• For out-of-network providers: You pay 40 percent of the allowed amount, and the provider may balance bill you. The plan pays most covered services at 60 percent of the allowed amount. Professional charges, such as for physician services while you are in the hospital or lab work, may be billed separately. Note: When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections. At an out-of-network facility, 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. Copay A copay is a set dollar amount you pay when you receive treatments, supplies, or services including, but not limited to: • Emergency room copay: $75 per visit. See the “Emergency room” benefit for details. • Facility charges for services received while an inpatient at a hospital, or mental health, skilled nursing, or substance use disorder facility: $200 per day (see “Inpatient copay” below). • Covered chiropractic, acupuncture, and massage services when you see a preferred provider will have a $15 copay per visit. The copay for these services will apply toward the annual out-of-pocket maximums. See the “Spinal and extremity manipulations” benefit, “Acupuncture” benefit, and “Massage therapy” benefit for more details. Inpatient copay FOR MEDICARE RETIREES: The maximum inpatient copay is $600 per facility admission up to your medical out-of-pocket limit. The inpatient copay of $200 per day is what you pay for inpatient services at a preferred facility, such as a hospital, or mental health, skilled nursing, or substance use disorder facility. You and your enrolled dependents pay up to $600 maximum per enrolled member per calendar year. The inpatient copay does not apply to your medical deductible but does apply to your medical out-of- pocket limit. Note: Professional charges, such as lab work or provider services, while you are in the hospital may be billed separately and are not included in this copay. When you pay Most of the time, you pay after your claim is processed. • You will receive an Explanation of Benefits (EOB) from the plan that explains how much the plan paid the provider. The Member Responsibility section of your EOB tells you how much you owe the provider. • The provider sends you a bill. • You pay the provider. 26 2024 UMP Classic (PEBB) Certificate of Coverage