Page 4 - Mi Health and Hospital 2021 Renewal Booklet.2

Michigan Health & Hospital Association: Medical Cost Analysis

Effective January 2021

Current Renewal Current Renewal
BCBSM BCBSM BCBSM BCBSM
CB PPO $250 Ded CB PPO $250 Ded SB PPO HSA $1350 SB PPO HSA $1400
Rates Counts
Single 7 $768.04 $751.75 32 $578.38 $572.21
Two Person 6 $1,843.28 $1,804.20 25 $1,388.11 $1,373.32
Family 5 $2,304.11 $2,255.25 44 $1,735.13 $1,716.64
Estimated Monthly Premium $27,957 $27,364 $129,557 $128,176
Estimated Annual Premium $335,478 $328,364 $1,554,680 $1,538,111
Percentage Change -2.12% -1.07%
Total Est Annual $Change -$23,683
Total Est Annual % Change -1.25%
Deductible In-Network In-Network In-Network In-Network
Individual $250 $250 $1,400 $1,400
Family $500 $500 $2,800 $2,800
Coinsurance Maximum 100% 100% 100% 100%
Individual N/A N/A N/A N/A
Family N/A N/A N/A N/A
Out-of-Pocket Maximum
Individual $1,000** $1,000** $2,250** $2,250**
Family $2,000** $2,000** $4,500** $4,500**
Hospitalization 100% after ded 100% after ded 100% after ded 100% after ded
Emergency Room $200 $200 100% after ded 100% after ded
Urgent Care $20 $20 100% after ded 100% after ded
Office Visit/Online Visit $20/$10 $20/$10 100% after ded 100% after ded
Specialist copay $20 $20 100% after ded 100% after ded
Preventative Care 100% 100% 100% 100%
Prescription Drugs
Tier 1 $15 $15 $15 after deductible $15 after deductible
Tier 2 $30 $30 $30 after deductible $30 after deductible
Tier 3 $60 $60 $60 after deductible $60 after deductible
Tier 4 N/A N/A N/A N/A
Tier 5 N/A N/A N/A N/A

This is a summary analysis only. Please refer to certificate of coverage for all specific details. This summary is not a
contract and makes no representations or warranties as to final outcomes of claim adjudication.
Final rates are subject to underwriting approval and are subject to change. Rates include taxes and fees.
** OOP includes deductible, copays, coinsurance and RX copays.