What’s Not Covered

Some medical services and supplies are not covered under the plan. If you have a question about whether a service or supply is covered, call the Pequot Plus Health Benefit Services at 1-888-779-6872 to check. The plan administrator makes the final determination as to which charges are excluded, based on the policies that govern the MPTN Medical Plan.

If your request for benefits is denied, you may appeal. For more information on appealing a claim, see “Claims Review and Appeals Procedures” in the Rules and Regulations section.

The following items are excluded by the MPTN Medical Plan:

  • Services, supplies or first aid items not prescribed or performed by a physician or another professional health care provider, as determined by the plan.
  • Services, supplies or treatments not recognized by the plan as generally accepted and medically necessary for the diagnosis and/or treatment of an active illness or injury.
  • Charges for procedures, surgical or otherwise, which are specifically listed by the American Medical Association, the American Dental Association, or any other such professional body as having no medical value.
  • Services or supplies which are not medically necessary as determined by the medical utilization company and/or plan administrator.
  • Cosmetic or reconstructive procedures and any related services or supplies which alter appearance but do not restore or improve impaired physical function, except when performed for:
    • Repair within one year of an accident which occurred while covered under the plan,
    • Replacement of tissue or diseased tissue surgically removed or altered while covered under the plan, or
    • Treatment (that is simply cosmetic in nature) of a birth defect in a child who has been continuously covered under the plan since the date of birth.
  • Wigs or hairpieces except when prescribed by a physician as a prosthetic for hair loss due to:
    • Burns resulting in permanent alopecia,
    • Chemotherapy, or
    • Radiation therapy.
  • Services that are performed by a person who is related to the participant as a spouse, parent, child, brother or sister, whether the relationship exists by virtue of “blood” or “in law”.

Time During Approved Family Medical Leaves

If you take an approved Family Medical Leave, the plan provisions and benefits that apply when you return from that leave will be equivalent to the benefit you would have had if you had not taken leave.

