What’s Covered

If You Have Other Coverage

The medical option available through MPTN has a coordination of benefits feature. The coordination of benefits rules prevent duplication of payments when you or your family members are covered by another group medical plan, including government coverage such as TRICARE, Medicare or medical coverage under the “no fault” or payment provisions of an automobile insurance contract. For more information, see “If You Have Other Coverage” in the Health Care Benefits section.

This section describes the benefits covered by the Pequot Open Plan. Coverage amounts are subject to change.

The plan pays benefits for covered services, treatment, supplies and facilities that are medically necessary or appropriate (as determined by the medical utilization reviewer) to diagnose, treat, or monitor a sickness, injury, mental illness, substance abuse, or general symptoms. In some cases, services are covered by the plan only if they are medically necessary and appropriate and if they are approved in advance by the medical utilization company. For more information, see “Pre-Certification” within the Open Access Plan section.

To be considered medically necessary, services, treatment, supplies and facilities must:

• Not be maintenance therapy or maintenance treatment. Its purpose must be to restore health.
• Not be primarily custodial in nature.
• Not be a listed item or treatment not allowed for reimbursement by the Centers for Medicare and Medicaid Services (CMS).

The plan reserves the right to incorporate CMS guidelines in effect on the date of treatment as additional criteria for determination of medical necessity and/or an allowable expense. For more information, please see the definition of Medically Necessary in the Terms to Know section.

Some examples of services covered by the MPTN Medical Plan include the following:

• Outpatient care, such as:
  • Office visits
  • Specialist visits
  • Preventive care, such as physicals, well-child care, and screening tests 
  • Diagnostic testing, including lab tests and x-rays
  • Outpatient surgery
  • Emergency care
  • Prescription drugs
  • Outpatient mental health and alcohol/substance abuse care
  • Physical/occupational therapy
  • Home health care
  • Chiropractic care
  • Durable medical equipment
• Inpatient care, such as:
  • Inpatient surgery
  • Room and board for semi-private hospital accommodations
  • Intensive care
  • Inpatient mental health/chemical dependency or detoxification care
  • Inpatient hospice care
  • Transplants

Some of the services listed above may be subject to deductibles and copays. In addition, you should have your health care provider call the beneficiary services telephone number on the back of your benefits card to determine whether a particular service requires pre-certification. Services requiring pre-certification are covered at a lower rate or may not be covered at all if the pre-certification is not obtained in advance.

Mastectomy Care and Reconstructive Surgery

The MPTN Medical Plan covers 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 of physical complications at any stage of the mastectomy, including lymphedemas.

Maximum Allowable Amount

For physicians and ancillary services:

The maximum benefit payable for a specific coverage item or benefit under the Plan. The Maximum Allowable Amount will be a negotiated rate, if one exists. If and only if there is no negotiated rate for a given claim, the Plan Administrator will exercise its discretion to determine the Maximum Allowable Amount based on any of the following: Medicare reimbursement rates, Medicare cost data, amounts actually collected by providers in the area for similar services, or average wholesale price (AWP) or manufacturer’s retail pricing (MRP). These ancillary factors will take into account generally-accepted billing standards and practices.

For hospitals/facilities:

The “Maximum Allowable Amount” shall mean the benefit payable for a specific coverage item or benefit under this Plan. The Maximum Allowable Amount will be a negotiated rate, if one exists; if no negotiated rate exists, the Maximum Allowable Amount will be determined by the Plan to be the Medicare reimbursement rates utilized by the Centers for Medicare and Medicaid Services (“CMS”), based on current-year CMS data for the year in which the date of service occurs, multiplied by 140%.

If no Medicare reimbursement rate is available for a given item of service or supply, Medicare reimbursement rates will be calculated based on one of the following:

1. Prices established by CMS utilizing standard Medicare Payment methods and/or based upon supplemental Medicare or Medicaid pricing data for items Medicare doesn’t cover based on data from CMS;
2. Prices established by CMS utilizing standard Medicare payment methods and/or based upon prevailing Medicare rates in the community for non-Medicare facilities for similar services and/or supplies provided by similarly skilled and trained providers of care; or
3. Prices established by CMS utilizing standard Medicare payment methods for items in alternate settings based on Medicare rates provided for similar services and/or supplies paid to similarly skilled and trained providers of care in traditional settings.

No member shall be entitled to and in no event will the Plan’s maximum liability for any claim exceed the Maximum Allowable Amount.

For all Covered Expenses:

When more than one treatment option is available, and one option is no more effective than another, the least costly option that is no less effective than any other option will be considered within the Maximum Allowable Amount. The Maximum Allowable Amount will be limited to an amount which, in the Plan Administrator’s discretion, is charged for services or supplies that are not unreasonably caused by the treating provider, including errors in medical care that are clearly identifiable, preventable, and serious in their consequence for patients. A finding of provider negligence or malpractice is not required for services or fees to be considered ineligible pursuant to this provision.