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FREQUENTLY
ASKED QUESTIONS
The answers to these questions are designed to assist you in
understanding the basics of a particular issue. In some cases
you will need to speak with one of our health care experts
to go over the specifics involved in answering the question.
• How do I know if I am eligible?
• Do I qualify for group coverage options
if my wife and children are going
to covered under my plan?
• What types of plans and coverage's are available to
sole proprietors?
• How are my rates determined?
• How
long will it take for me to obtain coverage?
•
Are pre-existing conditions covered under these plan?
•
Are my rates guaranteed for 12 months
• Can
I make changes to my plan?
• Can
I change physicians during my coverage period?
• How
can I find out if my physician participates with my specific
plan?
• What if my physician does not participate with Blue
Cross, can I still get coverage?
• I
am turning 65, what will happen to my coverage?
• If I am traveling out of state, can I use my coverage?
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How do I know if I am eligible?
There are two sets of circumstances under which a person may
qualify for individual coverage. Either as a sole proprietor
(One Subscriber Group) or as an employee of a firm who is
the only person (Group of One) in need of health care coverage.
A One-Subscriber Group (OSG) is defined as an individual
who is a sole proprietor or sole shareholder (owner) of a
Michigan
based business that does not have any eligible employees
who works on a full time basis with a normal work week of
30 or
more hours, for which he or she provides or contributes towards
any
health care coverage. The owner must be a Michigan resident.
A Group of One (GOO) is defined as an employee of a Michigan
based firm who works on a full time basis with a normal work
week of 30 or more hours and who is the only person in that
firm who seeking employer paid health care coverage.
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Do I qualify for group coverage options if my wife and children
are going to covered under my plan?
No, you can only qualify for group coverage if your plan will
include 2 or more eligible full time employees. In this circumstance,
the owner would be considered a eligible full-time employee.
Also, the fact that you belong to an association does not
qualify you for group coverage unless there are 2 or more employees
covered under the plan.
What types of plans and coverage's are available to sole proprietors?
There are 2 plan designs available to sole proprietors.
Community Blue PPO Plan 8 – This plan
combines the benefits of traditional care with the wellness and
prevention features
of managed care. You may elect to use an in-network physician
with low out-of-pocket expenses and preventative care. Or you
may choose an out-of-network physician with higher out-of-pocket
expenses
Blue Care Network HMO - This plan emphasizes preventative care.
Provides services for hospital care, physician services (including
routine care), diagnostic testing and prescription drugs with
minimal co-payments.
My Blue – These plans are for the individual
who is not eligible for coverage through either their employer
or their spouse’s employer. They include Individual Care
Blue, Value Blue, Young Adult Blue, and Flexible Blue HSA.
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How are my rates determined?
Rate for individual plans are based on a number of factors including
the geographical areas (there are 8 rating areas in Michigan),
industry, and age of the individual. For a specific quote please
contact our office at 800-632-4591.
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How long will it take for me to obtain coverage?
After all the proper materials have been submitted to Blue Cross
Blue Shield of Michigan, the underwriting process takes 30 days.
Upon approval, coverage is effective on the 1st of the month
following the 30-day processing period.
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Are pre-existing conditions
covered under these plan?
In some case pre-existing conditions may be covered. Please contact
our office at 800-632-4591for the specific Blue Cross Blue Shield
of Michigan and Blue Care Network requirements that must be meet.
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Are my rates guaranteed for 12 months?
All rates will be adjusted each year on your association’s
annual rate renewal date. The State Bar of Michigan’s rate
renewal date is May 1 and the Michigan Association of CPA’s
rate renewal date is July 1.
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Can I make changes to my plan?
There are two types of changes that can be made, a benefit change
and a maintenance change.
A benefit change would be when you wish to make a change to the
type of plan you have. For example you are currently insured
through a BCBSM Community Blue PPO plan and want to change to
the Flexible Blue High Deductible plan. This type of change can
be made at any time, however you can only make a benefit change
once every 12 months. You should also note that you can only
change to a plan that is currently available and not an old plan.
A maintenance/membership change would include such changes as
adding a newborn, adding a spouse through a marriage, and an
address change. Adding a newborn or spouse can be made on the
date of the event and address changes can be done at any time.
Certain types of changes can also be made once per year during
the plans open enrollment period. For specific information concerning
open enrollment please contact our office at 800-632-4591
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Can I change physicians during my coverage period?
For BCBSM plans the answer is yes. It is recommended that you
confirm that the new physician participates with your specific
BCBSM plan in order to receive in-network benefits.
You can also change physicians if you have a Blue Care Network
HMO plan.
This change must be reported before any services are
rendered, and can be done on-line or by calling BCN customer
service.
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How can I find out if my physician participates with my specific
plan?
You can visit the Blue Cross web site (go to the links section
on this site), however the best way to know for sure is to simply
ask your current physician.
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What if my physician does not participate with Blue Cross, can
I still get coverage?
If you choose the Community Blue and use a
non-participating physician, you will be subject to out-of-network
deductibles and co-pays.
If you choose the Blue Care Network HMO plan, you must use a
participating physician.
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I am turning 65, what will happen to my coverage?
When you turn 65 you coverage will transfer to a Medicare supplement
plan. The plan that you transfer into is determined by your current
plan and you will maintain the same prescription co-pay as your
current plan. To discuss this process and other options please
contact our office at 800-632-4591.
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If I am traveling out of state, can I use my coverage?
If you are covered by Blue Care Network HMO, you must follow
specific guidelines and receive treatment from a participating
physician. If you are covered by Community Blue PPO or Flex
Blue you have the same flexibility as if you were being treated
in state.
Blue Cross does provide an 800# that can be used to locate a
participating physician or facility.
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