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. Inter-Plan Programs: Federal or state taxes, surcharges, or fees Federal law or state law may require a surcharge, tax or other fee that applies to self-insured accounts. If applicable, any such surcharge, tax or other fee will be included as part of the claim fee passed on to the claimant. Out-of-network providers outside Regence’s service area Member liability When covered services are provided outside of Regence’s service area by out-of-network providers, the amount you pay for such services will generally be based on either the Host Blue’s out-of-network provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be liable for the difference between the amount that the out-of-network provider bills and the payment Regence will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for nonparticipating emergency services. Exceptions In certain situations, Regence may use other payment bases. such as billed covered charges, the payment Regence would make if the health care services had been obtained within Regence’s service area, or a special negotiated payment, to determine the amount Regence will pay for services rendered by out-of- network providers. In these situations, you may be liable for the difference between the amount that the out-of-network provider bills and the payment Regence will make for the covered services as set forth in this paragraph. 26 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage