Coinsurance/copayments

Coinsurance

Coinsurance is the percentage of the allowed amount you pay when the plan pays less than 100 percent of it.

Your coinsurance depends on the provider's network status:

  • Preferred providers: You pay 15 percent of the allowed amount.
  • Participating providers: You pay 40 percent of the allowed amount, but they may not balance bill you.
  • Out-of-network providers: You pay 40 percent of the allowed amount and may be balance billed.

See Preferred vs. out-of-network costs for an example of how this works.

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

Why does balance billing matter? Balance billing means an out-of-network provider charges you the difference between their billed amount and the plan's allowed amount. The difference between these two can be large. For example, if the provider bills $500 and the allowed amount is $400, you will pay the $100 difference. To avoid balance billing, use preferred or participating providers.

Copayments

Copayments (“copays”) are separate from your coinsurance.  A copayment is a flat dollar amount you pay for services, treatments, or supplies, including but not limited to:

  • Emergency care.
  • Inpatient services at a hospital, mental health, chemical dependency, or skilled nursing facility.

See the UMP Classic Summary of benefits page for details about specific benefits.

How much you pay for medical services

Type of service How much you pay

Standard

Subject to the medical deductible and coinsurance.

You must pay your medical deductible, the first $250 in covered services, before the plan begins to pay. How much you pay (your coinsurance) depends on the provider’s network status:

Preventive

Not subject to the medical deductible or coinsurance. See Preventive care to learn more.

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

Outpatient

Subject to the medical deductible and coinsurance.

If you receive services at a facility that offers inpatient services (like a hospital) but you are not admitted, you pay for outpatient services. See the specific benefit (i.e., emergency room or diagnostic tests) for how much you will pay. You may be billed separately for facility fees in addition to provider fees.

Inpatient

Subject to the medical deductible, copay, and coinsurance.

Most inpatient services require both preauthorization and notification (your provider must notify the plan upon admission to a facility).

You pay the $200 per day copayment at preferred facilities.

  • Employees and retirees not enrolled in Medicare: You pay $600 maximum per calendar year.
  • Retirees enrolled in Medicare: You pay $600 maximum per admission up to the medical out-of-pocket limit.

Note: The inpatient copay counts toward your medical out-of-pocket limit.

When you are admitted to a preferred facility, you will pay all of the following:

  • Any remaining medical deductible.
  • The inpatient copay.
  • Your coinsurance for professional services (such as doctor consultations or lab tests), which depends on the provider’s network status.

If you go to an out-of-network facility for non-emergency inpatient care, you pay 40 percent of the allowed amount, and the facility may balance bill you.

If you go to a preferred, participating, or out-of-network facility and see an out-of-network provider, you will pay 40 percent of the allowed amount, and the facility may balance bill you.

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

(for example, ambulance)
Subject to the medical deductible

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