Limitations and Exclusions - Dean Health Plan

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Limitations and Exclusions

2017 Limitations and Exclusions

This list is based on the limitations and exclusions included in the commercial certificates filed in 2016 for the 2017 benefit year.

GENERAL LIMITATIONS & EXCLUSIONS

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in either your Policy and Benefit Summary (“Policy”) if you have individual coverage or your Group Member Certificate (“Certificate”) if you have coverage through your employer. The following list is not exhaustive and may vary based on your Policy or Certificate. For a complete listing refer to your Member Policy or Certificate.

Medical

  • Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
  • Hair analysis (unless lead or arsenic poisoning is suspected).
  • Preimplantation genetic testing of embryos and gametes.
  • Convenience items for a Member or a Member’s family, unless otherwise specified in this policy.
  • Drugs provided in conjunction with the treatment of infertility, including but not limited to those administered in a physician’s office.*
  • Outpatient prescription drugs, except those prescriptions otherwise covered under this Policy.
  • Oral Nutrition: Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by state law or covered under Our medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor breast milk.
  • Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect.
  • Sexual dysfunction supplies, including but not limited to medications and injections.*
  • Autopsy.
  • Charges or costs relating to donor sperm.
  • Consultation for, or procedures in connection with, in vitro fertilization, embryo transplantation, and/or any other assistive reproductive technique (e.g. GIFT, ZIFT).
  • Cosmetic services, including cosmetic surgery.
  • Experimental or investigational services, treatments, or procedures, and any related complications as determined by our Quality and Care Management division, unless coverage is required by state or federal law.
  • Infertility-related services or procedures.*
  • Infertility-related services or procedures not otherwise covered by this policy, including but not limited the collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility, including for surrogacy or Gestational Carriers.*
  • Items that can be purchased over the counter.
  • Laser treatment for Port Wine Stain (PWS) lesions, except on the face and neck.
  • Medical and surgical treatment of excessive sweating (hyperhidrosis).*
  • Podiatry services or routine foot care rendered in the absence of localized illness, injury, or symptoms in connection with, but not limited to: (a) the examination, treatment, or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; (b) the cutting, trimming, or other non-operative partial removal of toenails; or (c) for any treatment or services in connection with any of these.
  • Obesity-related services, including any weight loss method, surgical treatment or hospitalization for treatment of obesity, unless specifically covered under this Certificate.
  • Reversal of voluntary sterilization and related procedures.
  • Services related to surrogacy.
  • Sexual dysfunction treatment and services including but not limited to surgical treatment.
  • Sex transformation surgery.
  • Sterilization procedures for men.*
  • Sterilization procedures for women and patient education and counseling related to contraception for all women with reproductive capacity. (Although these are technically excluded from your group’s health plan insurance coverage, they will be paid for as preventive services by Dean Health Plan, as required by federal regulations).*
  • Travel immunizations.*
  • Acupuncture.*
  • Behavioral health therapy services provided in the home.
  • Chelation therapy for atherosclerosis.
  • Coma stimulation programs.
  • Dry needling.
  • Holistic medicine and any other form of alternative medicine.
  • Low Level Light Therapy.
  • Massage therapy.
  • Prolotherapy.
  • Swim or pool therapy, unless Prior Authorization is obtained.

Non-Medical

  • Administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.*
  • Court-ordered care, unless Medically Necessary and otherwise covered under this Certificate.
  • Educational services, except for diabetic self-management classes.
  • Internet and phone consultations, including all related charges and costs, except as defined by our medical policy.
  • Missed appointment charges.
  • Telephone consultation charges by or between providers.
  • Charges or costs exceeding a benefit maximum or Maximum Allowable Fee where applicable.
  • Expense incurred before the supply or service is actually provided unless prior approved by our Quality and Care Management division.
  • Services, treatment, and supplies provided to a Member while the Member is held or detained in custody of law enforcement officials, or imprisoned in a local, state, or federal penal or correctional institution.
  • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
  • Service for hospital or medical care not listed in this Certificate.
  • Services, treatment, and supplies provided in connection with any illness or injury caused by: (a) a Member’s engaging in an illegal occupation or (b) a Member’s commission of, or an attempt to commit, a felony. (Note that this exclusion does not apply to the treatment of injuries that result from an act of domestic violence, to the extent that such treatment would otherwise be covered.)
  • Services provided by members of the Subscriber’s Immediate Family or any person residing with the Subscriber.
  • Services or supplies for, or in connection with: a non-covered procedure or service, including complications, regardless of when a non-covered procedure or service is or was performed; a denied Prior Authorization; or a denied admission.
  • Services or supplies not Medically Necessary, not recommended or approved by a provider, or not provided within the scope of the provider’s license.
  • Services and supplies rendered outside the scope of the provider’s license.
  • Services or items required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
  • Services to the extent a Member receives or is entitled to receive any benefits, settlement, award, or damages for any reason of, or following any claim under, any Workers’ Compensation Act, employer’s liability insurance plan, or similar law or act. “Entitled” means the Member is actually insured under Workers’ Compensation.

