UMP Plus – Puget Sound High Value Network FAQ

Frequently Asked Questions

 

What is UMP Plus – Puget Sound High Value Network?

Uniform Medical Plan (UMP) is a health plan offered to eligible Washington state public employees (active and retired), Leave Without Pay members, non-Medicare retirees or COBRA members. In 2017, UMP is offering eligible state employees access to two Accountable Care Programs (ACPs), one of which is UMP Plus – Puget Sound High Value Network (PSHVN).

UMP Plus – PSHVN is a group of eight industry-leading medical organizations — Edmonds Family Medicine, EvergreenHealth Partners, MultiCare Connected Care, Overlake Medical Center, Rockwood Health System, Seattle Children’s, SignalHealth and Virginia Mason — that are collectively committed to serving as your coordinated provider network and providing excellent customer service in Grays Harbor, King, Kitsap, Pierce, Snohomish, Spokane, Thurston and Yakima counties. In addition to these participating organizations, Capital Medical Center in Olympia is designated as a network hospital for Thurston County. This means all hospital services received at Capital Medical Center will be covered at the higher network level.

Supported by Regence, UMP Plus – PSHVN connects PEBB program members to high-quality primary and specialty care close to where people live and work. Our commitment is to provide you and any covered dependents with easy access to the right provider at the right time.

What is an Accountable Care Program (ACP)?

An ACP is a group of health care providers — including primary care physicians and specialists at hospitals and clinics — that work together collaboratively and accept collective accountability for the quality and cost of care delivered to a specific population of patients. An ACP can be formed around a variety of existing provider organizations, multispecialty groups, hospitals, emergency departments, trauma centers, urgent care clinics, etc.

What are the goals of the ACP?

The ACP supports UMP Plus – Puget Sound High Value Network’s (UMP Plus – PSHVN) mission of providing patients access to the most comprehensive health care network in Washington state. By creating an ACP with leading health care organizations throughout Washington state, which includes a full range of health care services from preventive and primary to highly specialized care, UMP Plus – PSHVN provides patients with increased access to high-quality, affordable care.

The goals of UMP Plus – PSHVN include:

  • Build healthier communities and people through prevention and early attention to disease

  • Integrate care and social support for individuals who have both physical and behavioral health needs

  • Reward quality health care over quantity, with government leading by example as Washington State’s largest purchaser of health care

What does UMP Plus – Puget Sound High Value Network provide patients access to?

In addition to primary care, UMP Plus – Puget Sound High Value Network provides patients access to:

  • A variety of highly specialized services, including cancer care, cardiovascular care, endocrinology, rheumatology, orthopedics and surgical services

  • Urgent, emergency and trauma care

  • Obstetrics, pediatrics and specialty pediatrics UMP Plus – Puget Sound High Value Network includes:

  • More than 2,300 primary care providers

  • Over 5,000 physician specialists

  • Approximately 470 clinics

  • 15 hospitals

  • Over 45 urgent care clinics

  • An extensive network of emergency departments and trauma centers

What health care organizations are included in UMP Plus – Puget Sound High Value Network?

UMP Plus – Puget Sound High Value Network is a group of eight industry-leading medical provider organizations located throughout Washington state. Medical groups, hospitals and health systems in UMP Plus – PSHVN include:

In addition to these participating organizations, Capital Medical Center in Olympia is designated as a network hospital for Thurston County. This means all hospital services received at Capital Medical Center will be covered at the higher network level.

What services does UMP Plus – Puget Sound High Value Network provide patients access to?

UMP Plus – Puget Sound High Value Network provides patients access to a comprehensive array of services available throughout Washington state, including:

  • One of the most comprehensive health care networks in Washington State, including services ranging from primary care to the most advanced specialty care available

  • Free office visits when you see a provider in the primary care network (Please note: Some services provided during the visit may require cost-sharing, so you are encouraged to ask your provider about that if you have any questions.)

  • Dozens of medical home clinics, where physicians coordinate many services for patients to help manage chronic disease

  • Access to 49 urgent care clinics located throughout Washington State

  • The largest home health and hospice agency in the Puget Sound area

  • The first skilled-nursing and outpatient chronic care management program in the United States planned, funded, built and staffed to meet the needs of people living with HIV-AIDS and other chronic or terminal illnesses

  • Comprehensive network of pediatric providers and pediatric hospitals, including one of the nation’s leading facilities as ranked by U.S. News & World Report

  • The top bariatric surgery program in Washington State based on clinical performance by Comparion® Medical Analytics

  • The only multispecialty clinic in Yakima County integrating community clinical health care services through innovative communication systems and population health initiatives that facilitate appropriate, convenient access to services for patients

  • A hospital-based chemical dependency unit and wound healing center in Grays Harbor County

  • The largest, most comprehensive, 24-hour nurse navigator and health line in the Puget Sound region

  • Dedicated phone number to support scheduling and appointments

Why is the ACP considered “accountable”?

Accountable Care Programs (also called Accountable Care Networks) use specific measurements to hold themselves accountable for improving the quality and coordination of care for individuals they serve. Measurements include improved health outcomes and patient satisfaction. The performance measurements are used to drive continuous service improvements.

How will UMP Plus – Puget Sound High Value Network better coordinate each person’s health care?

