What the PPO Plan Covers

This section describes the benefits covered by the PPO Plan. The plan pays benefits for services, treatment, supplies, and facilities that are covered health services (as determined by the plan). See “What’s Not Covered” in the Your Medical Plan section for more information about services that may not be covered by the plan.

Plan benefits, features and limits are described in more detail in “Your Health Care Options at a Glance” in the Your Medical Plan section, and in the benefit summary included with your enrollment materials.

Outpatient Care

When you receive same-day care without an overnight hospital stay, your care is called outpatient or ambulatory care. Similarly, doctor’s office visits and specialist visits are considered outpatient care. In some cases — for outpatient surgery, for example — you must have the plan approve your care in order to receive maximum benefits. See “Pre-Certification” within this section for more information.

Physician Services

Both the in-network and out-of-network benefits cover the following doctor’s charges. Out-of-network benefits cover the doctor’s charges for these services at a lower percentage. To receive in-network benefits, you must visit a doctor who is part of the PPO network.

• Hospital visits
• Surgery
• Anesthesia
• Maternity care, including prenatal, delivery, and post-natal care for you and your eligible spouse only

See “Your Health Care Options at a Glance” in the Your Medical Plan section for the amount of copays and coinsurance.

Know Your Care Provider

Be sure you know whether the center providing your care is classified as an emergency room, an urgent care center, or a walk-in care center, and whether it is hospital-based or hospital-associated.

Specialist Visits

The PPO Plan also covers office visits to specialists such as allergists, cardiologists, dermatologists, and neurologists. You can see a network specialist without a referral from your primary care physician (PCP) or your PCP may suggest that you see a specialist.

Before you see a specialist, check whether the specialist is in the PPO network, so you know what benefits to expect. In some cases, a particular service or specialty provider may not be available in the network. In these cases, with a referral from your PCP, services may be reimbursed at the higher, in-network level. For more information, contact Pequot Plus Health Benefit Services before you see the specialist.

Preventive Care

Generally, in-network benefits cover preventive and wellness care at 100% for each office visit. Out-of-network benefits for preventive care generally pay a percentage of the covered expense.

These services are described in more detail in “Your Health Care Options at a Glance” in the Your Medical Plan section, and in the benefit summary included with your enrollment materials.

Be sure to check your coverage before receiving out-of-network care.

Diagnostic Testing

The plan covers a portion of eligible charges for diagnostic testing, including lab tests and X-rays.

Maternity Care

In-network and out-of-network benefits cover a portion of the expenses related to pregnancy and childbirth for you or your spouse. The plan does not cover expenses related to pregnancy and childbirth for other eligible dependents, except as covered under the preventive care benefits of the plan.

Your care will generally be coordinated by your PCP or your obstetrician. You should try to use an in-network provider to minimize your out-of-pocket expenses.

Outpatient Surgery

The plan covers a portion of surgery performed on an outpatient basis and necessary medical services and supplies. Keep in mind that some outpatient surgery requires pre-certification.

Non-Emergency Services

You should visit your family physician or a walk-in center for non-emergency services, such as treatment for an ear infection or the flu. Non-emergency services should not be provided in the emergency room.

Emergency Care

The PPO Plan covers eligible charges related to emergency care. Whenever you have a true medical emergency, you should go to the nearest emergency facility. If you are admitted, your provider must contact the medical utilization company at the telephone number shown on your benefit card within 48 hours of your admission. If your provider does not contact the medical utilization company within 48 hours, the 20%/$5,000 precertification penalty may apply. (See “Pre-Certification” within this section for more information on when to pre-certify a hospital admission.)

A medical emergency is generally defined as a sickness or injury that, without immediate medical attention, could place a person’s life in danger or cause serious harm to bodily functions. Examples of emergencies include an apparent heart attack, severe bleeding, loss of consciousness, and severe or multiple injuries.

Urgent Care and Walk-In

The plan’s benefits for urgent and walk-in care, including care provided through convenience care centers, differ depending on whether the care:

• is provided through a hospital-based or hospital-associated facility, or
• is not provided through a hospital-based or hospital-associated facility.

Urgent care that is provided by a hospital-based or hospital-associated facility is subject to the emergency room copay.

Urgent and walk-in care that is not provided by a hospital-based or hospital-associated facility is subject to the office visit copay.

All emergency room visits are subject to the emergency room copays.

You do not need a referral or any pre-certification to use an urgent care or walk-in center.

Ambulance

The plan covers a portion of local professional ambulance service when medically necessary to transport a patient to the nearest hospital where appropriate treatment is available.

Hospital Emergency Room

Hospital emergency room treatment is covered if you need emergency medical treatment. For more detail see “Your Health Care Options at a Glance,” in the Your Medical Plan section.

Inpatient Care

Non-emergency inpatient admissions must be pre-certified to receive full benefits. If your admission is not pre-certified, you pay the first 20% of charges, up to $5,000.

The PPO Plan covers a portion of the charges related to inpatient hospitalization, but the coverage levels vary depending on whether you use an in-network or out-of-network provider. Such charges may include the following:

• Pre-admission testing up to seven days in advance of admission
• Laboratory, X-ray and radiotherapy services approved by your physician
• Room and board for semi-private hospital accommodations for treatment of illness, injury, or pregnancy up to 120 days per illness (Mental health treatment and treatment for alcohol/substance abuse is covered separately, see the Mental Health and Alcohol/Substance Abuse Coverage section.)
  • “Illness” is defined by the plans as treatment related to a specific ICD diagnosis as provided to the plans by the health care provider.

