For UMP 2025 premiums, visit the Health Care Authority (HCA) website for retirees.
This plan and Medicare are two separate health plans that work together to pay for covered services and supplies. Here is how coordination of benefits generally works:
- Your provider bills Medicare. Medicare pays your claims first. After Medicare processes the claim, Medicare sends the claim to UMP.
- UMP pays your claims second. For most covered services, UMP pays the rest of the Medicare allowed amount and you owe $0.
Each calendar year, you must meet your UMP medical deductible before UMP starts paying benefits. These rules are explained in full in the UMP Classic Medicare with Part D (PDP) certificate of coverage.
Your UMP Classic Medicare with Part D (PDP) certificate of coverage is available online. For general topics, check the table of contents. For an overview of the most common benefits, see the “Summary of benefits” section. The summary also shows:
- How much you will pay.
The page numbers where you may learn more about a benefit.
To look up unfamiliar terms, see the “Definitions” section.
A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying for covered services.
The medical deductible amount is $250 per member, with a maximum of $750 per family. When you first get services, you pay the first $250 in charges. After you pay that first $250, the plan begins to pay for covered services. This applies to each covered member, up to the $750 maximum.
If your family has four or more members enrolled, each member has a medical deductible of $250 and the maximum the family pays toward medical deductibles is $750. Once a member pays their $250 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward the family deductible. Once the family deductible has been met, the plan begins paying for all covered services for all enrolled family members, even if some have not met their own deductible.
UMP will transfer certain medical accumulators, such as deductibles and out-of-pocket limits, for the existing plan year when subscribers and their enrolled dependents change plans during a special open enrollment and enroll in another UMP plan. This applies only to subscribers who remain the subscriber, and to enrolled dependents who change plans with the subscriber.
The following out-of-pocket expenses do not count toward your $250 medical deductible:
- Charges for services that exceed the benefit limit.
- Charges that exceed the maximum dollar limit
- Out-of-network provider charges above the allowed amount
- Prescription drugs covered under Medicare Part D
- Services that are not subject to your medical deductible, even if you had out-of-pocket costs. For example, covered preventive care received from an out-of-network provider.
- Services you pay for that are not covered by the plan
- Your emergency room copay
- Your inpatient hospital copay
- Your chiropractor copay
- Your acupuncture copay
- Your massage therapy copay
The plan pays the allowed amount for services (subject to cost-share) listed below even if you have not met your medical deductible. When you see a preferred or participating provider, you do not have to meet your medical deductible before the plan pays for these services:
- Covered contraceptive supplies and services
- Covered preventive care services, including covered immunizations
- Prescription drugs covered under Medicare Part D
- Routine hearing exams
- Hearing aids
- Routine vision care; exams, glasses, and contacts
- Second opinions required by the plan
- Covered screening mammograms and medically necessary diagnostic and supplemental breast exams
Coinsurance is the percentage of the allowed amount that you pay for most medical services when the plan pays less than 100%.
After you meet your medical deductible, you pay the percentages described below for most covered medical services:
- For preferred providers: You pay 15% of the allowed amount. The plan pays most covered services at 85% of the allowed amount.
- For participating providers: You pay 40% of the allowed amount. The plan pays most covered services at 60% of the allowed amount.
- For out-of-network providers: You pay 40% of the allowed amount, and the provider may balance bill you. The plan pays most covered services at 60% 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.
When you receive emergency services at an out-of-network facility you pay the network rate regardless of the network status of the provider or facility and cannot be balance billed.
When you receive covered ground or air ambulance services in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider.
A copay is a set dollar amount you pay when you receive services, treatments, or supplies, including, but not limited to:
- Emergency room copay: $75 per visit
- Facility charges for services received while an inpatient at a preferred hospital, or mental health, skilled nursing, or substance use disorder facility: $200 per day up to a maximum of $600 per enrolled member per admission
- 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.
Read the copay section of your UMP Classic Medicare with Part D (PDP) certificate of coverage for more information.
The medical out-of-pocket limit is the most you pay during a calendar year for covered services from preferred providers. After you meet your medical out-of-pocket limit for the year, the plan pays for covered services by preferred providers at 100% of the allowed amount. The plan will not pay more than the allowed amount. Expenses are counted from January 1, 2025, or your first day of enrollment (whichever is later), through December 31, 2025, or your last day of enrollment (whichever is earlier). Your medical deductible and coinsurance paid to preferred and participating providers, inpatient and emergency room copays and chiropractic, acupuncture and massage therapy copays to preferred providers all count toward your medical out-of-pocket limit.
Your medical out-of-pocket limit is $2,500 per member and $5,000 per family*.
*"Family" is defined as all eligible family members (subscriber and dependents) who are enrolled on a single account.
- Amounts paid by the plan, including services covered in full
- Costs you pay under the Medicare Part D prescription drug benefit including the prescription drug deductible and copay
- Amounts paid by Medicare
- Your monthly premiums
- Your coinsurance paid to out-of-network providers and your coinsurance and copayments paid to non-network pharmacies
- Balance billed amounts
- Amounts paid for services the plan does not cover
- Amounts that are more than the maximum dollar amount paid by the plan. Any amount you pay over the allowed amount does not count toward the medical out-of-pocket limit.
- Amounts paid for services over a benefit limit. For example, the benefit limit for acupuncture is 24 visits. If you have more than 24 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit.
When services are covered by Medicare, you must see providers who accept Medicare for the services to be covered by Medicare and the UMP Classic Medicare with Part D (PDP) plan. If your provider is not contracted with Medicare or has chosen to “opt out” of participating in Medicare, this plan will not cover services by that provider, even if the provider is in the Regence or Blue Card network (preferred).
For benefits not covered under Medicare but covered under your UMP Classic Medicare with Part D (PDP), you’ll pay less when you see a preferred provider for these services. The amount you pay for services depends on the network status of the provider. Visit the UMP provider search to find a provider.