Incentive PPO

Summary of benefits chart

Each time you need care you have a choice to make — you can use providers in the network or you have the option to use providers outside the PPO network. To encourage you to use PPO providers whenever possible, the plan pays a higher percentage of covered charges when you use a PPO provider. The plan has separate deductibles and out-of-pocket maximums for in-network and out-of-network providers. The deductible and out-of-pocket maximum amounts are lower if you use in-network providers. Different campuses have different provider networks. See the box below.

Primary care benefit for in-network office visits

The Incentive PPO includes a Primary Care Benefit to cover office visit charges from certain types of in-network health care providers. Under this benefit, you’ll pay a lower coinsurance (10 percent) and no deductible. The Primary Care Benefit applies to any office visits with any network pediatrician, family practice physician, general practitioner, internist, and OB/GYN who participates in the PHCS network (for West Lafayette, Calumet, and North Central employees only) or in the Signature Care network (for Fort Wayne employees only). In addition, their supporting physician’s assistants and nurse practitioners are also included. Amounts you pay under the Primary Care Benefit do not count toward your out-of-pocket maximum. Should you reach your maximum, you will still be responsible for paying a 10 percent coinsurance for Primary Care Benefit office visits.

Other in-network care

When you receive care from a network provider—other than that provided under the Primary Care Benefit outlined above—you pay for services until you meet your in-network calendar year deductible. After you meet this deductible ($400 per individual/$800 per family), you pay 15 percent coinsurance on future expenses until you reach the out-of-pocket maximum for in-network services ($1,800 per individual/$3,600 per family). Once you reach the out-of-pocket maximum, the plan pays 100 percent of covered in-network expenses for the remainder of the calendar year, excluding charges that fall under the Primary Care Benefit. Network providers will generally file claims for you, and you won’t be billed for amounts above the usual and customary (U&C) fee. 

Out-of-network care

If you decide that you need care from a provider outside the plan’s network, you pay for the full amount of services until you meet your out-of-network calendar year deductible ($800 per individual/$1,600 per family). After you meet the deductible, you pay 40 percent coinsurance on future expenses until you reach the out-of-pocket maximum for out-of-network services ($3,600 per individual/$7,200 per family). If you reach the out-of-pocket maximum, the plan will pay 100 percent of your eligible expenses for the rest of the calendar year.

You may have to pay for services and file claim forms if you visit providers outside the network. Because out-of-network providers have not agreed to negotiated rates, they are free to charge any amount for services or supplies—which can cost you more. If you visit an out-of-network provider, you are also responsible for paying any amount above U&C, in addition to your coinsurance. Amounts over the U&C do not count toward your deductible or out-of-pocket maximum. There is no Primary Care Benefit on providers outside the plan’s network. Out-of-network primary care office visits are subject to the deductible and coinsurance, just as all other out-of-network services.

Should you need to go to an out-of-network emergency room or be admitted to an out-of-network hospital due to a sudden and severe medical condition, the in-network deductible and coinsurance will apply. You will not be responsible for any amount above the U&C.

Preventive care benefit

Preventive care includes health care services and screenings that can alert you to a medical condition that you were not aware of having. This early detection, plus appropriate action on your part, can prevent you from developing a more severe medical condition. Preventive care also includes care or services that will actually keep you from getting a medical condition, such as immunizations.

Preventive care does not include care or services you receive as a result of medical symptoms you are experiencing or as treatment or monitoring of a medical condition.

Preventive care includes such things as physical examinations, immunizations, well baby care, mammograms, pap smears, prostate exams, colonoscopies, and screenings for high blood pressure, bone density, and sexually transmitted diseases. However, as noted above, if you receive any of these services to monitor or treat a medical condition or as a result of any medical symptoms you are experiencing, they are not considered preventive. You and your covered dependents will each receive an annual $400 benefit for preventive care, which you may only use with in-network providers. This amount is not subject to the deductible. Annual in-network preventive care beyond $400 is subject to the in-network deductible and coinsurance. All preventive care through out-of-network providers is subject to the out-of-network deductible and coinsurance.

If you or your dependents undergo a preventive colonoscopy or flexible sigmoidoscopy, you will not pay anything for these services if you use an in-network provider. Additionally, these in-network procedures do not count against the annual $400 preventive care maximum.

Good communication between you and your physician is the key to having your preventive care claim paid correctly. It is important that you inform your medical provider that you have a preventive care benefit so that your doctor will code your service as “preventive” rather than “medical.” This upfront communication can help you avoid the effort of having your claim corrected later.

Summary of Incentive PPO benefits

* Includes in-network amounts.