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 PPO 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 Preferred Provider Organization (PPO) 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.

Under the following circumstances, the higher PPO payment will be made for certain Non-PPO providers:

• Expenses incurred from Non-PPO physicians who are covering for PPO physicians (due to vacation, etc.) are paid as PPO benefits. The covering physician must note on the claim form that he is covering for a PPO physician.

SPECIAL NOTE ON REFERRALS:

Referrals by PPO providers to Non-PPO providers will be considered as Non-PPO services and supplies. In order to receive the higher PPO benefits, ask your provider to refer you to one of the participating preferred providers.

Usual and Customary Charges (U&C)

Out-of-network benefits are based on the Usual and Customary (U&C) charges for treatment of illness, accident, injury or pregnancy. U&C charges are based on the normal range of fees charged by health care providers of similar standing (for example, with similar training and experience) in the same locality for treatment, services or supplies for a similar illness or injury.

The MPTN Medical Plan covers only U&C charges for out-of-network services. If your out-of-network health care provider charges more than the U&C amount, you are responsible for paying the portion that exceeds U&C. Charges that exceed the U&C amount do not count toward your deductible or out-of-pocket maximum.

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.