Health & Wellness

Medical

While each medical plan covers in-network preventive screenings in full, the plans vary on annual deductibles, copays, and levels of coinsurance. Each plan has its own set of strengths. The ideal medical plan should cover your health needs within your budget.

Which Plan Is Right for You?

Benefit	Kaiser HMO w/HRA	UMR EPO	UMR CDHP w/HSA	UMR PPO
Primary Care Physician required	✓	✓	x	x
Referrals needed for specialists	✓	✓	x	x
Annual deductible to satisfy	✓	✓	✓	✓
Copayment for services	✓	✓	✓	✓
Coinsurance for services	✓	✓	✓	✓
In-network coverage	✓	✓	✓	✓
Out-of-network coverage	x	x	✓	✓

Understanding Your Cost for coverage

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RPB

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Reference Based Pricing (RBP) Plan

What’s the Difference?

It all comes down to how pricing and billing works, mostly behind the scenes.

Traditional Plans (including the Kaiser HMO w/HRA, UMR EPO, UMR CDHP w/HSA, and UMR PPO)	RBP Plan
What the plan and you pay for medical services is based on prices negotiated with providers in the plan’s network.	What the plan and you pay for medical services is based on a fixed price tied to Medicare rates, plus an additional percentage.

What You Need to Know About RBP

You won’t notice a change. RBP feels like the plans you’re used to. You still have copays, deductibles, out-of-pocket maximums, coinsurance, and an ID card.
There is no network with RBP. This means you can visit any doctor or hospital you’d like. When you access care, show the provider your UMR ID card. They will obtain pricing from there.
Balance bills may happen. In some instances, you may receive a balance bill after your treatment. A balance bill means the provider is attempting to charge an amount above the negotiated RBP rate. If this happens, contact UMR, who will negotiate the bill on your behalf.

Get Comfortable with the UMR Team

The UMR team will work with you before and after you receive care, to make sure you have the coverage you need, including:

Understanding benefits.
Finding a doctor.
Questions about a treatment plan.
Understanding a claim or bill.

UMR Benefits Advocacy

CDHP and POS II enrollees: 800.207.3172

Healthscope: 800.600.0920

UMR.com

What Do You Need to Do?

The primary difference from a patient perspective is the amount of communication you must have with providers and [Carrier’s] health advocacy team.

Finding a Provider	Before Scheduled Care	At the Provider’s Office	After Your Visit
Instead of checking if a provider is in network, you will confirm that the provider will accept the plan’s payment arrangement.	You may need to contact the plan’s support team before services to help you understand costs and confirm approval.	Some providers may not recognize the plan. The support team can explain how the plan works and speak with the provider if needed.	Your bill may not match your Explanation of Benefits. If you receive an unexpected bill, contact the plan before paying it.

How Do You Know If RBP Works for You?

Before choosing this plan, ask:

Can I continue seeing the doctors and facilities I use?
Am I comfortable contacting the plan before scheduled or high-cost care?
Do I understand what I will pay?
Do I know where to turn if I receive an unexpected bill?

Remember: You may receive care from any provider. However, because the plan does not rely on traditional network contracts, contact UMR’s team before scheduled care to confirm the provider and understand how the service will be paid.

Your ID Card Is Key

Your benefits ID card has all the information you and your provider need to access care and obtain pricing. Make sure to:

Present your ID card when you go to a healthcare provider. It’s important to tell them your coverage is through UMR.
Ask them to call the phone number on the card if they have any questions about your coverage.

What's a CDHP & Why Consider It?

Understanding the CDHP

With a CDHP, what you pay changes as you receive care throughout the year. You’ll pay more at first, then share costs with the plan, and eventually you may reach a point where the plan pays 100%.

You can use a Health Savings Account (HSA) to help cover expenses along the way. When you open an HSA, Big 5 contributes to your account: $250 / individual or $500 / family.

Here’s how it works:

Pay for Medical Care	Share the Cost	Reach the Limit
You pay the full cost of your care until you reach your deductible. You can use money from your HSA to help pay for these costs.	After you reach your deductible, you and the plan split the cost of care until you meet your out-of-pocket maximum.	If you reach the out-of-pocket maximum, the plan pays 100% of covered medical and prescription costs for the rest of the plan year.

Consider the CDHP if:

You want to pay less per paycheck for your medical coverage.
You want free money contributed to your HSA.
You like to save for the future.
You don’t go to the doctor often but want coverage when you need it.

Medical Plan Comparison

Plan Features	Kaiser HMO w/hra*	UMR EPO	UMR CDHP w/HSA		UMR PPO
Plan Features	In-Network Only	In-Network Only	In-Network	Out-of-Network**	In-Network	Out-of-Network**
Annual DeductibleIndividual/Family	$750 / $1,500	$750 / $1,500	$2,000 / $4,000	$2,700 / $5,400	$1,500 / $3,000	$2,500 / $5,000
Annual OOPMIndividual/Family	$3,400 / $6,800	$1,500 / $3,000	$3,000 / $6,000	$4,000 / $8,000	$3,000 / $6,000	$5,000 / $10,000
Big 5 Annual HSA ContributionIndividual/Family	N/A	N/A	$250 / $500		N/A
	You pay:	You pay:	You pay:		You pay:
Preventive Care Visit	Covered in full	Covered in full	Covered in full	50%^***	Covered in full	50%^***
Telemedicine/Virtual Visit	Covered in full	$30 copay	20%^***	50%^***	20%	50%^***
Primary Care Visit	$20 copay	$30 copay	20%^***	50%^***	20%	50%^***
Specialist Visit	$30 copay	$50 copay	20%^***	50%^***	20%^***	50%^***
Lab & X-ray	$10 copay	10%^***	20%^***	50%^***	20%^***	50%^***
Urgent Care	CA: $20 copay Other States: $30 copay	$30 copay	20%^***	50%^***	20% after $25 copay	50%^***
Emergency Room(copay waived if admitted)	20%^***	$150 copay	20%^***	20%^***	$150 copay + 20%	$150 copay + 20%
Outpatient Hospital Services	20%^***	10%^***	20%^***	50%^***	20%^***	50%^***
Inpatient Hospital Services	20%^***	$500 copay^***	20%^***	50%^***	20%^***	$500 copay + 50%^***
Outpatient Mental Health Services	20%^***	$30 copay	20%^***	50%^***	20%^***	50%^***
Chiropractic(20 visits per year)	20%^***	$50 copay	20%^***	50%^***	20%^***	50%^***
Acupuncture(visit limitations vary)	20%^***	$50 copay	20%^***	50%^***	20%^***	50%^***
Prescription Drugs: Retail (up to a 30-day supply)
Generic	$10 copay	$15 copay	$15 copay	N/A	$15 copay	N/A
Formulary Brand	$30 copay	$25 copay	$25 copay		$25 copay
Non-Formulary Brand	N/A	$50 copay	$50 copay		$50 copay
Specialty	20% up to $250 max	50% up to $150 max	50% up to $150 max		50% up to $150 max
Prescription Drugs: Mail Order (90-day UMR & 100-Day Kaiser supply)
Generic	$20 copay	$30 copay	$30 copay	N/A	$30 copay	N/A
Formulary Brand	$60 copay	$50 copay	$50 copay		$50 copay
Non-Formulary Brand	20% up to $250 max	$100 copay	$100 copay		$100 copay

*Plan available in 4 states: CA, OR, WA, CO.

**Receiving services out-of-network may result in balance billing.

***After deductible.

Self-Service Resources

My Health Manager

(Kaiser Plan Members Only)

If you are enrolled in the Kaiser medical plan, you have access to My Health Manager, a FREE online resource that allows you to:

Find a provider.
Email your doctor.
View test results.
Manage prescriptions.
Request or cancel an appointment.
Explore your medical plan details.
And more!

Visit kp.org to get started.

UMR Member Services

(UMR Plan Members Only)

If you are enrolled in a UMR medical plan, you have access to the UMR member portal and mobile app at no additional cost. Use UMR to manage your health benefits and find the care you need.

With UMR, you can:

Find in-network doctors and facilities.
View your benefits and coverage.
Estimate costs for care.
View your medical claims and EOBs.
Track your deductible and health care spending.
Access your digital ID card.
Submit medical claims.
Get answers to benefits questions.
Access health education and wellness resources.

Visit umr.com or download the UMR app.

[Name of Online Resource]

([Carrier] RBP Plan)

[This content will be revised once we have details] When you enroll in the RBP Plan, you have access to the [RBP Resource Site or Carrier Team]. They will work with you before and after you receive care, to make sure you have the coverage you need, including:

Understanding benefits.
Finding a doctor.
Questions about a treatment plan.
Understanding a claim or bill.

Get started by visiting [url needed] or calling [contact info].