Hospital A hospital is an institution accredited under the Hospital Accreditation Program of the Joint Commission and licensed by the state where it is located. A hospital has a defined course of therapeutic intervention and special programming in a controlled environment. A hospital also offers a degree of security, supervision, and structure. Hospital patients must be medically monitored with 24-hour medical availability and 24-hour onsite services as defined in federal guidelines outlining Conditions of Participation for Hospitals. The term hospital does not include a convalescent nursing home or institution (or a part of one) that: • Furnishes primarily domiciliary or custodial care. • Is operated as a school. • Is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged. Inpatient copay The inpatient copay is what you pay for inpatient services at a network facility, such as a hospital, or skilled mental health, nursing, or substance use disorder facility. Non-Medicare members pay $200 per day up to $600 maximum per member per calendar year. The inpatient copay does not apply to your medical deductible but does apply to the medical out-of-pocket limit. Professional charges, such as for physicians or lab work, may be billed separately and are not included in this copay. Inpatient rate The inpatient rate means that you pay your deductible and copay at network facilities After you have met your deductible and paid your copay, the plan pays 100 percent of the allowed amount. The plan pays for professional services, such as provider visits or lab tests, based on the provider’s network status during an inpatient stay: • Network providers: You pay 15 percent of the allowed amount after you meet your medical deductible. The plan pays 85 percent of the allowed amount. Note: For behavioral health professional services, the plan pays 100 percent of the allowed amount. • Out-of-network providers: You pay 50 percent of the allowed amount after you pay your medical deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The plan pays 50 percent of the allowed amount. Inpatient stay An inpatient stay begins when you are admitted to a hospital or other medical facility, and ends when you are discharged from that facility. Independent review organization (IRO) An independent review organization (IRO) conducts the independent (or external) review of an appeal. An IRO is a group of medical and benefit experts certified by the Washington State Department of Health and not related to the plan, Regence BlueShield, WSRxS, or HCA. An IRO is intended to provide unbiased, independent clinical and benefit expertise, as well as evidence-based decision making while ensuring confidentiality. The IRO reviews your appeal to determine if the plan’s decision is consistent with state law and the applicable COC. The plan pays the IRO’s charges. See “External review (independent review)” on page 129. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 177