Coinsurance/copayments

Coinsurance

UMP Classic covers most medical services based on a percentage of the allowed amount that preferred providers agree to accept as payment in full. (The allowed amount is the most the plan will pay for a specific covered service or supply.)

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

  • Preferred providers: You pay 15 percent of the allowed amount.
  • 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.

Copayment

You also pay a copayment (“copay”) when you receive certain services. Copayments are set dollar amounts.

The only copayments under UMP Classic are for:

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

See the UMP Classic Summary of benefits for details.

How much will I pay for medical services?

Type of service How much you pay

Standard

Subject to the medical deductible. You must pay 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 (you don’t have to pay your deductible before the plan pays).

Your coinsurance depends on the provider’s network status:

Outpatient

Subject to the medical deductible

If you receive services at a facility that offers inpatient services but you are not admitted as an inpatient, the services are covered as outpatient. See the specific benefit—for example, diagnostic tests—for how much you will pay.

Inpatient

Subject to the medical deductible.

See the specific benefit—for example, diagnostic tests—for how the plan covers these related services.

  • 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).

The inpatient copay is $200 per day at preferred facilities.

  • Employees and retirees not enrolled in Medicare: $600 maximum per calendar year.
  • Retirees enrolled in Medicare: $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 as an inpatient, 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); depends on the provider’s network status as described under the Standard type of service, above.

If you receive non-emergency inpatient care at an out-of-network facility, you will pay according to the Standard benefit. Services are considered inpatient only when you are admitted as an inpatient to a facility.

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 medical deductible

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