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Limitations and Exclusions

Doctor

Please Note

All benefits are subject to limitations and exclusions as described in your Member Certificate and Summary of Benefits.

The following list is not exhaustive. For a complete listing refer to the Member Certificate and Summary of Benefits or contact the Customer Care Center.

2014 Limitations and Exclusions For Individual policies

Individual exclusions and limitations ONLY

 

Updated 12.26.2013 – Includes Limitations and Exclusions based on those noted in the individual certificates filed in 2013 for the 2014 benefit year.  This list is applicable for marketing materials that go to only those who purchases coverage in the individual market. 

 

GENERAL LIMITATIONS & EXCLUSIONS

 

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in your Individual Policy and Benefit Summary (“Policy”). The following list is not exhaustive and may vary based on your Policy. For a complete listing refer to your Member Policy.

  • Acupuncture, dry needling, and prolotherapy.
  • Autopsy.
  • Chelation therapy for atherosclerosis.
  • Coma Stimulation programs.
  • Court-ordered care, unless Medically Necessary and otherwise covered under this Plan.
  • Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
  • Dental or dental-related services, treatments, or procedures not specifically covered under the “Dental Services” subsection of this Policy.
  • Dental implants. 
  • Orthognathic surgery, except for the treatment of TMD when prior authorized by our Medical Affairs Division.
  • Services required for administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.
  • 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.
  • Services provided by members of the Subscriber’s Immediate Family or any person residing with the Subscriber.
  • Holistic medicine and any other form of alternative medicine.
  • Lyme disease vaccination.
  • Massage therapy.
  • Oral surgery, unless specifically covered under the “Dental Services” subsection of this Policy.
  • Swim or pool therapy, unless Prior Authorization is obtained.
  • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
  • Items or services required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
  • 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; (c) the treatment of flexible flat feet; or (d) for any treatment or services in connection with any of these.
  • Any 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.
  • Treatment, services, 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.)
  • Treatment, services, 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.
  • Hair analysis (unless lead or arsenic poisoning is suspected).
  • Obesity-related services, including any weight loss method, unless specifically covered under this Policy.
  • All services or supplies provided in conjunction with the treatment of sexual dysfunction or sexual transformation, including, but not limited to, medications, surgical treatment, and injections.
  • Any hospital service or medical care not listed in this Policy.
  • Outpatient prescription drugs, except those prescriptions otherwise covered under this Policy.
  • Services and supplies rendered outside the scope of the provider’s license.
  • An expense incurred before the supply or service is actually provided unless prior approved by our Medical Affairs Division.
  • 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 authorization; or a denied admission.
  • Services provided in conjunction with the diagnosis and treatment of infertility.
  • Treatment, services or supplies for a non-Member Traditional Surrogate or Gestational Carrier.
  • All charges or costs exceeding a benefit maximum or Maximum Allowable Fee where applicable.
  • Collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility including for surrogacy or Gestational Carriers.
  • Oral Nutrition: Oral nutrition is not considered a medical item. Dean does not cover nutritional support that is taken orally (i.e. by mouth), unless mandated by state law or covered under a Dean medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor breast milk.
  • Educational services, except for diabetic self-management classes.
  • Cosmetic services, including cosmetic surgery.
  • Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse or neglect, unless such a replacement is specifically covered under this Policy.
  • No coverage is available for missed appointment charges, or telephone consultation charges by or between providers.
  • Low Level Light Therapy.
  • In-home behavioral health therapy services provided for the convenience of the Member.
  • Laser treatment for Port Wine Stain (PWS) lesions, except on the face.
  • Items of convenience for a Member or a Member’s family.
  • Travel immunizations.

 

Last updated 12/26/2013.

2014 Limitations and Exclusions For Group policies

Small group and large group Limitations and Exclusions ONLY

 

Updated 12.26.2013 –Includes Limitations and Exclusions based on those noted in the small group and large group certificates filed in 2013 for the 2014 benefit year.  This list is applicable for marketing materials that go to ONLY members who have policies purchased in the group market. 

 

GENERAL LIMITATIONS & EXCLUSIONS

 

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

  • Acupuncture*, dry needling, and prolotherapy.
  • Autopsy.
  • Chelation therapy for atherosclerosis.
  • Coma Stimulation programs.
  • Court-ordered care, unless Medically Necessary and otherwise covered under this Certificate.
  • Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
  • Dental or dental-related services, treatments, or procedures not specifically covered under the “Dental Services” subsection of this Certificate.
  • Dental implants.
  • Orthognathic surgery, except for the treatment of TMD when prior authorized by our Medical Affairs Division.
  • Services required for administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.*
  • 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.
  • Services provided by members of the Subscriber’s Immediate Family or any person residing with the Subscriber.
  • Holistic medicine and any other form of alternative medicine.
  • Massage therapy.
  • Swim or pool therapy, unless Prior Authorization is obtained.
  • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
  • Items or services required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
  • Outpatient prescription drugs, except those prescriptions otherwise covered under this Policy.
  • 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.
  • Any 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.
  • Treatment, services, 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.)
  • Treatment, services, 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.
  • Hair analysis (unless lead or arsenic poisoning is suspected).
  • Obesity-related services, including any weight loss method, unless specifically covered under this Certificate.
  • Services or supplies not Medically Necessary, not recommended or approved by a provider, or not provided within the scope of the provider’s license.*
  • Any hospital service or medical care not listed in this Certificate.
  • Services and supplies rendered outside the scope of the provider’s license.
  • An expense incurred before the supply or service is actually provided unless prior approved by our Medical Affairs Division.
  • 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 authorization; or a denied admission.
  • All charges or costs exceeding a benefit maximum or Maximum Allowable Fee where applicable.
  • Collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility including for surrogacy or Gestational Carriers.
  • All services or supplies provided in conjunction with the treatment of sexual dysfunction or sexual transformation, including, but not limited to, medications, surgical treatment, and injections.
  • Services provided in conjunction with the diagnosis and treatment of infertility.*
  • Treatment, services or supplies for a non-Member Traditional Surrogate or Gestational Carrier. *
  • All charges and costs related to internet and phone consultations.*
  • Oral Nutrition: Oral nutrition is not considered a medical item. Dean does not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by state law or covered under a Dean medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor breast milk.
  • Educational services, except for diabetic self-management classes.
  • Cosmetic services, including cosmetic surgery.
  • Laser treatment for Port Wine Stain (PWS) lesions, except on the face.
  • Items of convenience for a Member or a Member’s family.
  • In-home behavioral health therapy services provided for the convenience of the Member.
  • Low Level Light Therapy.
  • No coverage is available for missed appointment charges, or telephone consultation charges by or between providers.
  • Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect.
  • 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.*

