services. Some providers (out of network providers) don't contract with the Host Blue. The section below explains how the Plan pays these different kinds of providers. BlueCard® Program Under the BlueCard® Program, when you access covered services within the geographic area served by a Host Blue, Regence will remain responsible for doing what was agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its preferred or participating providers. When covered services are received outside the Regence’s service area and the claim is processed through the BlueCard® Program, the amount you pay for covered services is calculated based on the lower of: • The billed covered charges for your covered services; or • The negotiated price that the Host Blue makes available to Regence. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your health care provider. Sometimes, it is an estimated price that considers special arrangements with your health care provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of health care providers after considering the same types of transactions as with an estimated price. Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing of claims, as noted above. However, such adjustments will not affect the price Regence BlueShield uses for your claim because they will not be applied after a claim has already been paid. Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, Regence would then calculate your liability for any covered services according to applicable law. Value Based Programs If covered services are received under a Value-Based Program inside a Host Blue's service area, you will not be responsible for paying any of the provider incentives, risk-sharing, and/or care coordinator fees that are a part of such an arrangement, except when a Host Blue passes these fees to the Regence through average pricing or fee schedule adjustments. For the purpose of this section, the following definitions apply. Value-Based Program: An outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. Provider Incentive: An additional amount of compensation paid to a healthcare provider by a Blue Cross and/or Blue Shield Plan, based on the provider's compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. A Care Coordination Fee is a fixed amount paid by a Blue Cross and/or Blue Shield Licensee to Providers periodically for Care Coordination under a Value-Based Program. 22 2024 UMP CDHP (PEBB) Certificate of Coverage