Dialysis Support network provider type: You must use a UMP Plus–PSHVN provider or a covered provider within the support network to receive network level benefits (see description in the “Support network providers” section). Inpatient Dialysis You pay the standard rate for covered inpatient dialysis services. The plan pays based on the allowed amount and the network status of the provider. Other professional providers may bill separately from the facility. Outpatient Dialysis and Supplemental Kidney Dialysis During your initial outpatient treatment period of three months (42 treatments of hemodialysis or 30 days of peritoneal dialysis), you pay the standard rate for covered outpatient dialysis services. Once the supplemental treatment period begins, you pay the special rate (0% of the allowed amount) for covered outpatient dialysis services. You will also be eligible for Medicare Part B coverage. Our care managers can help you apply for Medicare Part B. To reach a care manager, call UMP Customer Service. Once enrolled in Medicare Part B, you are eligible to get your Medicare Part B premiums reimbursed by the plan as long as you remain enrolled in Medicare Part B and are eligible under this plan. Proof of payment of your Medicare Part B premiums is required for reimbursement. If you are not enrolled in Medicare Part B and you receive outpatient dialysis from an out-of-network provider, you may be balance billed. Durable medical equipment (DME), supplies, and prostheses TIP: The plan pays for covered DME at the standard rate. To receive the highest benefit, you must get the equipment or supply from a network DME supplier or other network medical provider. To find network DME providers, see the “Finding a network DME supplier” section below. You pay the standard rate for covered DME services and supplies if they are prescribed by a provider practicing within their scope of practice, medically necessary, and used to treat a covered condition, including, but not limited to: • Artificial limbs or eyes (including implant lenses prescribed by a physician and required due to cataract surgery or to replace a missing portion of the eye). • Automatic Positive Airway Pressure (APAP) devices and related supplies. • Bi-level Positive Airway Pressure (BiPAP) devices and related supplies. • Bone growth (osteogenic) stimulators. • Breast prostheses and bras as required by mastectomy. See the “Mastectomy and breast reconstruction” benefit. • Breast pumps for pregnant and nursing members (see “Services covered as preventive” on page 65). • Casts, splints, crutches, trusses, and braces. 52 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage