UW Medicine ACN

185 Pages·2017·2.25 MB·English

by  Sarah Rolph

2018 UMP Plus
Certificate of Coverage
UW Medicine Accountable Care Network
Self-Insured by the State of Washington · Effective January 1, 2018
Printed under the direction of the Washington State Health Care Authority Public Employees Benefits Board
HCA 57-231 (11/17)
Directory
UW Medicine Accountable Care 1-855-520-9500 (TRS: 711)
Network: Contact Center Monday–Friday: 6:30 a.m. to 8 p.m. Pacific Time (PT)
Find network providers Saturday: 7 a.m. to 8 p.m. PT
Sunday: 8 a.m. to 5 p.m. PT
www.uwmedicine.org/umpplus
UMP Customer Service 1-888-849-3681 (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. PT
Medical: claims, what the plan Saturday: 8 a.m. to 4:30 p.m. PT
covers
Regence provider directory Use the Provider Search at 24 hours, 7 days a week
See descriptions in the “Finding www.hca.wa.gov/ump
a health care provider” in this
Call 1-888-849-3681 (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. PT
section.
Saturday: 8 a.m. to 4:30 p.m. PT
Live chat via www.regence.com Monday-Friday: 7 a.m. to 5 p.m. PT
Medical appeals, grievances, Uniform Medical Plan Fax [phone]
and general correspondence Attn: Appeals and Grievances
PO Box 2998
Tacoma, WA 98401-2998
Preauthorization Providers call 1-888-849-3682 Fax [phone]
(medical services)
Online access to medical claims Your account at www.regence.com
Claims mailing address Regence BlueShield Fax [phone]
(medical services; member PO Box 1106
submitted) Lewiston, ID 83501-1106
Prescription drugs Washington State Rx Services 1-888-361-1611 (TRS: 711)
(customer service, network See end of prescription drug section
pharmacies, preferred drug for more detailed contact
questions, complaints) information.
Network mail-order pharmacy Postal Prescription Services (PPS) 1-800-552-6694
Paper claims Washington State Rx Services 1-888-361-1611 (TRS: 711)
Prescription drug appeals PO Box 40168 Fax claims 1-800-207-8235
Portland, OR 97240-0168 Fax appeals 1-866-923-0412
Drug preauthorization Washington State Rx Services 1-888-361-1611 (TRS: 711)
Providers and pharmacists only Fax [phone]
Online access to prescription Find a link to your pharmacy account at
drug claims www.hca.wa.gov/ump/log-your-accounts
Eligibility and enrollment, Employees: All other members:
address changes Contact your personnel, PEBB Program
payroll, or benefits office 1-800-200-1004 (TRS: 711)
www.hca.wa.gov/pebb Monday–Friday: 8 a.m. to 5 p.m. PT
Tobacco cessation Quit for Life www.quitnow.net/ump
See “Tobacco cessation 1-866-784-8454
services” in the Benefits: what the Monday–Friday: 8 a.m. to 6 p.m. PT
plan covers section for detailed
information.
To obtain this booklet in another format (such as Braille or audio), call 1-888-849-3681 (TRS: 711).
How to use this book
For general topics, check the Table of contents.
For an overview of the most common benefits, see the “Summary of benefits” (pages 27–42). The
table also shows how much you will pay, any limits on the benefit (such as number of visits or
dollar amount), whether preauthorization or notification is required, and the page numbers
where you can find more about that benefit.
To look up unfamiliar terms, see the “Definitions” section beginning on page 162.
Helpful symbols
The symbols below provide important information you may find useful as you read.
TIP: Indicates information that may be helpful in understanding a subject.
FOR MORE INFORMATION: Refers you to information found elsewhere.
ALERT! Important information you should know or something you need to do.
If you still have questions
If you have a specific question for which you can’t find the answer:
 Use our online search function at www.hca.wa.gov/ump.
 Call UMP Customer Service at 1-888-849-3681 (TTY: 711) Monday through Friday, 5 a.m. to 8
p.m. and Saturday 8 a.m. to 4:30 p.m. Pacific Time.
See the Directory page on the inside front cover of this document for more contact information.

