2009 Summary of Benefits
See also: 2010 Summary of Benefits
This summary of benefits does not include all benefit limitations or special requirements. Also, copayments, coinsurance, and deductibles (both medical and prescription drug) must be satisfied (except as indicated with an *) before the plan pays benefits. Please refer to the UMP 2009 Certificate of Coverage for details.
| Benefits*** | UMP pays network providers (percentage of UMP allowed amount) | UMP pays** non-network providers (percentage of UMP allowed amount) | Preauthorization required? |
|---|---|---|---|
* Not subject to the annual medical deductible. ** Your enrollee coinsurance for services from non-network providers does not count towards your annual medical out-of-pocket limit, unless UMP pays the claim at the out-of-area rate. You must pay the provider's charges over UMP's allowed amount. *** Several exclusions listed in "What UMP Doesn't Cover" may apply to all benefits. Please review carefully. |
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| Acupuncture 16 treatments max/year | 90% | 60% | No |
| Ambulance Air and ground | Does not apply (no network providers) | 80% | No |
| Biofeedback Therapy Mental Health coverage limits apply if used for mental health treatment |
90% | 60% | No |
| Chemical Dependency Treatment UMP pays up to $14,500 per consecutive 24 calendar months for inpatient and outpatient treatment combined | |||
| • Inpatient Facility services Doctors and other professionals may bill separately for their services |
100% after you pay $200 copay/day; $600 max copay/person/year | 60% | No |
| Professional Services | 90% | 60% | No |
| • Outpatient | 90% | 60% | No |
| Diabetes Education | 90% | 60% | No |
| Diagnostic Tests, Laboratory, and X-Rays (outpatient) | 90% | 60% | Certain services |
| Dialysis | 90% | 60% | No |
| Durable Medical Equipment, Supplies, and Prostheses | 90% | 60% | Yes, for rentals over 3 months and purchases over $1,000 |
| Emergency
Room (ER) You do not have to pay the ER copay if admitted to the hospital directly from the ER. If the patient the didn't have access to network providers, UMP pays at the out-of-area rate (80%). |
No | ||
| • Facility | You pay $75 copay/visit; UMP pays 90% of remaining amount | You pay $75** copay/visit; UMP pays 60% of remaining amount | |
| •Professional | 90% | 60% at a non-network hospital | |
| Hearing Exams & Hearing Aids* | No | ||
| • Exams, routine | 100% once per calendar year | 60% once per calendar year | |
| • Hearing aids | $800 max plan payment every 3 calendar years | $800 max plan payment every 3 calendar years | |
| Home Health Care | 90% | 60% | Yes, for some services |
| Hospice Care Six months maximum benefit; must be preauthorized |
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| • Inpatient | 100% | 60% | Yes |
| • Respite care $5,000 lifetime max |
100% | 60% | Yes |
| Hospital Services | |||
| • Inpatient | |||
| Facility services Doctors and other professionals may bill separately for their services |
100% after you pay $200 copay/day; $600 max copay/person/year | 60% | Some services; see "Physical, Occupational, and Speech, Therapy" |
| Professional services See important information about hospital-based physicians |
90% | 60% | No |
| • Outpatient | 90% | 60% | No |
| Mammograms | |||
| • Screening mammograms* (beginning at age 40, once per calendar year) | 100% | 60% | No |
| • Diagnostic mammograms | 90% | 60% | No |
| Massage Therapy 16 visits max/year | 90% | Not applicable; massage therapists must be network providers to be covered | No, but must be prescribed by diagnosing provider |
| Mastectomy and Breast Reconstruction | 90% | 60% | No |
| Mental Health Treatment | |||
| • Inpatient: Facility services Doctors and other professionals may bill separately for their services |
100% after you pay $200 copay/day; $600 max copay/person/year | 60% | Yes |
| Professional services | 90% | 60% | No |
| • Outpatient: 50 visits max/year | 90% | 60% | No |
| Naturopathic Physician Services | 90% | 60% | No |
| Neurodevelopmental Therapy See "Physical, Occupational, Speech, and Neurodevelopmental Therapy" | |||
| Obstetric and Newborn Care | |||
| • Inpatient | |||
| Facility services | 100% after you pay $200 copay/day; $600 max copay/person/year (No copay for routine newborn nursery care) | 60% | No |
| Professional services | 90% | 60% | No |
| • Outpatient | 90% | 60% | No |
| Office Visits | 90% | 60% | No |
| Out-of-Area Care This is care received in locations without access to network providers |
Does not apply | 80% | Varies by service/supply |
| Outpatient Surgery | 90% | 60% | No |
| Physical, Occupational, Speech, and Neurodevelopmental Therapy | |||
| • Inpatient: 60 visits max/year for all types of therapy combined | 100% after you pay $200 copay/day; $600 max copay/person/year | 60% | Yes |
| • Outpatient: 60 visits max/year for all types of therapy combined | 90% | 60% | No |
| Prescription Drugs* See Prescription Drug Benefits for information on prescription drug coverage |
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| Preventive Care* See lists of covered services. |
100% | 60% | No |
| Skilled Nursing Facility (see important information regarding Medicare coverage) |
100% after you pay $200 copay/day; $600 max copay/person/year | 60% | Yes |
| Spinal and Extremity Manipulations 10 visits max/year |
90% | 60% | No |
| Tobacco Cessation Program* Free & Clear program only | 100% | Not covered | No |
| Transplants | |||
| • Inpatient | |||
| Facility services | 100% after you pay $200 copay/day; $600 max copay/person/year | 60% | Yes |
| Professional services | 90% | 60% | Yes |
| • Outpatient | 90% | 60% | Yes |
| Vision Care* | |||
| • Eye exams (routine) One exam per calendar year |
90% | 60% | No |
| • Vision hardware Including frames, lenses, contact lenses, and fitting fees combined |
$150 max plan payment every two calendar years | $150 max plan payment every two calendar years | No |
| Well-Baby
Preventive Care Services* See specific services covered under "Preventive Care" |
100% | 60% | No |
