State Health Plan PPO - Administered by Blue Cross Blue Shield of Michigan (BCBSM)
The State Health Plan PPO provides reimbursement for medical care expenses when you need treatment for an illness, injury, or disease. The plan covers inpatient hospital care, as well as other outpatient services received at a hospital including emergency room care. The Plan also covers most of your community-based care (office visits), as well as necessary medical equipment and supplies (crutches, hearing aids, etc.).
This plan provides health benefits using providers and facilities that are in-network, meaning the providers and facilities have agreed to accept a discounted fee from BCBSM in order to be in-network. They won't charge you the difference between their normal charge and the amount paid by the State Health Plan PPO. When you see a PPO network provider for covered services, your out-of-pocket costs are limited to deductibles, co-insurance, and copays.
Under the State Health Plan PPO, members choose their in-network providers from the BCBSM Community Blue/Blue Preferred PPO Network. The network covers all 83 Michigan counties and is the largest PPO network in Michigan. It has more than 20,000 physicians, including specialists, and more than 140 all acute care hospitals in Michigan. Please refer to www.bcbsm.com/som for the list of providers.
You still have the freedom to go out-of-network to see any physician, hospital or other provider of your choice. But, if you receive services from a provider not in the PPO network, you may be responsible for paying additional out-of-pocket costs. Those costs include increased copay and deductible amounts. If the provider you select doesn't participate at all with BCBSM (BCBSM has several different provider arrangements), you may also be required to pay additional charges.
An important note regarding the State Health Plan PPO deductibles: You have the freedom to see both in-network and out-of-network providers. If you choose to do so, you will be responsible for both deductibles. For example: a single person chooses an in-network hospital for surgery. They are responsible for the deductible, then the hospital is reimbursed according to the plan design. Later in the year, that same person needs an MRI and chooses an out-of-network provider. They are responsible for the out-of-network deductible. After that deductible is met, out-of-network charges are paid according to the plan design.
Prescriptions
OptumRx is the Pharmacy Benefit Manager for the State Health Plan PPO and will administer all retail, mail-order, and specialty prescription services for active employees and both Medicare-eligible and non-Medicare eligible retirees.
Behavior Health/Substance Abuse Administrator
Effective October 1, 2019, Blue Cross Blue Shield of Michigan, in partnership with New Directions, will be replacing Magellan Health as the State Health Plan (SHP) PPO Behavioral Health/Substance Abuse carrier. Current SHP PPO enrollees will be automatically transitioned with no gap or changes in coverage. New SHP PPO membership ID cards will be mailed in September 2019.
Blue Cross Blue Shield of Michigan, in partnership with New Directions
866-503-3158
www.bcbsm.com/som
State Health Plan PPO – Behavioral Health/Substance Abuse Frequently Asked Questions
