Healthy Blue Living℠ plans BCN Qualification Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Healthy Blue Living plan member, use this form if you've just enrolled or renewed within the last 90 days.

If you want to get lower deductibles and copays, your doctor needs to fax or email this form within 90 days after you enroll in or renew the Healthy Blue Living plan.

This applies to everyone covered by the plan who has to meet the requirements for intermediate or enhanced benefits.

Access the form here: Healthy Blue Living BCN Qualification Form (PDF)

You’ll need a printer to print the form. It's a good idea to take it with you to your appointment as a reminder for your doctor.

How to read the qualification form

The form uses a simple A, B, C grading system:

A = You meet the health target

B = You have a health condition that may not be controlled, but you are actively participating in treatment to improve the condition.

C = You’re not meeting the wellness target, and you haven’t committed to treatment to improve your condition.

The grades you need to earn for your benefit level are different for each plan.

For Healthy Blue Living:

  • If you and your covered spouse earn all A's or B's, you’ll get enhanced benefits for the entire plan year.
  • If you or your covered spouse get a C on any health measure, everyone on your contract moves to standard benefit level.