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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 – 12/31/2018 Uniform Medical Plan: Consumer-Directed Health Plan Coverage for: Individual/Family I Plan Type: PPO 1 of 7 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.hca.wa.gov/ump or call 1-888- 849-3681 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call 1-[PHONE REDACTED] (TTY: 711) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $1,400/individual, $2,800/family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. Are there services covered before you meet your deductible? Yes: preventive care, sterilization, tobacco cessation prescription drugs designated as preventive on the UMP Preferred Drug List, and vision hardware. This plan covers some items and services even if you haven’t yet met the deductible amount. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. But a copayment or coinsurance may apply to some services, for example deductible and cost sharing may be applied on lab or radiology services during a preventive care visit. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $4,200/individual, $8,400/family. Out-of-pocket expenses for a single member under a family account not to exceed $6,850. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. What is not included in the out-of-pocket limit? Premiums, balance billing charges, prescription drug costs, member coinsurance paid to out-of-network providers, health care this plan doesn’t cover, and services that exceed plan limits or maximums. Even though you pay these services, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See www.hca.wa.gov/ump or call 1-[PHONE REDACTED] (TTY: This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a ---PAGE BREAK--- 2 of 7 For more information about limitations and exceptions, see the plan or policy document at www.hca.wa.gov/ump.] 711) for a list of network providers. bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 15% coinsurance 40% coinsurance Not applicable Specialist visit 15% coinsurance 40% coinsurance Not applicable Preventive care/screening/ immunization $0 40% coinsurance This plan covers some items and services even if you haven’t met the deductible amount. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. But a copayment or coinsurance may apply to some services, for example deductible and cost share may be applied on lab or radiology services during a preventive care visit. See a list of covered preventive services at e-care-benefits/. If you have a test Diagnostic test (x-ray, blood work) 15% coinsurance 40% coinsurance Not applicable Imaging (CT/PET scans, MRIs) 15% coinsurance 40% coinsurance No coverage for routine Computed Tomographic Colonography, upright MRI, Carotid Intima Media Thickness testing, and Coronary Artery Calcium Scoring. Discography and Computed Tomographic Angioplasty require preauthorization. ---PAGE BREAK--- 3 of 7 For more information about limitations and exceptions, see the plan or policy document at www.hca.wa.gov/ump.] Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.hca.wa.gov/ump -drugs-cdhp. Generic drugs 15% coinsurance 15% coinsurance No coverage for prescription drugs with an over-the-counter alternative. Prior authorization may be required. Mail order at exclusive mail order pharmacy, Postal Prescription Services (PPS). Preferred brand drugs 15% coinsurance 15% coinsurance No coverage for prescription drugs with an over-the-counter alternative. Prior authorization may be required. Mail order at exclusive mail order pharmacy, Postal Prescription Services (PPS). Non-preferred brand drugs 15% coinsurance 15% coinsurance No coverage for prescription drugs with an over-the-counter alternative. Prior authorization may be required. Mail order at exclusive mail order pharmacy, Postal Prescription Services (PPS). Specialty drugs 15% coinsurance Not covered Coverage is limited to up to a 30-day supply per prescription or refill from the plan's specialty pharmacy, Ardon Health. Prior authorization is required. If you have outpatient surgery Facility fee ambulatory surgery center) 15% coinsurance 40% coinsurance Not applicable Physician/surgeon fees 15% coinsurance 40% coinsurance Preauthorization may be required. If you need immediate medical attention Emergency room care 15% coinsurance 15% coinsurance Not applicable Emergency medical transportation 20% coinsurance 20% coinsurance Coverage is not provided for air or water ambulance if ground ambulance would serve the same purpose. Ambulance services for personal or convenience purposes are not covered. Urgent care 15% coinsurance 40% coinsurance Not applicable If you have a hospital stay Facility fee hospital room) 15% coinsurance 40% coinsurance Provider must notify plan on admission. Physician/surgeon fees 15% coinsurance 40% coinsurance Preauthorization may be required. ---PAGE BREAK--- 4 of 7 For more information about limitations and exceptions, see the plan or policy document at www.hca.wa.gov/ump.] Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services 15% coinsurance 40% coinsurance Preauthorization may be required. No coverage for marriage or family counseling. Inpatient services 15% coinsurance 40% coinsurance Preauthorization required for inpatient admissions. Provider must notify the plan for detoxification, intensive outpatient program, and partial hospitalization. If you are pregnant Office visits 15% coinsurance 40% coinsurance Ultrasounds during pregnancy are limited to one in week 13 or earlier and one during weeks 16-22 (additional may be covered when medically necessary). Childbirth/delivery professional services 15% coinsurance 40% coinsurance Elective deliveries before 39 weeks gestation covered only if medically necessary. Childbirth/delivery facility services 15% coinsurance 40% coinsurance Elective deliveries before 39 weeks gestation covered only if medically necessary. If you need help recovering or have other special health needs Home health care 15% coinsurance 40% coinsurance Custodial care, maintenance care, and private duty nursing or continuous care are not covered. Rehabilitation services 15% coinsurance 40% coinsurance Coverage is limited to 60 inpatient days per calendar year for all therapies combined and 60 outpatient visits per calendar year for all therapies combined. Inpatient admissions for rehabilitation services must be preauthorized. Habilitation services 15% coinsurance 40% coinsurance Coverage includes neurodevelopmental therapy. Coverage is limited to 60 inpatient days per calendar year for all therapies combined and 60 outpatient visits per calendar year for all therapies combined. Skilled nursing care 15% coinsurance 40% coinsurance Coverage is limited to 150 days per calendar ---PAGE BREAK--- 5 of 7 For more information about limitations and exceptions, see the plan or policy document at www.hca.wa.gov/ump.] Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) year. Services must be preauthorized. Durable medical equipment 15% coinsurance 40% coinsurance Foot orthotics are covered only for prevention of diabetic complications. Lost, stolen, or damaged durable medical equipment is not covered. Hospice services $0 after deductible is met 40% coinsurance Hospice coverage is limited to 6 months. Coverage for respite care is limited to 14 visits per the patient’s lifetime. If your child needs dental or eye care Children’s eye exam $0 40% coinsurance Eye exams for medical conditions are subject to deductible and coinsurance. Contact fitting fees covered up to $65 per year, and member may pay charges exceeding that limit. Children’s glasses $0 for one set of glasses per calendar year $0 for one set of glasses per calendar year Not subject to the deductible. Coverage for children ages 0-18 only. 15% coinsurance for contact lenses, and no limit to number purchased. Children’s dental check-up Not Covered Not Covered Not applicable Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Coronary or cardiac artery Calcium Scoring • Cosmetic Surgery • Custodial care • Dental care • Immunizations for travel or employment • Infertility treatment after initial diagnosis • Lost, stolen, or damaged durable medical equipment • Maintenance care • Marriage or family counseling • MRI, upright • Out-of-network massage therapy • Private duty nursing and continuous care • Computed Tomographic Colonography for routine colorectal cancer screening • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture • Bariatric surgery • Chiropractic care • Hearing Aids • Non-emergency care when traveling outside the U.S. • Routine eye care (Adult) • Routine foot care for certain medical conditions ---PAGE BREAK--- 6 of 7 For more information about limitations and exceptions, see the plan or policy document at www.hca.wa.gov/ump.] Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-[PHONE REDACTED]. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: UMP Customer Service at 1-[PHONE REDACTED] (medical benefits) (TTY: 711); 1-[PHONE REDACTED] (prescription benefits) (TRS: 711) or Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: [Spanish (Español): Para obtener asistencia en Español, llame al 1-[PHONE REDACTED] (TTY: 711).] [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-[PHONE REDACTED] (TTY: 711).] [Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-[PHONE REDACTED] (TTY: 711).] [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-[PHONE REDACTED] (TTY: 711).] see examples of how this plan might cover costs for a sample medical situation, see the next ---PAGE BREAK--- 7 of 7 The plan would be responsible for the other costs of these EXAMPLE covered services. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan’s overall deductible $1,400 Specialist coinsurance 15% Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,840 In this example, Peg would pay: Cost Sharing Deductibles $1,400 Copayments $0 Coinsurance $1,900 What isn’t covered Limits or exclusions $60 The total Peg would pay is $3,360 The plan’s overall deductible $1,400 Specialist coinsurance 15% Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Durable medical equipment (glucose meter) Total Example Cost $7,460 In this example, Joe would pay: Cost Sharing Deductibles $1,400 Copayments $0 Coinsurance $1,100 What isn’t covered Limits or exclusions $60 The total Joe would pay is $2,560 The plan’s overall deductible $1,400 Specialist coinsurance 15% Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,010 In this example, Mia would pay: Cost Sharing Deductibles $1,400 Copayments $0 Coinsurance $300 What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,700 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.