Currently Blue Cross Blue Shield of Michigan (BCBSM) is a non-profit health care corporation regulated under Public Act 350 of 1980 (also known as the Nonprofit Health Care Corporation Reform Act). BCBSM is not currently licensed under the Michigan Insurance Code and therefore is not an insurance company. Effective January 1, 2014, Blue Cross Blue Shield of Michigan will be a non-profit mutual insurance company and will be regulated under the Michigan Insurance Code.
Although there are several Blue Cross Blue Shield plans in the United States, the Michigan Department of Insurance and Financial Services (DIFS) only has regulatory authority over Blue Cross Blue Shield of Michigan. The other Blue Cross Blue Shield Plans are regulated by the state in which it operates.
FULLY INSURED COVERAGE OR SELF-FUNDED HEALTH CARE PLAN ADMINISTERED BY BCBSM:
Many large employers provide health coverage for employees by creating self-funded health care plans. The employers then contract with entities such as insurance companies and third party administrators to administer the self-funded health care plan. BCBSM is an administrator of many self-funded health plans including the health care plans for employees/retirees of Ford, Chrysler, General Motors and the State of Michigan. The Human Resources Department of your employer can advise you if your coverage is provided under a self-funded health care plan or a fully insured plan if it is not clear in the coverage information already provided to you. Also, BCBSM can advise you whether your coverage is a self-funded health care plan if you call the customer service staff and provide your group and contract number. DIFS does not have authority over the contracts for self-funded health care plans created by employers but DIFS has authority over the administrators of such plans and in some cases, DIFS handles external appeals for these plans.
MICHIGAN FARM BUREAU AND BCBSM:
If you purchased what appears to be BCBSM health coverage as a member of Michigan Farm Bureau and are under age 65, your coverage is actually provided by 4 Ever Life Insurance Company (formerly BCS Life Insurance Company) and not BCBSM. BCBSM does issue its identification card and administers the claims for these contracts but you do not have coverage through BCBSM. 4 Ever Life Insurance Company is licensed in Michigan and is under the authority of DIFS. If you are over age 65 and have purchased a Medicare Supplement contract as a member of Michigan Farm Bureau, your coverage is provided by BCBSM and underwritten by BCBSM. DIFS can handle your complaint in either case. Click here for the health coverage complaint form.
OUT OF STATE BLUE CROSS BLUE SHIELD COVERAGE:
Although there are several Blue Cross Blue Shield plans in the United States, DIFS only has regulatory authority over Blue Cross Blue Shield of Michigan. The other Blue Cross Blue Shield Plans are regulated by the state in which it operates. If you have Blue Cross Blue Shield coverage issued through a plan in another state, you should pursue any complaints with the state insurance department where the coverage was issued. You can obtain contact information for other state insurance departments at this website: NAIC - State Insurance Departments
FEDERAL EMPLOYEE PROGRAM ADMINISTERED BY BCBSM:
DIFS does not have authority over the Federal Employee Program. If you have a complaint regarding your coverage under the Federal Employee Program, you should contact the Federal Office of Personnel Management, Office of Insurance Programs at 202-606-0755 to pursue the matter.
If you are a subscriber of BCBSM, DIFS can handle your complaint against BCBSM. Complete this form and send it to DIFS. Click here for the health coverage complaint form.
BCBSM WRITTEN GRIEVANCE:
If you are a subscriber of BCBSM and have a grievance regarding the determination on a claim, you have the right to the
BCBSM internal grievance process. The internal grievance process of BCBSM should be explained in your coverage documents. The internal grievance process and your appeal options are also explained on the backside of your Explanation of Benefits form from BCBSM. Further information on the grievance process is available at Health Coverage Grievances and Appeals.
DETERMINING IF A PROVIDER IS PARTICIPATING WITH BCBSM:
BCBSM should be able to advise you if a provider participates with BCBSM or is in your network. This information may also be available on the BCBSM website. The provider may be able to advise you of their participation status with BCBSM. DIFS cannot advise you on the participation status of a provider.
SERVICES FROM A NON-PARTICIPATING PROVIDER:
If you receive services from a non-participating provider, you should refer to your certificate of coverage to determine if you have coverage and how your claim will be handled. Most often if the provider or specialist does not participate with BCBSM they may not accept the BCBSM payment as payment in full and you may be responsible for the difference in the amount billed by the provider or specialist and the amount paid by BCBSM.
BCBSM COVERAGE AND LIVING OUTSIDE OF MICHIGAN:
BCBSM was established to provide individual (non-group) coverage only to persons who are residents of Michigan. BCBSM considers persons who reside in Michigan at least 6 months of the year a Michigan resident. If you are no longer a Michigan resident and your coverage is not provided under an employer group plan, BCBSM can and will terminate your coverage or require that you transfer your coverage to a Blue Cross Blue Shield plan in the state where you are living. Contact BCBSM if you are planning to relocate outside of Michigan.
BCBSM MEDICARE SUPPLEMENT COVERAGE:
BCBSM sells both a Medicare Supplement Plan A and Plan C. Further information on Medicare Supplement coverage is available at Medicare, Medicare Supplement, Medicare Advantage and Long-Term Care Insurance.
BCBSM COVERAGE FOR INDIVIDUAL MICHIGAN RESIDENTS:
BCBSM is the designated insurer of last resort for Michigan residents who do not have access to group health coverage elsewhere. BCBSM will issue an individual (non-group) policy to Michigan residents. In addition, BCBSM will waive the 180-day waiting period on coverage for pre-existing conditions if the applicant provides a certificate of creditable coverage from their last group health plan and meets all of the following:
- Must be eligible by having at least 18 months of continuous health coverage
- Most recent coverage was group employment related
- Have accepted and exhausted all COBRA coverage to which they are entitled
- Cannot have more than a 62-day gap in coverage
HELPFUL LINKS FOR MORE INFORMATION: