Type of service How much you pay for covered How much the plan pays for covered services services • Out-of-network facilities: You pay 40% of the allowed amount. The provider may balance bill you. • Fees for professional services, such as, but not limited to, provider consultations or lab tests. How much you pay for professional services depends on the provider’s network status: • Preferred providers: You pay 15% of the allowed amount. The provider cannot balance bill you. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. Outpatient If you receive services at a facility that • Preferred providers: The plan pays offers inpatient services (like a hospital) 85% of the allowed amount. but you are not admitted, the services are • Participating providers: The plan covered as outpatient. See the specific pays 60% of the allowed amount. benefit (e.g., emergency room or • Out-of-network providers: The plan diagnostic tests) for how much you pay. pays 60% of the allowed amount. You may be billed separately for facility fees in addition to provider fees. • Preferred providers: You pay 15% of the allowed amount. The provider cannot balance bill you. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. 2024 UMP CDHP (PEBB) Certificate of Coverage 33