MMC Benefits Handbook
Musculoskeletal Surgery – Knee, Hip, Spine
The plan covers surgical treatment for knee, hip and spine provided by or under the direction of a physician. The Spine and Joint Solution program is available to employees, their spouses or domestic partners, and their dependent children age 18 or older enrolled in an eligible medical plan. Utilize the Spine and Joint Solution program if you, your spouse or domestic partner, or your dependent children age 18 or older are experiencing shoulder, hip, knee, recurring or long-term back pain or discomfort, or have been diagnosed with a musculoskeletal condition and are willing to speak with someone about treatment options.
The Medical plan pays benefits for spine and joint surgeries that are ordered by a physician. Spine and joint surgical procedures include spine fusion surgery, spine disk surgery, total knee replacement and total hip replacement.
Members who enroll in the Spine and Joint Solution for total knee replacements, total hip replacements, spine disc surgery and spinal fusions and who also utilize a designated provider or Center of Excellence (COE) for their surgery will have the surgery covered at 100% after the plan's in-network deductible. The COE is available in certain markets. Prior authorization is required.
To begin participating in the Spine and Joint Solutions program, or for more information:
  • Call Health Care Advisor at 866-540-5954 (or email advisor@optum.com).
  • Ask for the Spine and Joint Solutions program.
 
$400 Deductible Plan
$900 Deductible Plan
$1,500 Deductible Plan
$2,850 Deductible Plan
Tier 1: Center of Excellence
Covered at 100% after deductible
Covered at 100% after deductible
Covered at 100% after deductible
Covered at 100% after deductible
Tier 2: I
n-Network
You pay 20% after deductible
You pay
20% after deductible
You pay 20% after deductible
You pay 30% after deductible
Tier 3:
Out-of-Network
You pay 40% after deductible
You pay
40% after deductible
You pay 40% after deductible
You pay 50% after deductible
Travel and lodging expenses to and from your home will be reimbursed as defined below.
  • The patient is eligible for reimbursement if the facility is 100 miles or more from the patient's home.
  • The reimbursement for lodging expenses is limited to $50 per night.
  • The maximum reimbursement for all travel and lodging expenses is $10,000 per episode of care.