 

 

* Limitations and Exclusions may vary by policy.

 

Last updated 12/26/2013

2014 Limitations and Exclusions

Individual, Small Group and Large Group Limitations and Exclusions ONLY

 

Updated 12.26.2013 – Includes Limitations and Exclusions based on those noted in the individual, small group and large group certificates filed in 2013 for the 2014 benefit year.  This list is applicable for marketing materials that go to both individual and group members. 

 

GENERAL LIMITATIONS & EXCLUSIONS

 

All benefits are subject to limitations and exclusions as described in your Schedule of Benefits and in either your Individual 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.

  • Acupuncture, dry needling, and prolotherapy.
  • Autopsy.
  • Chelation therapy for atherosclerosis.
  • Coma Stimulation programs.
  • Court-ordered care, unless Medically Necessary and otherwise covered under this Policy or Certificate.
  • Cytotoxic testing and sublingual antigens in conjunction with allergy testing.
  • Dental or dental-related services, treatments, or procedures not specifically covered under the “Dental Services” subsection of this Policy or Certificate.
  • Dental implants. 
  • Orthognathic surgery, except for the treatment of TMD when prior authorized by our Medical Affairs Division.
  • Services required for administrative examinations such as employment, licensing, insurance, adoption, or participation in athletics.
  • 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.
  • Services provided by members of the Subscriber’s Immediate Family or any person residing with the Subscriber.
  • Holistic medicine and any other form of alternative medicine.
  • Lyme disease vaccination.*
  • Massage therapy.
  • Oral surgery, unless specifically covered under the “Dental Services” subsection of this Policy.*
  • Swim or pool therapy, unless Prior Authorization is obtained.
  • Services and supplies furnished by a government plan, hospital, or institution unless by law you must pay.
  • Items or services required as a result of war or any act of war, insurrection, riot, terrorism, or sustained while performing military service.
  • 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; (c) the treatment of flexible flat feet; or (d) for any treatment or services in connection with any of these.*
  • Any 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.
  • Treatment, services, 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.)
  • Treatment, services, 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.
  • Hair analysis (unless lead or arsenic poisoning is suspected).
  • Obesity-related services, including any weight loss method, unless specifically covered under this Policy or Certificate.
  • Any hospital service or medical care not listed in this Policy or Certificate.
  • Outpatient prescription drugs, except those prescriptions otherwise covered under this Policy.
  • Services and supplies rendered outside the scope of the provider’s license.
  • Services or supplies not Medically Necessary, not recommended or approved by a provider, or not provided within the scope of the provider’s license.*
  • An expense incurred before the supply or service is actually provided unless prior approved by our Medical Affairs Division.
  • 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 authorization; or a denied admission.
  • All charges or costs exceeding a benefit maximum or Maximum Allowable Fee where applicable.
  • Collection and storage of sperm and eggs outside the course of treatment for, and diagnosis of, infertility including for surrogacy or Gestational Carriers.
  • Oral Nutrition: Oral nutrition is not considered a medical item. Dean does not cover nutritional support that is taken orally (i.e. by mouth), unless mandated by state law or covered under a Dean medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula, and donor breast milk.
  • Educational services, except for diabetic self-management classes.
  • Cosmetic services, including cosmetic surgery.
  • Replacement of an item if the item is lost, stolen, or unusable/nonfunctioning because of misuse, abuse or neglect, unless such a replacement is specifically covered under this Policy.*
  • No coverage is available for missed appointment charges, or telephone consultation charges by or between providers.
  • Low Level Light Therapy.
  • In-home behavioral health therapy services provided for the convenience of the Member.
  • Laser treatment for Port Wine Stain (PWS) lesions, except on the face.
  • Items of convenience for a Member or a Member’s family.
  • All services or supplies provided in conjunction with the treatment of sexual dysfunction or sexual transformation, including, but not limited to, medications, surgical treatment, and injections.*
  • Services provided in conjunction with the diagnosis and treatment of infertility.*
  • Treatment, services or supplies for a non-Member Traditional Surrogate or Gestational Carrier.*
  • 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.*
  • All charges and costs related to internet and phone consultations.*
  • Travel immunizations.

 

* Limitations and Exclusions may vary by Policy or Certificate.

 

Last updated 12/26/2013.