UMP Plus 2018 Certificate of Coverage, UW Medicine Accountable Care Network 1
Table of contents
About UMP Plus --------------------------------------------------------------------- 8
Why create UMP Plus? ................................................................................................ 8
Online services ........................................................................................................... 8
Finding a health care provider -------------------------------------------------- 10
Your UMP Plus-UW Medicine Accountable Care Network ......................................... 10
How to find a network provider ................................................................................. 11
Network primary care providers ..........................................................................................1 2
Network specialty providers ...............................................................................................1 2
Ancillary providers ............................................................................................................. 13
Network facilities ............................................................................................................... 13
Other providers ..................................................................................................................1 4
Out-of-network providers ...................................................................................................1 4
Covered provider types .............................................................................................. 14
How much will I pay? ................................................................................................. 15
Why choose providers in the core network? .........................................................................1 6
Disadvantages of using out-of-network providers ............................................................... 16
Sample payments to different provider types ...................................................................... 17
Network consent for out-of-network services ........................................................... 18
Services received outside the service area ................................................................. 19
What you pay for medical services -------------------------------------------- 22
Deductible ................................................................................................................ 22
If you qualified for the SmartHealth wellness incentive ...................................................... 22
Coinsurance .............................................................................................................. 24
Copayment ............................................................................................................... 24
When do I pay? ......................................................................................................... 24
Medical out-of-pocket limit ...................................................................................... 25
Summary of payment ------------------------------------------------------------ 27
Deductibles and limits ............................................................................................... 27
Types of services ...................................................................................................... 28
Benefits: what the plan covers ------------------------------------------------- 30
Guidelines for coverage .............................................................................................3 0
Health Technology Clinical Committee (HTCC) ......................................................... 30

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What is the HTCC? ............................................................................................................ 30
How does HTCC affect my UMP benefits? .......................................................................... 31
Where do I find HTCC decisions? ........................................................................................ 31
List of HTCC decisions ....................................................................................................... 31
Summary of benefits ................................................................................................. 34
List of Benefits .......................................................................................................... 43
Acupuncture ...................................................................................................................... 43
Ambulance ........................................................................................................................ 43
Applied Behavior Analysis (ABA) Therapy .......................................................................... 44
Autism treatment .............................................................................................................. 44
Bariatric surgery ................................................................................................................ 45
Breast health screening tests ............................................................................................. 45
Chemical dependency treatment ....................................................................................... 46
Chiropractic physician services ........................................................................................... 47
Dental services .................................................................................................................. 47
Diabetes care supplies ....................................................................................................... 49
Diabetes Control Program ................................................................................................. 50
Diabetes education ............................................................................................................ 50
Diabetes Prevention Program ............................................................................................ 50
Diagnostic tests, laboratory, and x-rays ............................................................................. 51
Dialysis ............................................................................................................................. 52
Durable medical equipment, supplies, and prostheses ........................................................ 52
Emergency room ............................................................................................................... 54
End-of-life counseling ........................................................................................................ 54
Family planning services .................................................................................................... 54
Foot care, maintenance ..................................................................................................... 56
Genetic services................................................................................................................. 56
Headaches ........................................................................................................................ 57
Hearing care (diseases and disorders of the ear) ................................................................. 57
Hearing exams and hearing aids ........................................................................................ 57
Home health care .............................................................................................................. 58
Hospice care (inpatient, outpatient, and respite care) ......................................................... 59
Hospital services ............................................................................................................... 60
Knee arthroplasty .............................................................................................................. 61
Mammograms ................................................................................................................... 61
Massage therapy ............................................................................................................... 62
Mastectomy and breast reconstruction .............................................................................. 62
Mental health treatment ................................................................................................... 63
Naturopathic physician services ......................................................................................... 63
Nutrition counseling and therapy ....................................................................................... 64
Obstetric and newborn care ............................................................................................... 64

