Cause Defined

“Cause” is defined by the PPO 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 Preferred Provider Organization (PPO) 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 MPTN PPO 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 PPO Plan are subject to change.

For more information about how the PPO Plan works, see the Preferred Provider Organization (PPO) section. 

 

PPO Bargaining Unit Plan 

The chart in this section explains your health care options for the PPO Bargaining Unit Plan in effect as of January 1, 2023.

The amounts shown in this comparison reflect what you pay.

In-Network Benefits

Out-of-Network Benefits
Annual Deductible
(applies to annual out-of-pocket maximum)		    
  • Team Member
  • Team Member + Child or Spouse
  • Family

$500
$1,000
$1,500

$1,000
$2,000
$3,000

Annual Out-of-Pocket Maximum**

(penalties for lack of pre-certification and non-covered expenses do not apply)

 Includes deductibles, coinsurance and copays   Includes deductibles, coinsurance and copays
  • Team Member
  • Team Member + Child or Spouse
  • Family

$1,950
$3,900
$5,850

 $4,000
$8,000
$12,000

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 or zero reimbursement, depending on the network

 

20%, up to the first $5,000 of covered expenses or zero reimbursement, depending on the network

Preventive Care
Routine Physicals (one per plan year) no cost to you,
no deductible*		 30% of U&C,
after deductible
Annual Gynecological Exam
(One routine exam and Pap smear per plan year, 16 years and older)		 no cost to you,
no deductible*		 30% of U&C,
after deductible
Routine Mammogram

  • Ages 20 to 40 years: One routine mammogram every 24 months
  • Ages 40 and older: One every 12 months
 no cost to you,
no deductible*		 30% of U&C,
after deductible
Routine Colonoscopy
(Age 45 and older: One every five years)		 no cost to you,
no deductible*		 30% of U&C,
after 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*

30% of U&C,
after deductible
Routine Pediatric Care no cost to you,
no deductible*		 30% of U&C,
after deductible

Maternity Care
Hospital Services 10% after deductible 30% of U&C,
after deductible
Pre-Natal and Post-Natal Care 10% after deductible 30% of U&C,
after deductible
Birthing Facility Fee 10% after deductible 30% of U&C,
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

30% of U&C,
after deductible
Urgent Care
(hospital-based)
– Urgent Care visit charge only; for other services performed see that section.

$50 copay per visit,
no deductible

30% of U&C,
after $50 copay per visit, after deductible
Walk-In Center
(non-hospital-associated) – office visit only; for other services performed see that section.

$25 copay per visit,
no deductible

30% of U&C,
after deductible
X-rays, Ultrasounds, CT and PET Scans, MRIs, and SPECTs 10% after deductible 30% of U&C,
after deductible
Restorative Physical and Occupational Therapy $25 copay per visit,
no deductible		 30% of U&C,
after deductible
Chiropractic Care $25 copay per visit,
no deductible

Maximum 25 visits per year

30% of U&C,
after deductible

Maximum 25 visits per year
Acupuncture, when deemed medically necessary (maximum $500 per plan year) $25 copay per visit,
no deductible		 30% of U&C,
after deductible
Cardiac Rehabilitation
(Up to 60 visits per year)		 $25 copay per visit,
no deductible		 30% of U&C,
after deductible
Speech Therapy (must be physician approved) $25 copay per visit,
no deductible		 30% of U&C,
after deductible
Allergy Testing and Injections  10% after deductible 30% of U&C,
after deductible
Chemotherapy

 10% after deductible

 30% of U&C,
after deductible
Contraceptive Management
(16 years and older)		  10% after deductible 30% of U&C,
after deductible
Diagnostic Procedures
(performed in a hospital or for outpatient surgical care)

 10% after deductible

30% of U&C,
after deductible
Laboratory Tests (outpatient)

covered 100%†

30% of U&C,
after deductible
Ambulatory Surgical Facility Fee

N/A

30% of U&C,
after deductible
Pre-Admission Testing

 10% after deductible

30% of U&C,
after deductible
Second Surgical Opinion

$25 copay,
no deductible

30% of U&C,
after deductible

Inpatient Care

  • Room and Board
    Limited to 120 days per calendar year
    (semi-private room)
  • Inpatient physician services
  • Miscellaneous inpatient services and supplies

$250 copay per admission plus 10%, after deductible

$250 copay per admission plus 30% of U&C, after deductible

Skilled Nursing Facility

  • Medical care only; no custodial care

Limited to 365 days maximum per confinement

10% after deductible

$250 copay unless transferred
directly from inpatient

30% of U&C, after deductible

$250 copay unless transferred
directly from inpatient

Expenses related to surgery
(inpatient or outpatient)
Anesthesia Services

10% after deductible

30% of U&C,
after deductible
Assistant Surgical Services

10% after deductible

30% of U&C,
after deductible
Cast and Dressing Services

10% after deductible

30% of U&C,
after deductible
Elective Surgery    
  • With Pre-certification

10% after deductible

 30% of U&C,
after deductible
  • Without Pre-certification, if deemed medically necessary

10% after 20% pre-certification penalty,
up to first $5,000 of covered expenses, after deductible

  30% of U&C, after 20% pre-certification penalty,
up to first $5,000 of covered expenses, after deductible
Emergency Surgery

10% after deductible

30% of U&C,
after deductible
Maternity Surgery (including physician attendance)

10% after deductible

30% of U&C,
after deductible
Ambulance for Emergency

20%, no deductible

20%, no deductible
Durable Medical Equipment
(Some items may require pre-certification)		 10% after deductible

30% of U&C,
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,
no deductible

 

$100 copay per visit,
after deductible
Home Health (when skilled services are required)    
  • Combined with special duty nursing, limited to 120 days per calendar year
 10% after deductible 30% of U&C,
after deductible
  • Physician House Calls
 Not covered Not Covered
Hospice Care

10% after deductible

30% of U&C,
after deductible
Accident-Related Dental Services

10% after deductible

30% of U&C,
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 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 child immunizations provided by network 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 U&C charge
  • Dental coinsurance
  • Vision care expenses
  • Expenses not covered by the plan
 
 
 

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