Your Medical Plan

This Plan Document and SPD supersedes all earlier descriptions of the plans, as of January 1, 2024.

Because the benefits and other programs described in this Plan Document and SPD may change, MPTN will provide updated information as necessary and as required by tribal, federal or other applicable law. You will be notified of any material reduction in covered services under the health care plans within 60 days after the change is adopted.

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If you are eligible for health care coverage, MPTN provides coverage for a broad range of expenses, including hospitalization, surgery, doctor visits, prescription drugs, vision care and mental health and alcohol/substance abuse treatment.

Reference Based Pricing

For certain claims that are not considered in-network, the Plan will seek to reach an agreement with the hospital and/or facility regarding allowable Plan charges and reimbursement rates. In the event that no such agreement can be reached, the Plan’s liability for any allowed claim will be limited to the Maximum Allowable Amount. Notwithstanding anything to the contrary in this document, in the event that a determination of the Plan’s reimbursement amount in accordance with the methodology outlined herein results in an amount that exceeds the actual changes for the services and/or supplies, the Plan’s reimbursement amount for that claim will be deemed to be equal to (and may not exceed) the actual charges billed for the claim. The Plan will communicate with the provider(s) regarding the reference-based pricing. In the event you receive a bill more than what you owe, the plan sponsor will resolve it on your behalf.

Services subject to Reference Based Pricing include, but are not limited to, facilities, dialysis, and ambulance.

Facilities include services such as:

• Any inpatient services at a hospital, skilled nursing facility or behavioral health facility.
• Any outpatient services performed at, or operated by, a hospital, skilled nursing facility or behavior health facility.
• Emergency room.
• Other hospital, skilled nursing facility or behavioral health facility including:
  • Hospital rehabilitation (physical therapy, for example),
  • Hospital cardiac or pulmonary rehabilitation, and
  • Hospital inpatient or outpatient services.
• Any outpatient or ambulatory surgical facility including endoscopy facilities.
• Any outpatient CT, MRI, PET scan or Lithotripter services.

Balance Billing

In the event that a claim submitted by a provider is subject to a medical bill review or medical chart audit and that some or all of the charges in connection with such claim are repriced because of billing errors and/or overcharges, it is the plan’s position that the participant should not be responsible for payment of any charges denied as a result of the medical bill review or medical chart audit, and should not be balance billed for the difference between the billed charges and the amount determined to be payable by the plan administrator. However, balance billing is legal in many jurisdictions, and the plan has no control over providers that engage in balance billing practices.

In addition, with respect to services rendered by a provider being paid in accordance with a discounted rate, it is the plan’s position that the participant should not be responsible for the difference between the amount charged by the network provider and the amount determined to be payable by the plan administrator, and should not be balance billed for such difference. Again, the plan has no control over any network provider that engages in balance billing practices, except to the extent that such practices are contrary to the contract governing the relationship between the plan and the provider.

The participant is responsible for any applicable payment of coinsurances, deductibles, and out-of-pocket maximums and may be billed for any or all of these.

Claims Audit

In addition to the plan’s medical record review process, the plan administrator may use its discretionary authority to utilize an independent bill review and/or claim audit program or service for a complete claim.  While every claim may not be subject to a bill review or audit, the plan administrator has the sole discretionary authority for selection of claims subject to review or audit.

The analysis will be employed to identify charges billed in error and/or charges that are not usual and customary and/or medically necessary and reasonable, if any, and may include a patient medical billing records review and/or audit of the patient’s medical charts and records.

Upon completion of an analysis, a report will be submitted to the plan administrator or its agent to identify the charges deemed in excess of the Maximum Allowable Amount or other applicable provisions, as outlined in this Plan Document and SPD.

Despite the existence of any agreement to the contrary, the plan administrator has the discretionary authority to reduce any charge to the Maximum Allowable Amount, in accord with the terms of this Plan Document and SPD.

Benefit Summary

The Benefit Summaries show your contributions for coverage, deductibles, maximum benefits and other plan details. If you have questions about coverage under your plan, contact Pequot Plus Health Benefit Services at 1-888-779-6872 before you receive medical services.

For More Information …

This section describes your medical coverage. For more information about prescription drug, dental, vision, and mental health and alcohol/ substance abuse coverage, see the sections describing those benefits.