Cause Defined
“Cause” is defined by the Pequot Open Plan as a continuous treatment prescribed within a clinical treatment plan for a specific diagnosis.
Your Health Care Option at a Glance
MPTN provides an attractive package of competitive health care benefits to help with your health care needs and protect you from the potentially high cost of care. These benefits include coverage for the following types of health care expenses:
- Medical,
- Prescription drug,
- Vision,
- Dental, and
- Mental health and alcohol/substance abuse.
Understanding Deductibles and Maximums
For more information about how deductibles and maximums work, see “Out-of-Network Coverage” in the Open Access Plan section
For more information about prescription drug, vision, dental, and mental health and alcohol/substance abuse coverage, see the sections describing those benefits.
The charts in this section show the most common medical services covered under the Pequot Open Plan. This is not a complete list. You will find more details in the sections describing those benefits. Please note that the health care options and benefits provided under the Open Plan are subject to change.
For more information about how the Pequot Open Plan works, see the Open Access Plan section.
Pequot Open Plan
The chart in this section explains your health care options for the Pequot Open Plan in effect as of January 1, 2024.
| The amounts shown in this comparison reflect what you pay. |
Benefits |
| Annual Deductible (applies to annual out-of-pocket maximum) |
|
|
$1,000 |
|
Annual Out-of-Pocket Maximum** (penalties for lack of pre-certification and non-covered expenses do not apply) |
Includes deductibles, coinsurance and copays |
|
$3,000 |
|
Pre-Certification Penalty (for failure to pre-certify medically necessary procedures) (Expenses will not apply to out-of-pocket.) |
20%, up to the first $5,000 of covered expenses |
Preventive Care |
|
| Routine Physicals (one per plan year) | no cost to you, no deductible* |
| Annual Gynecological Exam (One routine exam and Pap smear per plan year, 16 years and older) |
no cost to you, no deductible* |
|
Routine Mammogram
|
no cost to you, no deductible* |
| Routine Colonoscopy (Age 45 and older: One every five years) |
no cost to you, no deductible* |
| Routine Immunizations (Up to age 19); and Routine Immunizations (Age 19 and older) as recommended by the Advisory Committee on Immunization Practices (ACIP)*** |
no cost to you, no deductible* |
| Routine Pediatric Care | no cost to you, no deductible* |
Maternity Care |
|
| Hospital Services | 10% of Maximum Allowable Amount after deductible |
| Pre-Natal and Post-Natal Care | 10% of Maximum Allowable Amount after deductible |
| Birthing Facility Fee | 10% of Maximum Allowable Amount after deductible |
Outpatient Care |
|
| Physician Office Visits (does not include charges for telephone calls between patient and physician, when there is a charge for such calls) |
$25 copay per visit, no deductible |
| Urgent Care (hospital-based) – Urgent Care visit charge only; for other services performed see that section. |
$50 copay per visit, no deductible |
| Walk-In Center (non-hospital-associated) – office visit only; for other services performed see that section. |
$25 copay per visit, no deductible |
| X-rays, Ultrasounds, CT and PET Scans, MRIs, and SPECTs | 10% of Maximum Allowable Amount after deductible |
| Restorative Physical and Occupational Therapy | $25 copay per visit, no deductible |
| Chiropractic Care | $25 copay per visit, no deductible
Maximum 25 visits per year |
| Acupuncture, when deemed medically necessary (maximum $500 per plan year) | $25 copay per visit, no deductible |
| Cardiac Rehabilitation (Up to 60 visits per year) |
$25 copay per visit, no deductible |
| Speech Therapy (must be physician approved) | $25 copay per visit, no deductible |
| Allergy Testing and Injections | 10% of Maximum Allowable Amount after deductible |
| Chemotherapy |
10% of Maximum Allowable Amount after deductible |
| Contraceptive Management (16 years and older) |
10% of Maximum Allowable Amount after deductible |
| Diagnostic Procedures (performed in a hospital or for outpatient surgical care) |
10% of Maximum Allowable Amount after deductible |
| Laboratory Tests (outpatient) |
covered 100%† |
| Ambulatory Surgical Facility Fee |
10% of Maximum Allowable Amount after deductible |
| Pre-Admission Testing |
10% of Maximum Allowable Amount after deductible |
| Second Surgical Opinion |
$25 copay, no deductible |
|
Inpatient Care
|
$250 copay per cause, plus 10% of Maximum Allowable Amount, after deductible |
|
Skilled Nursing Facility
|
|
Expenses related to surgery
|
|
| Anesthesia Services |
10% of Maximum Allowable Amount after deductible |
| Assistant Surgical Services |
10% of Maximum Allowable Amount after deductible |
| Cast and Dressing Services |
10% of Maximum Allowable Amount after deductible |
| Elective Surgery | |
|
10% of Maximum Allowable Amount after deductible |
|
10% of Maximum Allowable Amount after 20% pre-certification penalty, up to first $5,000 of covered expenses, after deductible |
| Emergency Surgery |
10% of Maximum Allowable Amount after deductible |
| Maternity Surgery (including physician attendance) |
10% of Maximum Allowable Amount after deductible |
| Ambulance for Emergency |
20% of Maximum Allowable Amount no deductible |
| Durable Medical Equipment (Some items may require pre-certification) |
10% of Maximum Allowable Amount after deductible |
| Emergency Room Services (at a hospital emergency room for sudden or serious illness or accident) – ER visit charge only; for other services performed see that section. |
$100 copay per visit, |
| Home Health (when skilled services are required) | |
|
10% of Maximum Allowable Amount after deductible |
|
Not covered |
| Hospice Care |
10% of Maximum Allowable Amount after deductible |
| Accident-Related Dental Services |
10% of Maximum Allowable Amount after deductible |
- Hearing aids: Maximum of $2000 paid every 36 months.
- Wigs: $100 and 1 wig every 3 years
*For annual physicals and preventive screenings covered under the Affordable Care Act.
**The annual out-of-pocket maximum includes deductibles, coinsurance and copays for medical and prescription drugs. Expenses incurred in the last quarter of the year do not carry over to the next year.
***http://www.immunize.org/catg.d/p2011.pdf
†Ask Provider to send to a network Laboratory
Deductible
The annual deductible is the amount you and each covered family member must pay each plan year for covered medical and prescription drug expenses before the plan begins to pay benefits. After you satisfy the annual deductible requirement, the plan reimburses a percentage of covered expenses.
Certain services, such as preventive services provided by physicians, are not subject to the deductible. For more information, see “Your Health Care Options at a Glance” in the Your Medical Plan section. Amounts you pay as copays do not count toward your deductible.
A family deductible is met when the accumulation of all individual family member’s deductibles combined, not exceeding each member’s individual deductible, meet the total family deductible amount. A new deductible applies each year.
Out-of-Pocket Maximum
The out-of-pocket maximum limits the amount you and your family pay for covered medical expenses each year. Essentially, the out-of-pocket maximum protects you against having to pay extraordinary medical bills in a given year.
Once your share of covered expenses reaches the out-of-pocket maximum, the plan pays 100% of the eligible charges for any additional covered expenses for the rest of the plan year.
The annual out-of-pocket maximum includes deductibles, coinsurance and copays for medical and prescription drugs.
The following expenses do not count toward your out-of-pocket maximum:
- Penalty for non-certified hospital stays and non-certified outpatient services requiring pre-certification
- Expenses above the Maximum Allowable Amount
- Expenses not covered by the Plan
- Balance billed amounts
- Dental coinsurance
- Vision care expenses