UMP Plus for SEBB – Puget Sound High Value Network FAQ

Frequently Asked Questions

What is a Uniform Medical Plan (UMP)?

The Uniform Medical Plan (UMP) was built to provide top-quality, affordable healthcare to eligible Washington state public employees (active and retired), Leave Without Pay members, non-Medicare retirees or COBRA members. Most health plans cover many services people don’t use, driving the cost up for healthcare. UMP-Plus was built with this in mind, lowering the cost of care by making sure you’re only paying for the services you need.

What is the Puget Sound High Value Network (PSHVN)?

PSHVN is a group of five industry-leading medical organizations — CHI Franciscan and independent providers as part of Rainier Health Network, The Polyclinic, Seattle Children’s, Virginia Mason and Virginia Mason Memorial as part of Signal Health. Together, we’re committed to providing affordable, expert care and excellent customer service in King, Kitsap, Pierce, Snohomish, Thurston and Yakima counties.

In addition to these organizations, Capital Medical Center in Olympia is designated as a network hospital.

What is an Accountable Care Program (ACP)?

UMP Plus — PSHVN 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 to give their patients high-quality, affordable healthcare. ACPs are formed around a variety of existing provider organizations, multispecialty groups, hospitals, emergency departments, trauma centers and urgent care clinics.

Measures such as improved health outcomes and patient satisfaction are used to hold PSHVN accountable for improving the quality of care that is provided.

What kind of care can patients access?

In addition to primary care, UMP Plus — PSHVN gives patients access to:

  • Highly specialized services, including cancer care, cardiovascular care, endocrinology, rheumatology, orthopedics and surgical services
  • Urgent, emergency and trauma care
  • Obstetrics, pediatrics and specialty pediatrics

Our network also includes:

  • More than 700 primary care providers
  • More than 5,500 physician specialists
  • More than 1,000 clinics
  • 12 hospitals and emergency departments
  • Over 25 urgent care clinics

What health care organizations are included?

UMP Plus — Puget Sound High Value Network is made up of industry-leading medical groups, hospitals and health systems, including:

Additionally, Capital Medical Center in Olympia is designated as a network hospital.

What services does UMP Plus — Puget Sound High Value Network offer?

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 primary care provider for primary care services. Related services, like X-rays or labs, may be subject to the medical deductible and coinsurance.
     
  • Hundreds of primary care and multispecialty clinics, where physicians coordinate services for patients to help them manage chronic disease.
     
  • Dozens of urgent care clinics conveniently located throughout Washington state.
     
  • 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 hospitals, including one of the nation’s leading facilities as ranked by U.S. News & World Report.
     
  • Two of the top bariatric surgery programs 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. This facilitates appropriate, convenient access to services for patients.
     
  • Network includes two of the top three highest ranked medical groups in the state on a range of quality measure for commercially insured patients in the Washington Health Alliance's (WHA) 2018 Community Checkup report.
     
  • Access to 24-hour nurse navigator and health line
     
  • Dedicated phone number to support scheduling and appointments:
     
    • 1-877-345-8760 for SEBB Member


How do I find a provider in...?

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

To find additional providers in the UMP-Plus support network, search Regence.com.

Important: Eligible Washington state public employees who choose UMP Plus — PSHVN as their Accountable Care Program are required to access primary and specialty care providers through one of the participating medical organizations.
 

How do we ensure patients receive coordinated care between their doctors?

UMP Plus — PSHVN uses an approach called the medical home model, where a team of physicians work together to make sure patients get top-quality care. This approach focuses on preventative medicine and communication between doctors and other providers. 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. Our goal is to provide the best possible care and to make going to the doctor as easy as possible on patients and their families.

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

The following groups are eligible for UMP Plus — PSHVN coverage:

  • Eligible Washington state public employees (active and retired)
  • Leave Without Pay members
  • Non-Medicare retirees or COBRA members,
  • Current Washington state school district, charter schools,
  • Union-represented ESD employees
  • Current or former Washington state school district, charter school, or union-represented ESD employees

Those who select UMP Plus — PSHVN will:

  • Be encouraged, but not required, to select a primary care provider to oversee their care.
    • 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 patients select a primary care provider who practices outside one of the participating medical organizations, their care will not be covered.
  • Have access to a broad network of providers throughout Washington.

    • Upon selecting a primary care provider, you will need to use primary care and specialty care within UMP Plus — PSHVN. As long as patients remain within our network, they can see any provider without an approved referral from their primary care provider.

  • Receive the highest level of benefit coverage.

    • For services to be covered at the highest level, Washington state public employees must use UMP Plus — PSHVN primary care or specialty care providers.

  • If a service is not available within one of the UMP Plus — PSHVN 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.

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.

What qualifies as a free primary care visit?

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. Related services during an office visit may be subject to the deductible and coinsurance.

For example, a patient visits with their primary care network provider, and their provider orders tests. 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, you must see 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. You can search for an in-network provider at PugetSoundHighValueNetwork.org. To find additional providers in the UMP-Plus support network, search Regence.com.

What is PSHVN Organized Health Care Arrangement (OHCA)?

Under federal law, provider health care entities can share patient health information with each other for quality improvement and other health care operations activities, through  an Organized Health Care Arrangement (OHCA). PSHVN provider organizations have created an OHCA for these purposes, and appointed PSHVN its agent, or business associate, to conduct OHCA quality improvement and related health care operations activities.

How can I 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 1-877-345-8760.

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