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For Medicare Retirees: See "I'm a Medicare retiree; should I see a UMP network provider?"
Network providers have contracted directly with UMP (or are part of a network that has contracted with the UMP) to render services to UMP enrollees at a reduced rate. In Washington State and the Idaho counties of Bonner, Kootenai, Latah, and Nez Perce, use the UMP network. For services received in all other states, use the Beech Street network to receive network benefits.
While you may receive coverage for services performed by any approved provider type, there are a lot of good reasons to use a network provider, such as:
- The plan pays 85% for most network services, after you pay your medical deductible.
- The plan pays 100% for covered preventive care services when you see a network provider. You don’t have to pay a deductible or coinsurance.
- A network provider won’t bill you for more than the allowed amount.
- You won’t have to file a claim if the plan is your primary coverage.
Note: You will have to pay for services or supplies that exceed benefit limits or are not covered, even if you see a network provider.
ALERT! Some providers are in the UMP network at one practice location but not another. If you are seeing a provider at a new or different location than usual, make sure he or she is a network provider at the alternate location as well. If you see a provider at a non-network location, the plan pays for the services as non-network, even if the provider is network elsewhere.
Non-network providers are providers who do not contract with UMP. When you see a non-network provider:
- The plan pays only 60% of the allowed amount to non-network providers. The allowed amount is the amount network providers agree to accept as payment in full. Non-network providers can charge more than the allowed amount. You will pay 40% of the allowed amount plus the amount above the plan’s allowed amount.
- You still have to meet your medical deductible before the plan begins to pay. Any amount you pay above the plan’s allowed amount does not count toward your medical deductible.
- In most cases, any money you pay to a non-network provider won’t count toward your medical out-of-pocket limit.
- You may have to pay upfront and send the claim to the plan yourself.
In some instances, non-network providers may be paid at a higher rate (80% of the allowed amount) if you do not have access to a network provider in your area. This is called "out-of-area" reimbursement. Since these providers are not in the UMP network, they can bill you for charges that are above the allowed amount.
- In the Idaho counties of Bonner, Kootenai, Latah, and Nez Perce, providers who do not contract with UMP are paid at 80% of the allowed amount. (See “Does UMP have network providers outside of Washington?” for more about network providers in Idaho.)
- When a provider is paid as "out-of-area," the amount you pay does apply to your medical out-of-pocket limit.
- When Medicare is the primary payer, all services provided outside of Washington State and the four Idaho counties listed above will be paid at the out-of-area rate.
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