Coinsurance/copayments

Coinsurance

Coinsurance is the percentage of the allowed amount that you pay for most medical services and for prescription drugs when the plan pays less than 100 percent.

After you have paid your medical deductible, you pay the following percentages for most medical services:

  • For preferred providers: 15 percent of the allowed amount.
  • For participating providers: 40 percent of the allowed amount.
  • For out-of-network providers: 40 percent of the allowed amount and you may be balance billed.

Read Sample payments to different provider types for examples of how much you pay for professional services from preferred, participating, and out-of-network providers when UMP is  your primary insurance.

To learn more about how much you pay for prescription drugs, visit What you pay for drugs.

Copayment

A copayment is a flat dollar amount you pay when you receive services, treatments, or supplies, including but not limited to:

  • Emergency room copay: $75 per visit.
  • Facility charges for services received while an inpatient at a hospital, mental health, substance use disorder, or skilled nursing facility: $200 per day copay.

Read the copayment section of your certificate of coverage for more information.

How much will I pay for medical services?

The table below describes how much you will pay for services. Unless otherwise noted, all payments are based on the allowed amount and services are subject to the medical deductible. Visit Summary of benefits to find out which services fall under the standard, preventive, outpatient, inpatient, facility fees, and special categories. 

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 (e.g., emergency room or diagnostic tests) for how much you pay. You may be billed separately for facility fees in addition to the 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.

  • Members not enrolled in Medicare: You pay $600 maximum per calendar year.
  • Retirees and their dependents 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:

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

Services are considered inpatient only when you are admitted to a facility. See inpatient stay.

If you go to an out-of-network facility for non-emergency inpatient care, you pay 40% 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% 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.

How much you pay 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.