Navigating health insurance can be complex, especially when it comes to understanding coverage for specific services like therapy and the associated diagnosis codes. U-M Premier Care, administered by Blue Care Network (BCN), offers a unique healthcare plan designed for the University of Michigan community. This plan operates with a two-tiered provider network to manage costs and offer varying levels of benefits. To fully utilize your U-M Premier Care benefits, it’s crucial to understand how their network system works and what it means for your healthcare needs, including therapy services and related diagnosis codes.
Decoding U-M Premier Care Provider Networks
U-M Premier Care is structured around two distinct provider networks, each impacting your out-of-pocket expenses and access to care:
Network 1: The Preferred Choice
Network 1 is the centrally located network around Ann Arbor and surrounding areas. It represents the “preferred” option within the U-M Premier Care plan, offering the most advantageous benefits. Key features of Network 1 include:
- No Annual Deductible: When you exclusively use Network 1 providers, you avoid annual deductibles, reducing your upfront costs for care.
- Primary Care Physician (PCP) Requirement: You are required to select a PCP from within Network 1, based in Michigan. This PCP acts as your primary point of contact for healthcare and coordinates referrals when needed within the network.
Network 2: Statewide Access with Considerations
Network 2 expands beyond the immediate Ann Arbor area, encompassing the broader BCN statewide participating provider network. While providing wider access, Network 2 comes with different financial implications:
- Annual Deductible: Utilizing Network 2 providers means you will be subject to an annual deductible. This is an important factor to consider when planning your healthcare expenses.
- Referral Requirement: To access covered services from a Network 2 provider, you typically need a referral from your Network 1 PCP. This step is crucial for ensuring coverage when seeking care outside of Network 1.
Services obtained outside of both Network 1 and Network 2 are generally not covered by U-M Premier Care, except in emergency situations. Always refer to your plan documents for comprehensive details on emergency coverage and network exceptions.
[alt]: U-M Premier Care Network 1 offers benefits like no annual deductible and requires selecting a primary care physician from their Michigan-based network, making healthcare access simpler and more cost-effective for members.
Summary of Benefits: Network 1 vs. Network 2
To clearly understand the cost differences between Network 1 and Network 2, review the summary of benefits:
Network 1 Providers
- Deductible: No annual deductible
- Preventive Care: No out-of-pocket cost
- Office Visit (Injury/Illness): $25 copay
- Specialist Visit: $30 copay
- Urgent Care: $25 copay
- Emergency Care: $100 copay (waived if admitted)
- Mental Health/Substance Abuse Services: $25 copay
- Inpatient Services: No out-of-pocket cost
- Outpatient Surgery: No out-of-pocket cost
- Out-of-Pocket Maximum (Networks 1 & 2 Combined): $3,000 individual/$6,000 family
Network 2 Providers (Referral Needed)
- Annual Deductible: $2,000 individual/$4,000 family
- Preventive Care: No out-of-pocket cost
- Post-Deductible Costs: No out-of-pocket cost after deductible is met for:
- Office visits (injury/illness)
- Specialist visits
- Inpatient services
- Outpatient surgery
- Mental health/substance abuse services
- Urgent Care: $25 copay
- Emergency Care: $100 copay (waived if admitted)
- Out-of-Pocket Maximum (Networks 1 & 2 Combined): $3,000 individual/$6,000 family
For complete details on benefits and coverage specifics, always consult your official plan documents.
[alt]: Comparing U-M Premier Care Network 1 and Network 2 benefits reveals distinct cost structures, with Network 1 offering lower upfront costs and Network 2 requiring deductibles but providing broader access.
Utilizing Your U-M Premier Care Plan Effectively
To maximize your U-M Premier Care plan benefits, keep these points in mind:
- Service Area: Generally, members must reside in Michigan or specific counties in Ohio. Ohio residents should be aware that U-M Premier Care is Michigan-based, potentially affecting home healthcare services outside of Michigan.
- Dependent Coverage: Dependents residing outside the service area may be covered if they meet eligibility guidelines. Pre-certification and BCN registration are required for out-of-area dependent coverage – contact BCN at 1 (800) 658-8878 for assistance.
- Hearing Services: U-M Premier Care includes a Hearing Services Value Network. Utilizing providers within this Value Network can lower your out-of-pocket costs for hearing services and hearing aids. Michigan Medicine Audiology Services and TruHearing providers are part of this network.
Understanding Therapy Diagnosis Codes in Relation to Coverage
While the original document doesn’t explicitly list “therapy diagnosis codes,” it’s important to understand how diagnosis codes function within healthcare coverage, including U-M Premier Care.
Diagnosis codes are standardized medical codes used to classify and report diagnoses, symptoms, and procedures. They are crucial for:
- Medical Billing: Healthcare providers use diagnosis codes when submitting claims to insurance companies like Blue Care Network for reimbursement.
- Determining Medical Necessity: Insurance companies use diagnosis codes to assess the medical necessity of services. For therapy, specific diagnosis codes related to mental health conditions or physical health issues requiring therapy are essential for coverage.
- Healthcare Statistics and Research: Diagnosis codes contribute to broader healthcare data analysis and research.
U-M Premier Care and Therapy Coverage:
U-M Premier Care does cover mental health, behavioral health, and substance abuse services, as indicated in the benefits summary. To ensure your therapy services are covered:
- Verify Provider Network: Confirm your therapist is within Network 1 or Network 2 (and obtain a referral if needed for Network 2).
- Understand Copays/Deductibles: Be aware of the copays associated with mental health/substance abuse services in both networks. For Network 2, remember the annual deductible.
- Diagnosis Code Accuracy: While you don’t directly handle coding, ensure your healthcare provider accurately assigns the appropriate diagnosis code(s) that reflect your condition requiring therapy. This ensures proper claim processing.
[alt]: Accessing in-network providers within U-M Premier Care, like those in the Hearing Services Value Network, can significantly reduce out-of-pocket expenses and ensure comprehensive coverage for specialized services.
What Happens if You Move Out of the Service Area?
If you are enrolled in U-M Premier Care and relocate outside of the designated service area (Michigan and specific Ohio counties), you will need to change your health plan. To do so, download the “Moving out of a Managed Care Service Area form” from the University of Michigan Human Resources website and submit it within 30 days of your move. Your new health coverage will start on the first day of the month following your move or form receipt, whichever is later. Remember to update your address with the university as well.
Finding a Participating Provider
Easily locate a U-M Premier Care participating provider or check if your current doctor is in-network by using the BCN provider search tool.
Plan Documents and Contact Information
For detailed information, refer to your official U-M Premier Care plan documents. For questions or assistance, contact Blue Care Network directly:
- Website: bcbsm.com
- Phone: (800) 658-8878
- Address: Blue Care Network, 20500 Civic Center Dr., Southfield, MI 48076
- Group number: 001243160001
Consider a Health Care Flexible Spending Account (FSA)
To further manage your healthcare expenses, consider enrolling in a pre-tax Health Care Flexible Spending Account (FSA). An FSA allows you to set aside pre-tax dollars for eligible healthcare costs, potentially complementing your U-M Premier Care plan. Explore the University of Michigan HR website for more information on Health Care FSAs.
By understanding the nuances of U-M Premier Care, including its provider networks, benefits, and the role of diagnosis codes in healthcare coverage, you can confidently navigate your health plan and access the care you need.
