Physicians Health Plan

UNIVERSITY OF MICHIGAN HEALTH PLAN'S MISSION IS TO IMPROVE THE HEALTH STATUS OF ITS MEMBERS BY FACILITATING QUALITY, COMPASSIONATE, ACCESSIBLE, COST EFFECTIVE HEALTHCARE.

UNIVERSITY OF MICHIGAN HEALTH PLAN IS OWNED BY UNIVERSITY OF MICHIGAN HEALTH PLAN HOLDINGS, LLC AND HOLDS A CERTIFICATE OF AUTHORITY AS AN HMO IN THE STATE OF MICHIGAN. UNIVERSITY OF MICHIGAN HEALTH PLAN IS PRIMARILY A COMMERCIAL HMO AND ALSO OPERATES THREE SUBSIDIARIES, UNIVERSITY OF MICHIGAN HEALTH INSURANCE COMPANY, A COMMERCIAL INSURANCE COMPANY, UNIVERSITY OF MICHIGAN HEALTH MEDICARE, A MICHIGAN MEDICARE PLAN, AND UNIVERSITY OF MICHIGAN HEALTH SERVICE COMPANY A THIRD PARTY ADMINISTRATOR. ALL STAFFING FUNCTIONS AND REPORTING ARE ACCOMPLISHED THROUGH THE USE OF THE SAME STAFF AS UNIVERSITY OF MICHIGAN HEALTH PLAN. UNLESS SPECIFICALLY NOTED, ALL REFERENCES TO U OF M HEALTH PLAN APPLY TO U OF M HEALTH PLAN, U OF M HEALTH INSURANCE COMPANY, U OF M HEALTH SERVICE COMPANY AND U OF M HEALTH MEDICARE. U OF M HEALTH PLAN'S SERVICE AREA INCLUDES THE MICHIGAN COUNTIES OF INGHAM, EATON, CLINTON, SHIAWASSEE, MONTCALM, GRATIOT, IONIA, JACKSON, HILLSDALE AND PORTIONS OF ISABELLA, SAGINAW, WASHTENAW, AND LENAWEE. U OF M HEALTH INSURANCE COMPANY OFFERS PRODUCTS ACROSS MICHIGAN. AS OF DECEMBER 31, 2023, THERE WERE APPROXIMATELY 28,100 ENROLLEES IN U OF M HEALTH PLAN'S COMMERCIAL HMO, 25,300 IN TPA, 2,300 IN U OF M HEALTH INSURANCE COMPANY, AND 8,300 ENROLLEES IN UM HEALTH MEDICARE. THE U OF M HEALTH PLAN NETWORK IS APPROXIMATELY 3,068 PRIMARY CARE PHYSICIANS, 5,503 SPECIALTY CARE PHYSICIANS, 3,906 ALLIED HEALTH PROFESSIONALS, 3,482 BEHAVIORAL HEALTH PROVIDERS AND 746 ORGANIZATIONAL PROVIDERS THAT INCLUDE 60 HOSPITALS. U OF M HEALTH PLAN CONTRACTS WITH VARIOUS HDNS WHO PROVIDE HEALTHCARE SERVICES TO MEMBERS. U OF M HEALTH PLAN'S COMMITMENT IS TO DEVELOP AND DELIVER QUALITY MANAGED CARE PRODUCTS AT REASONABLE COSTS FOR ITS MEMBERS. U OF M HEALTH PLAN'S SUCCESS IN MANAGING HEALTH CARE IS DUE IN PART TO THE EXTENSIVE NETWORK OF PARTICIPATING PROVIDERS IN THE HDN NETWORK. THE HMO/HDN CONTRACTUAL ARRANGEMENTS ALLOW U OF M HEALTH PLAN TO ARRANGE FOR HEALTHCARE TO PATIENTS COVERED BY THE STATE OF MICHIGAN'S MEDICAID BENEFIT PLAN. THIS ARRANGEMENT ALLOWS THE MEMBERS TO ACCESS A WIDE VARIETY OF INDEPENDENT PROVIDERS WITHIN EACH HDN INCLUDING PHYSICIANS, HOSPITALS, PHARMACIES, SKILLED NURSING FACILITIES, AND ALLIED HEALTH PROFESSIONALS. U OF M HEALTH PLAN MEMBERS MAY ALSO RECEIVE CARE FOR SERVICES FROM A NONPARTICIPATING PROVIDER IF SUCH REFERRAL IS RECOMMENDED BY AN HDN PARTICIPATING PHYSICIAN AND THE SERVICE