UMP Plus – Puget Sound High Value Network uses the medical home model, where a patient’s health care is managed by a team of clinicians working in close coordination.  By employing evidence-based preventive measures, care teams identify and treat underlying health problems before they become chronic conditions. And with more integrated data and information sharing, each team member also has greater access to the latest information about every patient. This model of care is especially important for patients with chronic conditions — such as heart disease, diabetes or asthma — that often require care from multiple specialists. This model also facilitates integrated, coordinated scheduling and communication with patients.

How does UMP Plus – Puget Sound High Value Network work under the ACP?

Eligible Washington state public employees (active and retired), Leave Without Pay members, non-Medicare retirees or COBRA members who select UMP Plus – Puget Sound High Value Network as their ACP will: 

  • Be encouraged, but not required, to select a primary care provider to oversee their care.

    • Primary care providers are critical to the ACP structure.

    • If selecting an ACP, Washington state public employees are required to select a primary care provider within one of the participating medical organizations. The selection of a primary care provider will determine the ACP network for the patient.

    • Important: If a patient selects a primary care provider who practices outside one of the participating medical organizations, his/her services will not be covered.

  • Be given access to a broad network of providers throughout Washington State.

    • Upon selecting a primary care provider within one of the participating medical organizations, the Washington state public employee will need to utilize primary care and specialty care within UMP Plus – Puget Sound High Value Network. As long as the patient remains within UMP Plus – Puget Sound High Value Network (UMP Plus – PSHVN), he/she can see any provider within UMP Plus – PSHVN without an approved referral from his/her primary care provider.

  • Receive the highest level of benefit coverage.

    • For services to be covered at the highest level, Washington state public employees must utilize UMP Plus – Puget Sound High Value Network primary care or specialty care providers.

  • If a service is not available within one of the UMP Plus – Puget Sound High Value Network practices, or within a reasonable distance, the patient may be referred outside of UMP Plus – PSHVN.

    • A referral to a non-UMP Plus Puget Sound High Value Network provider requires that a ‘waiver request’ be submitted to Regence by the referring provider.

    • Upon receipt, Regence will review it for verification of no in-network provider availability.

    • If an in-network provider is available, Regence will advise the requesting provider to redirect the patient to the in-network provider.

    • If there is no in-network provider, or there is a good reason for the out-of-network referral, Regence will approve the waiver and in-network benefits will apply.

    • If a referral/waiver is not submitted or approved, patients’ out-of-network benefits will apply.

  • How do people search for a UMP Plus – Puget Sound High Value Network provider?

    • You can search for an in-network provider at PugetSoundHighValueNetwork.org.

    • Important: Eligible Washington state public employees who choose UMP Plus – Puget Sound High Value Network as their Accountable Care Program are required to access primary and specialty care providers through one of the participating medical organizations.

Primary Care and Prevention Services

Is a primary care provider required?

While not required, UMP Plus – Puget Sound High Value Network highly encourages you to select a primary care provider to oversee and coordinate your care.

Which provider office visits qualify as no-cost primary care visits?

Office visits, preventive care services and immunizations provided by primary care network providers affiliated with your UMP Plus network or Regence-affiliated naturopathic physicians are covered in full; you pay nothing. Related services during an office visit may be subject to the deductible and coinsurance. For example, at a visit with your primary care network provider, tests are ordered. The office visit will be covered at no cost to you; tests not considered preventive are subject to the deductible and coinsurance.

Is there a limit on the 100 percent coverage of primary and preventive care?

There is no limit to the number of appointments you and your family can have under the primary care office visits coverage benefit. To receive primary care office visits at no cost to you, services must be provided by primary care network providers affiliated with your UMP Plus network or Regence-affiliated naturopathic physicians.

What services qualify as preventive?

For a list of services covered as preventive, see the Certificate of Coverage. Note that recommendations added during the calendar year may not be covered as preventive until later years. You may also see examples of services covered as preventive in the networks’ Certificates of Coverage (benefits books).

What is coinsurance and what does it apply to?

Coinsurance is the out-of-pocket cost a member pays for medical services and prescription drugs. It is a percentage of the allowed amount for most services you pay when the plan pays less than 100 percent. To see what coinsurance applies to the UMP Plus networks, see the Certificate of Coverage.

Does it matter if my doctor is in both Puget Sound High Value Network and UW Medicine Accountable Care Network?

No. Doctors typically contract with multiple health plans. Members who stay within their selected plan’s primary care network for office visits will have no out-of-pocket costs, pay 15 percent coinsurance for in-network specialists and 50 percent co-insurance when using a non-network provider that is contracted by Regence. If a member uses a provider that is both out-of-network and not contracted by Regence, the co-insurance will be 50 percent plus any balance billing assessed by the provider.

If I have a primary care doctor, can I assume my doctor is part of one of the UMP Plus plans if the doctor’s offices are located in one of the listed plan hospitals or medical buildings?

No. You need to check the provider lists for your selected plan to verify if your provider is a network provider. For more information, contact Regence.

How do people get more information about UMP Plus – Puget Sound High Value Network?

For more information about UMP Plus – PSHVN and to find a network provider, visit PugetSoundHighValueNetwork.org or call 1-855-776-9503.

For information about your medical coverage, call Regence at 1-888-849-3681.