Understanding coverage - PEBB

Understanding your coverage

Your UMP health plan is a valuable benefit that includes medical and prescription drug coverage to help you stay healthy and pay for the cost of an illness or injury. When you see a network provider for covered preventive care services—including routine annual physical exams and certain immunizations—you pay $0.

For other covered benefits and services, the cost may depend on many factors such as:

  • The network status of your provider
  • Whether you have met your deductible
  • Whether a copay applies
  • The amount of your coinsurance
  • Your out-of-pocket limits
 Shared decision making and Health Education

As a UMP member, you now have access to resources that provide information about many health care topics and help you to make good decisions about your health care. Visit the Regence Health education webpage, supported by Healthwise, to get started. Resources include videos and other materials that will inform you about specific conditions, prevention strategies, decision making support, and more. The resources are evidence-based and easy to understand.

Members can also access shared decision tools by visiting the Regence Shared decision webpage, supported by Healthwise. These tools offer information to understand options for treating specific health care needs that can be reviewed with your health care provider to arrive at the best treatment decision for you. To learn more about shared decision making and what it means, visit the Health Care Authority’s Shared decision making webpage.

 Know your costs

Learn more about the medical and prescription drug costs specific to your UMP health plan.

UMP Classic

UMP Select

UMP CDHP

UMP Plus

 Plan basics

To learn more about these terms, read your plan's certificate of coverage.

Coinsurance: The percentage of the allowed amount you must pay the provider on claims for which the plan pays less than 100% of the allowed amount. This includes most medical services and prescription drugs.

Copay: The set dollar amount you pay when receiving specific services, treatments, or supplies, such as inpatient hospitalization or emergency room visits.

Deductible: A fixed dollar amount you must pay each calendar year for health care and/or prescription drug expenses before the plan starts paying for covered services.

Out-of-pocket limit: The most you pay during a calendar year for covered medical services when you see preferred (network for UMP Plus) providers and for covered prescription drugs and products when you use a network pharmacy before the plan pays 100% of the allowed amount.

 Understanding benefit limits and exclusions

To avoid unplanned costs, it’s a good idea to become familiar with the benefit limits and exclusions of your UMP health plan. A limited benefit is a benefit that is limited to a certain number of visits or a maximum dollar amount. The limit applies to these benefits even if the provider prescribes additional visits and even if the visits are medically necessary. Read your plan’s certificate of coverage to learn which services have a benefit limit.

Other benefits have additional limits related to medical necessity or pre-authorization of services. Read your plan’s certificate of coverage to learn more.

Exclusions are services that are not covered. Some services may be medically necessary, yet still are not covered. See “What the plan does not cover" and “Prescription drugs UMP does not cover" in your plan’s certificate of coverage.

 When to submit a medical claim

There are some circumstances in which you need to submit a claim to your UMP health plan. Learn more in the Claims & appeals section of this website.