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 Choice Plan

The chart in this section explains your health care options under the PPO Choice Plan in effect as of January 1, 2024.

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	$3,500 $5,250 $7,000	$7,000 $10,500 $14,000
Annual Out-of-Pocket Maximum (penalties for lack of pre-certification and non-covered expenses do not apply)
Team Member Team Member + Child or Spouse Family	$6,600 $9,900 $13,200	$12,000 $18,000 $24,000
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*	50% 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*	50% 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*	50% of U&C, after deductible
Routine Colonoscopy (Age 45 and older: One every five years)	no cost to you, no deductible*	50% 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*	50% of U&C, after deductible
Routine Pediatric Care	no cost to you, no deductible*	50% of U&C, after deductible
Maternity Care
Hospital Services	30% after deductible	50% of U&C, after deductible
Pre-Natal and Post-Natal Care	30% after deductible	50% of U&C, after deductible
Birthing Facility Fee	30% after deductible	50% 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)	$35 copay per visit, no deductible	50% of U&C, after deductible
Urgent Care (hospital-based) – Urgent Care visit charge only; for other services performed see that section.	$60 copay per visit, no deductible	50% of U&C, after $50 deductible
Walk-In Center (non-hospital-associated) – office visit only; for other services performed see that section.	$35 copay per visit, no deductible	50% of U&C, after deductible
X-rays, Ultrasounds, CT and PET Scans, MRIs, and SPECTs	30% after deductible	50% of U&C, after deductible
Restorative Physical and Occupational Therapy	$35 copay per visit, no deductible	50% of U&C, after deductible
Chiropractic Care	$35 copay per visit, no deductible Maximum 25 visits per year	50% of U&C, after deductible Maximum 25 visits per year
Acupuncture, when deemed medically necessary (maximum $500 per plan year)	$35 copay per visit, no deductible	50% of U&C, after deductible
Cardiac Rehabilitation (Up to 60 visits per year)	$35 copay per visit, no deductible	50% of U&C, after deductible
Speech Therapy (must be physician approved)	$35 copay per visit, no deductible	50% of U&C, after deductible
Allergy Testing and Injections	30% after deductible	50% of U&C, after deductible
Chemotherapy	30% after deductible	50% of U&C, after deductible
Contraceptive Management (16 years and older)	30% after deductible	50% of U&C, after deductible
Diagnostic Procedures (performed in a hospital or for outpatient surgical care)	30% after deductible	50% of U&C, after deductible
Laboratory Tests (outpatient)	covered 100%^†	50% of U&C, after deductible
Ambulatory Surgical Facility Fee	30% after deductible	50% of U&C, after deductible
Pre-Admission Testing	30% after deductible	50% of U&C, after deductible
Second Surgical Opinion	$35 copay, no deductible	50% 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 30%, after deductible	$250 copay per admission plus 50% of U&C, after deductible
Skilled Nursing Facility Medical care only; no custodial care Limited to 365 days maximum per confinement	30% after deductible $250 copay unless transferred directly from inpatient	50% of U&C, after deductible $250 copay unless transferred directly from inpatient
Expenses related to surgery (inpatient or outpatient)
Anesthesia Services	30% after deductible	50% of U&C, after deductible
Assistant Surgical Services	30% after deductible	50% of U&C, after deductible
Cast and Dressing Services	30% after deductible	50% of U&C, after deductible
Elective Surgery
With Pre-certification	30% after deductible	50% of U&C, after deductible
Without Pre-certification, if deemed medically necessary	30% after 20% pre-certification penalty, up to first $5,000 of covered expenses, after deductible	50% of U&C, after 20% pre-certification penalty, up to first $5,000 of covered expenses, after deductible
Emergency Surgery	30% after deductible	50% of U&C, after deductible
Maternity Surgery (including physician attendance)	30% after deductible	50% of U&C, after deductible
Ambulance for Emergency	30%, no deductible	50% of U&C, after deductible
Durable Medical Equipment (Some items may require pre-certification)	30% after deductible	50% 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.	$150 copay per visit, no deductible	$150 copay per visit, after deductible
Home Health (when skilled services are required)
Combined with special duty nursing, limited to 120 days per calendar year	30% after deductible	50% of U&C, after deductible
Physician House Calls	Not covered	Not Covered
Hospice Care	30% after deductible	50% of U&C, after deductible
Accident-Related Dental Services	30% after deductible	50% 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 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 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

Your Health Care Option at a Glance

PPO Choice Plan

In-Network Benefits

Out-of-Network Benefits

Preventive Care

Maternity Care

Outpatient Care

Expenses related to surgery (inpatient or outpatient)

Expenses related to surgery
(inpatient or outpatient)