When you receive nonemergency services from an out-of-network provider at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center, you pay the network rate and cannot be balance billed for services performed in Washington State or without your informed consent in states that allow you to waive the federal balance billing protections. When you receive emergency services you pay the network cost-sharing amount regardless of the network status of the provider or facility and cannot be balance billed. Mental health The plan covers mental health services for members with neuropsychiatric and mental health conditions. Marriage or family counseling is not covered. The amount the plan pays depends on the provider’s network status (see the “Finding a health care provider” section and page 30). See below for details about coverage for substance use disorder treatment. Inpatient ALERT! Your provider must notify the plan as soon as possible after you are admitted to a facility, but not later than 24 hours after you are admitted when you receive inpatient services. If the plan is not notified of inpatient treatment, the plan may not cover the treatment. Inpatient treatment is subject to clinical review. Services are considered inpatient when you are admitted to a facility. This may include either psychiatric inpatient hospitalization or care at a residential treatment facility. The plan must preauthorize non- emergency inpatient services. See the “Limits on plan coverage” section for details. Your provider must notify the plan as soon as possible after you are admitted to a facility, but no later than 24 hours after you are admitted to a: • Hospital • Residential treatment facility Contact UMP Customer Service about preauthorization requirements. Visit UMP Policies that affect your care webpage for a list of services that require plan notice. See Directory for link and contact information. You pay an inpatient copay for facility charges at a preferred facility (see the “Copay” section). Professional services (for example, doctors) may be billed separately from the facility charges. The plan pays the inpatient rate unless it is for emergency services. All covered professional services are paid based on the allowed amount. FOR MEDICARE RETIREES: The inpatient copay is $200 per day, with a maximum of $600 per inpatient admission, up to the medical out-of-pocket limit. Outpatient ALERT! See page 38 for preauthorization requirements related to Applied Behavior Analysis (ABA) Therapy services. 40 2024 UMP Classic (PEBB) Certificate of Coverage