• Intensive care
• Treatment rooms
• Drugs and medicines
• Dressings
• Splints and casts
• Reading of X-rays, EKGs and pathological reports
• Diagnostic laboratory services
• Oxygen and its administration
• Radiation therapy and treatment
• Physical therapy
• Professional nursing services 

Inpatient Surgery

The plan covers a portion of eligible charges for inpatient surgery. For non-emergency inpatient surgery, you must pre-certify to receive maximum benefits as described under “Pre-Certification” within this section. Otherwise, you pay the first 20% of charges, up to $5,000.

The plan also covers a portion of eligible expenses associated with reconstructive surgery following a mastectomy, expenses for reconstructive surgery on the other breast to achieve symmetry, the cost of prostheses, and the costs for treatment for physical complications at any stage of the mastectomy, including lymphedemas.

Transplant Benefits

*Special Transplant Network Provisions*

The plan arranges access to a national network of transplant facilities carefully selected for the specialized expertise in transplant. The facilities are chosen for the extensive experience with transplants and their high survival rates along with experienced surgical teams with transplant surgeon certification. The transplant centers have Medicare approval and membership in a national organ-sharing network.

Transplant services require pre-authorization. Contact an Optum Transplant Coordinator at 1-800-595-6241 as soon as either you or your dependent is identified as a transplant candidate. Transplant benefits are subject to all other plan exclusions, limitations and other plan provisions.

The plan covers transplant services providing:

• When the recipient is not covered by this plan and the donor is covered, the expenses will not be covered for either the recipient or the donor.

• When both the recipient and donor are covered by this plan services will be covered for each patient.

• When only the recipient is covered by this plan, benefits are provided for services for both the recipient and donor, provided benefits to the donor are not available under any other form of healthcare coverage.

• The transplant is medically necessary and is recognized by federal agencies as appropriate treatment for the active illness and injury.

• The transplant is not for cosmetic purposes unless the following apply:
  • Repair within one year of an accident which occurred while covered under the plan,
  • Replacement of tissue or diseased tissue surgically removed or altered while covered under the plan, or
  • Treatment of a birth defect in a child who has been continuously covered under the plan since the date of birth.

What Transplant Services are Covered      

• Hospital services
• Physicians services
• Immunosuppressive drugs
• Donor search services
• Donor charges related to the actual transplant
• Organ procurement or acquisition charges

What Transplant Services are not Covered

• Transportation
• Lodging
• Meals
• Loss of wages

Maternity Care

If you or an eligible spouse is admitted to the hospital in connection with childbirth, the mother and newborn child or children are permitted to stay in the hospital with full benefits for at least:

• 48 hours following normal delivery, or
• 96 hours following a cesarean section.

The provider, after consulting with the mother, may discharge the mother or her newborn earlier than 48 hours (or 96 hours as applicable), if the mother agrees to be discharged earlier than the 48/96-hour minimum.

No plan authorization is required if the care provider prescribes a hospital stay within the 48/96-hour minimum.

What the PPO Plan Does Not Cover

The PPO Plan does not pay benefits for services, treatment, supplies, and facilities that are not covered health services (as determined by the plan).

See “What’s Not Covered” in the Your Medical Plan section for additional information.

Home Health Care

The plan pays for home health care when skilled nursing or other professional services are required (i.e., physical therapy, etc.). Combined with special duty nursing, the plans cover home health care services for up to 120 days per plan year.

Physician house calls related to home health care are generally not covered.

Hospice Care

The PPO Plan covers hospice services for the end of life. Beneficiaries should contact the medical utilization company at the number listed on your benefit card for assistance in coordinating all necessary services with network providers. 

Routine Patient Costs for Participation in an Approved Clinical Trial

Charges for any Medically Necessary services, for which benefits are provided by the plan, when a participant is participating in a phase I, II, III or IV  clinical trial, conducted in relation to the prevention, detection or treatment of a life-threatening disease or condition, as defined under the ACA, provided:

• The clinical trial is approved by any of the following:
  • The Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services.
  • The National Institute of Health.
  • The U.S. Food and Drug Administration.
  • The U.S. Department of Defense.
  • The U.S. Department of Veterans Affairs.
  • An institutional review board of an institution that has an agreement with the Office for Human Research Protections of the U.S. Department of Health and Human Services.
• The research institution conducting the approved clinical trial and each health professional providing routine patient care through the institution, agree to accept reimbursement at the applicable allowable expense, as payment in full for routine patient care provided in connection with the approved clinical trial.

Coverage will not be provided for:

• The cost of an investigative new drug or device that is not approved for any indication by the U.S. Food and Drug Administration, including a drug or device that is the subject of the approved clinical trial.
• The cost of a service that is not a health care service, regardless of whether the service is required in connection with participation in an approved clinical trial.
• The cost of a service that is clearly inconsistent with widely accepted and established standards of care for a particular Diagnosis.
• A cost associated with managing an approved clinical trial.
• The cost of a health care service that is specifically excluded by the plan.
• Services that are part of the subject matter of the approved clinical trial and that are customarily paid for by the research institution conducting the approved clinical trial.