization with the U-M Medicare Advantage plans? 

U-M Medicare Advantage plans use the same prior authorization processes as the plans for active faculty and staff.

Prior authorization is between the provider and the health plan. The patient does not have a role in seeking prior authorization. Additionally, the Centers for Medicare and Medicaid Services (CMS), a federal agency, sets regulations as to how plans handle prior authorization. A plans’ medical necessity guidelines cannot be more stringent than CMS guidelines.

In instances when approval did not go through or was declined, we usually found that the provider had not provided medical documentation that needed to be submitted or that there had been a missed step (for example, the patient needed blood work before having an MRI approved). Most denials were temporary while awaiting additional documentation from the provider to support the requested service.

How does prior authorization with U-M Medicare Advantage plans compare with other MA plans?

U-M MA plans have higher prior authorization approval rates than publicly available Medicare Advantage plans. 

 The U-M Benefits Office closely monitors prior authorization approval rates with the vendors and addresses concerns as needed.

 Do I need to change my Durable Medical Equipment (DME) provider?

It depends on whether the DME provider is a participating provider in your selected Medicare Advantage plan. Ask your current DME provider if they are participating with the health plan you are enrolled in. If you have questions about a network provider, contact the health plan using the customer service number on the back of your ID card.

What are the residency requirements for each Medicare Advantage plan?

Blue Cross Blue Shield of Michigan's (BCBSM) Medicare Advantage PPO plan requires that you live within the U.S.

Blue Care Network's U-M Premier Care Advantage includes all counties in Michigan EXCEPT (limited access in) Alger, Baraga, Cass, Chippewa, Delta, Dickinson, Gogebic, Houghton, Iron, Keweenaw, Marquette, Menominee and Ontonagon. If you live in one of the above counties, please select the BCBSM Medicare Advantage PPO plan. 

I had a recent claim/service denied that historically had been covered. Why did this happen?

One possible reason that claims or services might be denied is that the provider is not using  your new ID card contract number. If that’s the case, this should be resolved by talking with your provider to ensure they have the correct plan information. If that doesn’t solve the problem, please talk with health plan customer service representatives; the phone number is on the back of your card.

Is my health care covered if I travel through the U.S. and internationally?

Urgent and emergency services are covered when you travel across the U.S. and internationally. 

When traveling internationally, if you require urgent or emergency services, providers may not be able to bill your health plan; in those instances, you may need to pay at the point-of-care and request reimbursement from the health plan. Use the customer service phone number on the back of your ID card for more information.

Do U-M Medicare Advantage plans cover vaccines?

Yes, but it depends upon where you receive them. Under U-M’s Prescription Drug Plan, all CMS-recommended vaccines are covered through contracted pharmacies; some are covered at participating physicians’ offices. It’s important to use the appropriate contracted provider when receiving vaccines: 

• Common vaccines for flu, COVID-19, pneumonia and hepatitis B are covered at participating physicians’ offices through U-M’s Medicare Advantage plans AND contracted pharmacies through the Prescription Drug Plan.
• Vaccines for shingles; tetanus; Tdap; meningitis, hepatitis A; HPV; measles, mumps and rubella; polio; RSV; and tuberculosis are only covered when administered at a contracted pharmacy and billed under your prescription drug plan.

Do U-M Medicare Advantage plans include dental and vision care?

No. U-M dental and vision plans are separate from the health plans. The Dental Plan is provided by Delta Dental of Michigan, and the Vision Plan by Davis Vision by MetLife. Benefits-eligible U-M retirees can enroll in these plans during Open Enrollment.

A routine vision exam is a covered benefit under the Medicare Advantage plan for all members who elect to waive participation in the Vision Plan.

How do I get an ID card for a member of my family who hasn’t received one? 

Health plan ID cards are mailed separately in nondescript white envelopes. If you have more than one family member on your contract, each Medicare Advantage member will receive their own ID card. If you or someone on your contract needs medical services before you have received your ID card, your provider can confirm enrollment through the health plan portal.