Coinsurance

Coinsurance

UMP CDHP covers most medical services based on a percentage of the allowed amount that preferred providers agree to accept as payment in full.

Coinsurance is the percentage of the allowed amount you pay when the plan pays less than 100 percent of the allowed amount. Your coinsurance varies based on the network status of the provider:

  • Preferred providers: You pay 15 percent of the allowed amount. (See Preferred vs. out-of-network costs for an example of how this works.)
  • Out-of-network providers: You pay 40 percent of the allowed amount, plus any amount billed by the out-of-network provider that is above the allowed amount.

Coinsurance also applies to prescription drugs. How much you pay depends on whether the prescription drug is generic, preferred, or nonpreferred.

How much will I pay for medical services?

Type of service How much you pay

Standard

Subject to the deductible.

How much you pay (your coinsurance) depends on the provider’s network status:

Preventive

Not subject to the deductible (you don’t have to pay your deductible before the plan pays)

Your coinsurance depends on the provider’s network status:

Inpatient

Subject to the deductible.

  • Facility charges and professional services (such as physicians and lab tests) are usually billed separately. See a specific benefit—for example, diagnostic tests—for how these related services are covered.
  • Professional providers may contract separately from a facility. Even if a facility is preferred, a professional provider may not be.
  • Most inpatient services require both preauthorization and notification (your provider must notify the plan upon admission to a facility).

Your coinsurance depends on the provider’s* network status:

Services are considered inpatient only when you are admitted as an inpatient to a facility.

*A facility, such as a hospital, may be referred to as a “provider.” 

Facility fees

May be charged in addition to provider fees when accessing hospitals or clinics.

Your coinsurance depends on the provider’s* network status:

*A facility, such as a hospital, may be referred to as a “provider” on Explanation of Benefits or facility bills.

Special

Subject to the deductible

These services have unique payment rules, which are described in the Summary of benefits table in your certificate of coverage.