Michigan Selection of Personal Injury Protection (PIP) Medical Coverage

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MICHIGAN SELECTION OF PERSONAL INJURY PROTECTION (PIP)

MEDICAL COVERAGE -- INDIVIDUALS

AGENCY:

APPLICANT/NAMED INSURED:

INSURANCE COMPANY:

POLICY/QUOTE NO.:

EFFECTIVE DATE:

READ THIS ENTIRE FORM CAREFULLY

THE PURPOSE OF THIS FORM

The purpose of this form is to explain the choice you have regarding your Personal Injury

Protection medical (PIP medical) coverage and to assist you in making that choice. Read this

form carefully because the choice you make will have financial consequences.

Definitions for all terms in bold type on this form have been provided on the next page.

This form is divided into four sections, which are described below.

• Section A will review your PIP medical coverage options and the risks and benefits of

each option.

• Section B will ask you to choose ONE coverage option.

• Section C will allow you to identify additional excluded persons not listed in Section B

(Option 4 only).

• Section D will ask you to certify your choice and acknowledge the information within this

form.

Personal Injury Protection (PIP) Coverage Explained

Personal Injury Protection (PIP) pays allowable expenses for a covered person’s care, recovery, rehabilitation, wage

loss, and replacement services. PIP coverage also includes some funeral expense benefits and survivor’s benefits,

which are paid to a covered person’s dependents if injuries from an auto accident result in their death. This form allows

you to select the level of PIP medical coverage you want included with your auto policy.

NOTICE

You must choose the level of PIP medical coverage you wish to have under your auto policy. If

you do not make a PIP medical coverage selection from the options listed:

• Your policy may be issued with unlimited PIP medical coverage; AND

• You will be charged the appropriate premium for the coverage issued.

If you are renewing an expiring policy that includes a PIP medical coverage selection of unlimited

(Option 1), $500,000 per person per accident (Option 2), or $250,000 per person per accident with

no excluded persons (Option 3), your policy will be issued with the same PIP medical coverage

as your expiring policy.

Qualified Health Coverage Proof Requirements

All policies with a PIP medical coverage selection of $250,000 with some or all persons excluded (Option 4) OR

$50,000 per person per accident (Option 5) OR No PIP medical coverage (Option 6) must provide current updated

documentation every year for Medicaid, Medicare, or other qualified health coverage as applicable to the chosen

coverage. If you do not provide the documentation AND:

• Your PIP medical coverage selection is $250,000 with some or all persons excluded (Option 4), your policy will

be issued with $250,000 PIP medical coverage with no excluded persons (Option 3) and you will be charged

the appropriate premium for this coverage.

• Your PIP medical coverage selection is $50,000 per person per accident (Option 5) OR no PIP medical

coverage (Option 6), your policy will be issued with unlimited PIP medical coverage (Option 1) and you will be

charged the appropriate premium for this coverage.

Proof of Medicaid coverage may be in the form of a current Medicaid ID card or a letter from the Michigan Department

of Health and Human Services.

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Definitions

The terms in bold letters throughout this form are defined below for informational purposes only and are not intended to

limit or expand coverage that may be available in a particular policy.

Applicant means a person who has submitted an application for insurance but is not yet insured under a policy.

Attendant care means services that are provided for the particular needs of an injured person, i.e., services that would not

have been required before the injury and that are not performed for the benefit of the whole household.

• Attendant care generally includes, but is not limited to, serving meals in bed, bathing, dressing, grooming,

administering medication, escorting, supervising, or transporting for medical treatment.

• Attendant care generally does not include providing transportation that is not for medical treatment, preparing

family meals, or maintaining the house, automobile, or yard—even if such tasks would have been performed by

the injured person but for the covered injury.

Excess attendant care means additional coverage purchased for attendant care above the PIP medical coverage limit

selected for your policy.

Michigan Assigned Claims Plan is a program that may pay benefits to people injured in an accident involving a motor

vehicle when there is no applicable automobile insurance policy.

Named insured means the individual(s) named in an insurance policy.

Personal Injury Protection (PIP) medical is coverage under an auto insurance policy issued in Michigan that pays

allowable expenses for medical care, recovery, rehabilitation, and some funeral expenses.

Qualified health coverage means either of the following:

• Health and accident coverage that does not exclude or limit coverage for injuries related to auto accidents and

has an annual individual deductible of $6,579 or less; OR

• Coverage under both Medicare Parts A and B (or a Medicare Advantage plan).