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Office visits ....................................................................................................................... 66
Orthognathic surgery ........................................................................................................ 66
Physical, occupational, speech, and neurodevelopmental therapy ...................................... 67
Prescription drugs .............................................................................................................. 67
Preventive care ................................................................................................................. 68
Second opinions ................................................................................................................. 70
Skilled nursing facility ........................................................................................................ 70
Spinal and extremity manipulations ................................................................................... 71
Spinal injections ................................................................................................................. 71
Surgery .............................................................................................................................. 71
Telemedicine services ......................................................................................................... 72
Temporomandibular Joint (TMJ) Treatment ........................................................................ 73
Tobacco cessation services ................................................................................................. 73
Transgender health ............................................................................................................ 75
Transplants ....................................................................................................................... 76
Urgent care ........................................................................................................................ 76
Vision care (diseases and disorders of the eye) .................................................................... 76
Vision exams (routine) ........................................................................................................ 77
Vision hardware (eyeglasses and contact lenses) ................................................................ 77
Your prescription drug benefit ------------------------------------------------- 78
What drugs are covered? The UMP Preferred Drug List ............................................ 78
How much will I pay for prescription drugs? .............................................................. 79
Your prescription drug out-of-pocket limit .......................................................................... 80
What you pay for prescription drugs .................................................................................. 80
Requesting preauthorization for an exception to the Tier 3 drug cost-share ......................... 82
If you have other medical coverage .....................................................................................8 3
Where to purchase your prescription drugs .............................................................. 84
Guidelines for drugs UMP covers ............................................................................... 87
Exceptions covered ............................................................................................................ 87
Products covered under the preventive care benefit ........................................................... 88
Some injectable drugs are covered only under the prescription drug benefit ........................ 89
Compounded prescription drugs ........................................................................................ 89
Limits on your prescription drug coverage ............................................................... 89
Programs limiting drug coverage ....................................................................................... 90
Can the pharmacist substitute one drug for another? .......................................................... 93
Travel overrides for prescription drugs ............................................................................... 94
Refill too soon ................................................................................................................... 94
What can I do if coverage is denied? ......................................................................... 94
Guidelines for drugs UMP does not cover ................................................................. 95

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Prescription drug contacts ........................................................................................ 96
Limits on plan coverage ---------------------------------------------------------- 97
Preauthorizing medical services ................................................................................ 97
Your preauthorization role ................................................................................................. 97
Where can I find the list of services requiring preauthorization or notification?..................... 98
Notification for facility admissions ..................................................................................... 98
What is the difference between preauthorization and notification? ..................................... 98
How long does the plan have to make a decision? ............................................................... 99
General information from customer service is not a guarantee
that a service is covered ............................................................................................ 99
Case management .................................................................................................. 100
What the plan doesn’t cover --------------------------------------------------- 101
If you have other medical coverage ----------------------------------------- 109
Coordination of benefits ......................................................................................... 109
Whom do I inform if I have other coverage? ............................................................ 109
Who pays first? ........................................................................................................ 110
When UMP Plus pays first ........................................................................................ 111
How UMP Plus coordinates benefits when it pays second ....................................... 111
How does coordination of benefits work with prescription drugs? ........................... 113
Does UMP coordinate with occupational injury or illness
(workers’ compensation) claims? ............................................................................ 114
Billing & payment: filing a claim----------------------------------------------- 115
Submitting a claim for medical services ...................................................................115
Submitting a claim for prescription drugs ................................................................ 117
False claims or statements ...................................................................................... 118
What you need to know: your rights and responsibilities --------------- 119
Information available to you ................................................................................... 120
Confidentiality of your health information .............................................................. 122
How to designate an authorized representative ................................................................ 122
Release of information ............................................................................................ 122
Complaint and appeal procedures -------------------------------------------- 123
What is a complaint or grievance? ........................................................................... 123
How to file a complaint or grievance ................................................................................ 123
What is an appeal? .................................................................................................. 124