* Indicates language that will likely vary in your Policy or Certificate.

Updated on 7/22/2016

2016 Limitations and Exclusions

This list is based on the limitations and exclusions included in the commercial certificates filed in 2015 for the 2016 benefit year.

GENERAL LIMITATIONS & EXCLUSIONS

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in either your Policy and Benefit Summary (“Policy”) if you have individual coverage or your Group Member Certificate (“Certificate”) if you have coverage through your employer. The following list is not exhaustive and may vary based on your specific Policy or Certificate. For a complete listing refer to your Member Policy or Certificate.

Medical

  • Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
  • Hair analysis (unless lead or arsenic poisoning is suspected).
  • Preimplantation genetic testing of embryos and gametes.
  • Convenience items for a Member or a Member’s family, unless otherwise specified in this policy.
  • Drugs provided in conjunction with the treatment of infertility, including but not limited to those administered in a physician’s office.*
  • Outpatient prescription drugs, except those prescriptions otherwise covered under this Policy.
  • Oral Nutrition: Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by state law or covered under Our medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor breast milk.
  • Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect.
  • Sexual dysfunction and sexual transformation supplies, including but not limited to medications and injections, unless mandated by law or covered under our medical policy.
  • Autopsy.
  • Charges or costs relating to donor sperm.
  • Consultation for, or procedures in connection with, in vitro fertilization, embryo transplantation, and/or any other assistive reproductive technique (e.g. GIFT, ZIFT).
  • Cosmetic services, including cosmetic surgery. Experimental or investigational services, treatments, or procedures, and any related complications as determined by Our Medical Affairs division, unless coverage is required by state or federal law.
  • Infertility-related services or procedures.*
  • Infertility-related services or procedures not otherwise covered by this policy, including but not limited the collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility, including for surrogacy or Gestational Carriers.*
  • Laser treatment for Port Wine Stain (PWS) lesions, except on the face and neck.
  • Podiatry services or routine foot care rendered in the absence of localized illness, injury, or symptoms in connection with, but not limited to: (a) the examination, treatment, or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; (b) the cutting, trimming, or other non-operative partial removal of toenails; or (c) for any treatment or services in connection with any of these.
  • Obesity-related services, including any weight loss method, unless specifically covered under this Certificate.
  • Reversal of voluntary sterilization and related procedures.
  • Services related to surrogacy.
  • Sexual dysfunction and sexual transformation treatment and services including but not limited to surgical treatment, unless mandated by law or covered under our medical policy.
  • Sterilization procedures for men.*
  • Sterilization procedures for women and patient education and counseling related to contraception for all women with reproductive capacity. (Although these are technically excluded from your group’s health plan insurance coverage, they will be paid for as preventive services by Dean Health Plan, as required by federal regulations).*
  • Travel immunizations.*
  • Acupuncture.*
  • Behavioral health therapy services provided in the home. Chelation therapy for atherosclerosis.
  • Coma stimulation programs.
  • Dry needling.
  • Holistic medicine and any other form of alternative medicine.
  • Low Level Light Therapy.
  • Massage therapy.
  • Prolotherapy.
  • Swim or pool therapy, unless Prior Authorization is obtained.

Non-Medical

  • Administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.*
  • Court-ordered care, unless Medically Necessary and otherwise covered under this Certificate.
  • Educational services, except for diabetic self-management classes.
  • Internet and phone consultations, including all related charges and costs, except as defined by our medical policy.
  • Missed appointment charges.
  • Telephone consultation charges by or between providers.
  • Charges or costs exceeding a benefit maximum or Maximum Allowable Fee where applicable.
  • Expense incurred before the supply or service is actually provided unless prior approved by Our Medical Affairs division.
  • Services, treatment, and supplies provided to a Member while the Member is held or detained in custody of law enforcement officials, or imprisoned in a local, state, or federal penal or correctional institution.
  • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
  • Service for hospital or medical care not listed in this Certificate.
  • Services, treatment, and supplies provided in connection with any illness or injury caused by: (a) a Member’s engaging in an illegal occupation or (b) a Member’s commission of, or an attempt to commit, a felony. (Note that this exclusion does not apply to the treatment of injuries that result from an act of domestic violence, to the extent that such treatment would otherwise be covered.)
  • Services provided by members of the Subscriber’s Immediate Family or any person residing with the Subscriber.
  • Services or supplies for, or in connection with: a non-covered procedure or service, including complications, regardless of when a non-covered procedure or service is or was performed; a denied Prior Authorization; or a denied admission.
  • Services or supplies not Medically Necessary, not recommended or approved by a provider, or not provided within the scope of the provider’s license.
  • Services and supplies rendered outside the scope of the provider’s license.
  • Services or items required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
  • Services to the extent a Member receives or is entitled to receive any benefits, settlement, award, or damages for any reason of, or following any claim under, any Workers’ Compensation Act, employer’s liability insurance plan, or similar law or act. “Entitled” means the Member is actually insured under Workers’ Compensation.

* Indicates language that will likely vary in your Policy or Certificate.

Updated on 11/20/2015

 

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