Medicaid and health care sharing ministries are examples of coverages that are NOT considered qualified health

coverage.

Resident relative means a relative of either you or your spouse who lives in the same household.

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Section A: Your PIP Medical Choices and the Risks and Benefits of Each

Option 1: Unlimited Coverage

This option provides the most coverage. It will pay for all allowable expenses for your care, recovery, and rehabilitation

if you are injured in an auto accident.

Risks The premiums for this option are higher than premiums for other options.

Benefits

PIP

medical

will cover costs that may not be covered by health insurance, such as rehabilitation and

attendant care.

This choice will significantly limit the risk that you will have out-of-pocket costs for your care.

Option 2: Limited Coverage of $500,000 per person per accident or

Option 3: Limited Coverage of $250,000 per person per accident

If you choose one of these limits, this amount is the most your auto insurance company will pay per person per accident

for an injured person’s expenses under PIP medical coverage.

NOTE: If you choose Option 2 or Option 3, your insurance company must offer excess attendant care coverage, which

you may purchase for an additional premium. Check with your agent or company for additional information.

Risks

Limited PIP medical coverages may not be enough to cover your medical expenses. If your PIP

medical limit is reached, you may need to rely on other health coverage, which may not cover all

medical, rehabilitation or attendant care costs. If you do not have other health coverage, you may be

personally responsible for paying these expenses.

Benefits

Lower coverage limits have less expensive premiums than plans with higher or unlimited

PIP medical

coverage.

Up to the limit chosen, PIP medical will cover the cost of products and services that may not be

covered by health insurance, such as rehabilitation and attendant care.

Option 4: Limited Coverage of $250,000 per person per accident with some or all persons excluded

You may select this option if both of the following are true:

• The applicant or named insured has qualified health coverage that is not Medicare; AND

• Each spouse or resident relative excluded from PIP medical has qualified health coverage.

Anyone who is excluded will have no PIP medical coverage. A person listed as excluded in Section B of this form will

only be excluded if proof of qualified health coverage is provided for that person. Any person who is not excluded will

be limited to $250,000 in PIP medical coverage and will be charged the appropriate premium for this coverage.

NOTE: If you choose this option, your insurance company must offer excess attendant care, which you may purchase

for an additional premium. This coverage is only available to those who are not excluded from PIP medical coverage.

Check with your agent or company for additional information.

Risks ANYONE YOU EXCLUDE WILL NOT HAVE PIP MEDICAL COVERAGE.

In addition:

• Persons relying on qualified health coverage to pay for auto accident injuries should be

aware that, unlike auto insurance, health insurance stops paying when the policy ends or is

canceled.

• If any excluded person loses qualified health coverage, you must notify your insurer within

30 days of loss of coverage.

• Within 30 days of losing qualified health coverage, if an excluded person is injured in an

auto accident, coverage will be provided by the Michigan Assigned Claims Plan up to

$2,000,000 if they have no other qualified health coverage or PIP medical coverage.

• A person who has not obtained qualified health coverage or PIP medical coverage within

30 days of the loss of qualified health coverage will not be entitled to any PIP medical

benefits.

Benefits

You will pay a reduced premium because you will not be charged a premium for PIP medical

coverage for anyone who is excluded.

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Section A (Continued)

Option 5: Limited Coverage of $50,000 per person per accident

If you choose this limit, $50,000 is the most your auto insurance company will pay per person per accident for an

injured person’s expenses under PIP medical coverage.

You may select this option if:

• The applicant or named insured is enrolled in Medicaid; AND

• Any spouse and all resident relatives have one of the following:

a) qualified health coverage;

b) coverage under Medicaid, or

c) coverage under another Michigan auto policy with PIP medical coverage.

NOTES:

• Proof of Medicaid coverage may be in the form of a current Medicaid ID card or a letter from the Michigan

Department of Health and Human Services.

• Your insurance company must offer excess attendant care coverage, which you may purchase for an

additional premium. Check with your agent or company for additional information.

Risks Limited PIP medical coverages may not be enough to cover the cost of your medical care. If your

PIP medical limit is reached, you may need to rely on other health coverage, which may not cover all

medical, rehabilitation, or attendant care costs. If you do not have other health coverage, you may

be personally responsible for paying these expenses.