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The appeals process ................................................................................................ 124
Complaints about quality of care ............................................................................. 129
Appeals related to eligibility .................................................................................... 129
When another party is responsible for injury or illness ------------------- 130
What are my and the plan’s legal rights and responsibilities? .................................. 130
Services covered by other insurance ........................................................................ 132
Motor vehicle coverage ........................................................................................... 132
Fees and expenses ................................................................................................... 132
Future medical expenses ......................................................................................... 132
Eligibility and enrollment for active employees --------------------------- 133
Eligibility .................................................................................................................. 133
Eligible employees ........................................................................................................... 133
Eligible dependents .......................................................................................................... 133
Enrollment ............................................................................................................... 135
How to enroll ................................................................................................................... 135
When medical enrollment begins ...................................................................................... 136
Annual open enrollment ................................................................................................... 137
Special open enrollment ................................................................................................... 137
National Medical Support Notice (NMSN) ......................................................................... 141
Medicare entitlement ....................................................................................................... 142
When medical coverage ends ........................................................................................... 142
Options for continuing PEBB medical coverage ...................................................... 143
Family and Medical Leave Act of 1993 ..................................................................... 144
Payment of premiums during a labor dispute .......................................................... 144
Conversion of coverage ........................................................................................... 144
Appeals of determinations of PEBB eligibility ......................................................... 145
Relationship to law and regulations ......................................................................... 145
Eligibility and enrollment for retirees and surviving dependents ------ 146
Eligibility ..................................................................................................................1 46
Eligible dependents .......................................................................................................... 146
Enrollment ............................................................................................................... 148
Deferring enrollment in PEBB retiree coverage .................................................................. 148
How to enroll ................................................................................................................... 149
When medical coverage begins ......................................................................................... 150
Enrollment following deferral ........................................................................................... 151

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Annual open enrollment .................................................................................................. 151
Special open enrollment .................................................................................................. 152
Medicare entitlement ............................................................................................. 154
Medicare Part A and Medicare Part B ............................................................................... 154
Medicare Part D .............................................................................................................. 155
When Medical Coverage Ends ................................................................................. 155
Options for continuing PEBB medical coverage ...................................................... 156
Conversion of coverage ............................................................................................ 157
Appeals of determinations of PEBB eligibility .......................................................... 157
Relationship to law and regulations ......................................................................... 157
Customer service ..................................................................................................... 157
General provisions -------------------------------------------------------------- 158
Definitions ------------------------------------------------------------------------ 162

UMP Plus 2018 Certificate of Coverage, UW Medicine Accountable Care Network 7
About UMP Plus
UMP Plus is a self-insured health plan offered through the Washington State Health Care
Authority’s Public Employees Benefits Board (PEBB) Program. The plan is administered by
Regence BlueShield and Washington State Rx Services. All prescription drugs, services, or other
benefit changes may require approval by the PEB Board at the time of procurement of benefits for
the next calendar year.
UMP Plus is available only to people eligible for coverage through the PEBB Program, including
employees and non-Medicare retirees of state government and higher-education institutions,
school district non-Medicare retirees, and employees of certain local governments and school
districts that participate in the PEBB Program, as well as their eligible dependents.
Only those who live in the following Washington State counties are eligible to enroll in UMP
Plus–UW Medicine Accountable Care Network (UW Medicine ACN) for 2018: Grays Harbor, King,
Kitsap, Pierce, Skagit, Snohomish, and Thurston.
UMP Plus covers health care services delivered through a network of providers. UW Medicine
ACN delivers these services through a network of primary care providers, specialty care providers,
ancillary providers, clinics, and hospitals.
UMP Plus is a “non-grandfathered health plan” under the Patient Protection and Affordable Care
Act (PPACA).
Why create UMP Plus?
Accountable Care Networks, like UMP Plus, were established to promote high-quality care at a
lower cost. The Health Care Authority designed UMP Plus to help providers achieve those goals
while allowing members to choose their own providers in the network.
Providers who join UMP Plus agree to be accountable for delivering and evaluating the quality of
your care. When you receive preventive care and coordinated treatment, the overall cost of that
care is lower. These cost savings help keep your premium and deductible lower without limiting
necessary care.
Online services
You can access plan information online at the UMP website, the Health Care Authority (HCA)
website, the Regence website, and your UW Medicine ACN website.
Visit the UMP website at www.hca.wa.gov/ump to:
 Review complaints and appeals procedures.
 Access UMP medical policies.
 Find network providers.
 Find a network pharmacy.
 Find out what your prescription will cost.
 Order prescription refills through your mail-order pharmacy account.
 Download or print documents and forms.
 Find your certificate of coverage.

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