REQUIRED FOR TREATMENT, AS DETERMINED BY HDN, IS NOT AVAILABLE WITHIN THE HDN'S NETWORK. U OF M HEALTH PLAN OFFERS A VARIETY OF HEALTHCARE PROGRAMS, OR PRODUCTS TO GROUPS AND INDIVIDUALS. U OF M HEALTH PLAN OFFERS CHOICES THAT PROVIDE COVERAGE WITHIN THE NETWORK OF CONTRACTED HDN PROVIDERS, LIMITED COVERAGE OUTSIDE OF THE U OF M HEALTH PLAN NETWORK, VARIOUS LEVELS OF DEDUCTIBLES, CO-PAYMENTS, AND COVERAGE LIMITS, ALL OF WHICH ARE DESIGNED TO BE RESPONSIVE TO CUSTOMER NEEDS. U OF M HEALTH PLAN MEASURES THE QUALITY OF CARE PROVIDED TO ITS ENROLLEES THROUGH ANNUAL REVIEW OF INDICATORS SUCH AS: - DISEASE MANAGEMENT PROGRAM PARTICIPATION AND OUTCOMES. - QUALITY OF CARE CONCERNS. - HEDIS MEASURES - THE HEALTH PLAN EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) IS A GROUP OF NATIONALLY RECOGNIZED MEASURES OF HEALTH PLANS PERFORMANCE IN A VARIETY OF CLINICAL AND NON-CLINICAL AREAS. U OF M HEALTH PLAN USES THE EFFECTIVENESS OF CARE MEASURES TO DETERMINE PROGRESS AND IMPROVEMENT IN AREAS SUCH AS: - DIABETES, - ASTHMA, - DEPRESSION AND FOLLOW-UP AFTER MENTAL HEALTH ADMISSIONS, - BREAST AND CERVICAL CANCER SCREENING, - USE OF BETA-BLOCKERS AFTER HEART ATTACKS, - CHILD AND ADOLESCENT IMMUNIZATIONS, - CHOLESTEROL MANAGEMENT, - CONTROLLING HIGH BLOOD PRESSURE, - SMOKING CESSATION, - PRENATAL AND POSTPARTUM CARE, AND - TREATMENT OF CHILDHOOD RESPIRATORY INFECTIONS. U OF M HEALTH PLAN MEASURES THE QUALITY OF SERVICE PROVIDED TO ITS ENROLLEES BY THE REVIEW OF PERFORMANCE MEASURES RELATED TO: - ACCESS AND AVAILABILITY OF PROVIDERS, - ENROLLEE COMPLAINTS AND APPEALS, - CUSTOMER SERVICE TELEPHONE ACCESS PERFORMANCE, AND - MEMBER ASSESSMENT: THE CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) SURVEY GIVES A GENERAL INDICATION OF HOW WELL THE ORGANIZATION MEETS MEMBERS' EXPECTATIONS. THE U OF M HEALTH PLAN QI PROGRAM IS ULTIMATELY ACCOUNTABLE TO THE BOARD OF DIRECTORS. IN 2021 U OF M HEALTH PLAN RECEIVED "FULL ACCREDITATION" STATUS FROM URAC FOR BOTH HEALTH PLAN ACCREDITATION AND HEALTH PLAN ACCREDITATION WITH HEALTH INSURANCE MARKETPLACE. URAC ACCREDITATION SIGNIFIES AN ISSUER HAS UNDERGONE AND PASSED A RIGOROUS AND INDEPENDENT REVIEW OF ITS OPERATION, INCLUDING THE QUALITY OF CARE AND LEVEL OF SERVICE PROVIDED TO ENROLLEES. ACCREDITATION HEALTH PLAN STANDARDS INCORPORATE MARKET TRENDS AND ADDRESS MAJOR POLICY ISSUES WHILE ALIGNING WITH CORE REQUIREMENTS FOUND IN THE AFFORDABLE CARE ACT. U OF M HEALTH PLAN HAS BEEN ACCREDITED BY URAC UNDER THE HEALTH PLAN STANDARDS SINCE 2012. THE CURRENT ACCREDITATION IS EFFECTIVE THROUGH JULY 1, 2024 AT WHICH TIME REACCREDITATION WILL OCCUR.