Benefits Lower coverage limits have less expensive premiums than plans with higher or unlimited PIP

medical coverage.

Up to the limit chosen, PIP medical will cover the cost of products and services that may not be

covered by health insurance, such as rehabilitation and attendant care.

Option 6: No PIP medical coverage for anyone covered by this policy

You may select this option if:

• The applicant or named insured has coverage under both Medicare Parts A and B (or a Medicare Advantage

plan), AND

• Any spouse and all resident relatives covered by the policy have qualified health coverage or are covered

under another auto policy with PIP medical coverage.

Risks NO PIP MEDICAL COVERAGE WILL BE PROVIDED UNDER YOUR POLICY.

You and any other persons covered by this policy will not have PIP medical coverage. You and

those persons may have to rely on other health coverage to pay for medical expenses resulting from

an auto accident, which may not cover all products and services that PIP medical provides.

•

Persons relying on qualified health coverage to pay for auto accident injuries should be

aware that, unlike auto insurance, health insurance stops paying when the policy ends or is

canceled.

• If anyone covered by the policy loses qualified health coverage, you must notify your

insurer within 30 days of loss of the coverage.

• Within the 30 days of losing qualified health coverage, if anyone covered by the policy is

injured in an auto accident, coverage will be provided by the Michigan Assigned Claims

Plan up to $2,000,000 if they have no other qualified health coverage or PIP medical

coverage.

• A person who has not obtained qualified health coverage or PIP medical coverage within

30 days of the loss of coverage will not be entitled to any PIP medical benefits.

Benefits You will pay a reduced premium because your policy will not be charged a premium for PIP medical

coverage.

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(Initial)

Section B: PIP Medical Coverage Options and Certification

INITIAL ONE AND ONLY ONE option on the line next to your choice. Make your selection carefully because the choice

you make will have financial consequences. If you choose more than one option, your insurer will provide you with the

option that has the highest level of benefits and will charge the appropriate premium for that option.

______ Option 1: Unlimited coverage

______ Option 2: $500,000 per person per accident

______ Option 3: $250,000 per person per accident

______ Option 4: $250,000 per person per accident with some or all persons excluded

To s

elect Option 4, both of the following must be true and proof must be provided:

• A named insured who is excluding PIP medical has qualified health coverage that is not Medicare.

• Any resident relative or spouse who is excluding PIP medical has qualified health coverage.

Full Name of Each Excluded Person on the Policy Date of Birth

______ Option 5: $50,000 per person per accident

To s

elect Option 5, both of the following must be true and proof must be provided:

• The applicant or named insured is enrolled in Medicaid; AND

• Any spouse and all resident relatives have qualified health coverage, is enrolled in Medicaid, or are

covered under another auto policy with PIP medical coverage.

______ Option 6: No PIP medical coverage.

To select Option 6, both of the following must be true and proof must be provided:

• The applicant or named insured has coverage under both Medicare Parts A and B (or a Medicare

Advantage plan); AND

• Any spouse and all resident relatives have qualified health coverage or are covered under another

auto policy with PIP medical coverage.

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(Initial)

Section C: Additional Excluded Persons (Option 4 Only)

Full Name of Each Excluded Person on the Policy Date of Birth

Section D: Certification

You must initial each line and sign and date this form.

______ I have read this form. I understand the PIP medical options available to me and the benefits and risks associated

with those options.

______ I have made a PIP medical coverage selection and I understand that the selection I have made applies to me

and any other person claiming benefits under this policy.

______ I understand that if I have not made a PIP medical selection, my policy will either be issued with the same

coverages as my expiring policy (if applicable) or unlimited PIP medical coverage and I will be charged the

premium for the coverage issued.

______ I understand that if I have chosen Option 4 or Option 6, I must notify my insurer within 30 days if a person who

has qualified health coverage loses their qualified health coverage. A person who has not obtained qualified

health coverage or PIP medical coverage within 30 days of the loss of coverage will not be entitled to any PIP

medical benefits.

______ I understand that if I have chosen Option 4, Option 5 or Option 6, I must provide proof of qualified health

coverage and that failure to do so will result in a change in coverage and I will be charged the appropriate

premium for this coverage.

APPLICANT/NAMED INSURED

SIGNATURE

DATE

APPLICANT/NAMED INSURED

SIGNATURE

DATE