  • Housing, hotel or motel expenses, or home reconstruction arising out of special medical needs in the place where the patient resides.
  • Personal hygiene and convenience items (for example, air conditioners or humidifiers); physical fitness equipment or supplies made or used for physical fitness, athletic training or general health up-keep.
  • Formula and Nutritional Supplements
    • Enteral tube feedings are not covered for individuals who are capable of adequate oral intake.
    • Food supplements, specialized infant formulas, vitamins and/or minerals taken orally are not covered even if they are required to maintain weight or strength.
    • Diet supplements.
  • Telephone consultations, charges because a person fails to keep a scheduled appointment, or charges to complete a claim form.
  • Custodial care, such as help in walking, getting out of bed, or any service that could be performed by a non-professional person, including rest care or nursing home care and personal comfort items.
  • Routine non-surgical foot care (unless diabetic), or the treatment of flat or pronated feet, calluses, toe nails (unless ingrown), weak or fallen arches, weak feet metatarsalgia, or chronic foot strain.
  • Foot Orthotics and shoe inserts.
  • Tax, shipping and handling for DME items, etc.
  • Charge for hospitalization when such confinement occurs primarily for physical therapy, hydrotherapy, convalescent or rest care.
  • Services and supplies for dental care, except as specified.
  • Hospital admissions primarily for care which can be safely done on an outpatient basis.
  • Services or supplies incurred after a concurrent review determines the services and supplies are no longer medically necessary.
  • Treatment or surgery for obesity, weight reduction, or weight control, including food supplements, gastric bypass, lap band, and reversal of gastric bypass or removal of lap band.
  • Charges for recreational therapy and art/music therapy.
  • Educational therapy for non-medical self care or self-help education and/or training and any related diagnostic testing or for medical social services.
  • Services pertaining to a Learning Disability or to Dyslexia.
  • Services pertaining to Developmental Delays, including, but not limited to:
    • Occupational Therapy,
    • Physical Therapy, or
    • Speech Therapy.
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  • Marriage counseling.
  • Nutritional counseling (except for Diabetic Counseling, six, life-time visit max).
  • Genetic counseling or testing when performed for investigational purposes except when medically necessary, or as covered under the preventive care benefit, for the following conditions:
    • For the purpose of identifying and treating a specific hereditary disease,
    • Prenatal testing  when the family history has established the child is at-risk for a genetic disease.
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  • Treatment or surgery to change gender or to improve or restore sexual function unless of organic cause.
  • Charges related to or in connection with fertility studies, sterility studies, procedures to test, restore or enhance fertility, including artificial inseminations, in vitro fertilization and/or GIFT procedures or surrogacy.
  • Services or supplies for the reversal of sterilization.
  • Alternative/Complementary Treatment
    • Hypnosis,
    • Holistic, homeopathic or naturopathic medicine, or
    • Other treatment that is not accepted medical practice as determined by the plan.
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  • Tobacco Addiction Services, except to the extent covered under the preventive care benefits of the plan.
  • Treatment and/or surgery of temporomandibular joint syndrome (TMJ), including the use of intra-oral prosthetic devices or any method to alter vertical dimension.
  • Charges due to abortion, except for charges incurred when:
    • the mother’s life would be endangered if the fetus is carried to term,
    • medical complications have arisen from an abortion, or
    • arising from incest or rape.
  • An artificial heart, lung, liver or pancreas or any other artificial organ or any associated expense, except as related to transplants of human organs.
  • Charges for pregnancy, childbirth or related medical conditions for dependents other than the employee or the covered spouse, except as covered undertake preventive care benefits of the plan.
  • Charges that are not payable under the plan due to application of any plan maximum or limit or because the charges are in excess of the Maximum Allowable Amount, or are for services not deemed to be reasonable or Medically Necessary, based upon the plan administrator’s determination as set forth by and within the terms of this document.
  • Any charge for care, supplies, treatment, and/or services for any condition, illness, injury or complication thereof arising out of or in the course of employment, including self-employment, or an activity for wage or profit; If you are covered as a dependent under this plan and you are self-employed or employed by an employer that does not provide health benefits, make sure that you have other medical benefits to provide for your medical care in the event that you are hurt on the job. In most cases workers compensation insurance will cover your costs, but if you do not have such coverage you may end up with no coverage at all. Any services covered by Workers’ Compensation or employer’s liability laws.
  • Any services that are covered by an auto insurance policy.
  • Illness or injury resulting from participation in war (whether declared or not declared), act of war, riot, civil disturbance, or general uprising and occurring after this coverage begins.
  • Services for which the patient is not legally obligated to pay.
  • Services or supplies received in a dental or medical department maintained by or on behalf of another employer, mutual benefit association, labor union, trust or similar group.
  • Services provided before the patient’s coverage begins.
  • Expenses incurred on account of a dependent during or in connection with a hospital confinement that began before the date the dependent becomes covered by the MPTN Medical Plan.
  • Services covered under any other group, blanket or franchise insurance coverage, other health insurance plan, union welfare plan, labor management trusteed plan, tax-supported or government plan.
  • Services required by a third party, government agency or authority, or court judgment, whether or not medically necessary, including but not limited to immigration physical, court ordered detoxification or counseling of any type, except when such treatment is pre-certified by the medical utilization company for the plan.
  • Charges for which payment is made by any other plans as defined by and in connection with the coordination of benefits provision of this plan.
  • Any charge for care, supplies, treatment, and/or services to a plan participant, arising from taking part in any activity made illegal due to the use of alcohol. Expenses will be covered for injured plan participants other than the person partaking in an activity made illegal due to the use of alcohol, and expenses may be covered for substance abuse treatment as specified in this plan, if applicable. This exclusion does not apply if the injury (a)  resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions);
  • Any charge for services, supplies, care or treatment to a participant for injury or sickness incurred while the participant was voluntarily taking or was under the influence of any controlled substance, drug, hallucinogen or narcotic not administered on the advice of a Physician. Expenses will be covered for injured participants other than the person using controlled substances and expenses will be covered for substance abuse treatment as specified in this plan. This exclusion does not apply if the injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions).
  • Any charge for care, supplies, treatment, and/or services that are experimental or investigative;
  • Illegal Acts: Any charge for care, supplies, treatment, and/or services arising from or caused during the commission of any illegal act for which the participant could be incarcerated for any period of time.  It is not necessary for an arrest to occur, charges to be filed, incarceration to occur, or a conviction to be had for this exclusion to apply. This exclusion does not apply if the injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions);
  • Any charge for care, supplies, treatment, and/or services that are the result of intentionally self‑inflicted injuries or illnesses.  This exclusion does not apply if the injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions);
  • Any charge for care, supplies, treatment, and/or services of an injury or sickness not payable by virtue of the plan’s subrogation, reimbursement, and/or third-party responsibility provisions;
  • Charges that arise in connection with a fraudulent, materially false or misleading statement of claim submitted by any person who knowingly intends to defraud or deceive the plan’s authorized representatives.
  • Any service or treatment that takes place after the patient ended previous treatment against physician or medical staff advice.
  • Immunizations over the age of 18 unless otherwise specified in this Plan Document and SPD. Immunizations for travel, needed for the participant’s job, to take part in school, camp and sports activities; or by employers or third parties, regardless of age are not covered.
  • Charges arising from care, supplies, treatment, and/or services that are incurred by the participant on or after the date coverage terminates, even if payments have been predetermined for a course of treatment submitted before the termination date, unless otherwise deemed to be covered in accordance with the terms of the plan or applicable law and/or regulation.
  • Charges arising from care, supplies, treatment, and/or services that are amounts applied toward satisfaction of deductibles and expenses that are defined as the participant’s responsibility in accordance with the terms of the plan.
  • Charges arising from care, supplies, treatment, and/or services that are expenses actually incurred by other persons.
  • Charges arising from care, supplies, treatment, and/or services that are for injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the part of any caregiver, institution, or provider, as determined by the plan administrator, in its discretion, in light of applicable laws and evidence available to the plan administrator.
  • Charges arising from care, supplies, treatment, and/or services that are incurred at a time when no coverage is in force for the applicable participant and/or dependent.
  • Charges arising from care, supplies, treatment, and/or services that are not specified as covered under any provision of this plan.
  • Charges arising from care, supplies, treatment, and/or services that are to the extent that payment under this plan is prohibited by law.
  • Charges arising from care, supplies, treatment, and/or services that are required as a result of unreasonable provider error.
  • Charges arising from care, supplies, treatment, and/or services that are not “reasonable” and are required to treat illness or injuries arising from and due to a provider’s error, wherein such illness, injury, infection or complication is not reasonably expected to occur. This exclusion will apply to expenses directly or indirectly resulting from circumstances that, in the opinion of the plan administrator in its sole discretion, gave rise to the expense and are not generally foreseeable or expected amongst professionals practicing the same or similar type(s) of medicine as the treating provider whose error caused the loss(es).
  • Balance billed amounts.

With respect to any injury which is otherwise covered by the plan, the plan will not deny benefits otherwise provided for treatment of the injury if the injury results from being the victim of an act of domestic violence or a documented medical condition. To the extent consistent with applicable law, this exception will not require this plan to provide particular benefits other than those provided under the terms of the plan.

 
 
 
 
 
 
 
 

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