This table presents a sampling of general exclusions, beginning with a set of what was presented as typical of industry-wide practices,1 followed by a Federal Employees Health Benefits (FEHB) program fee-for-service product,2 and then exclusions among CIGNA typical small group employer plan,3 UnitedHealthcare small group plans,4 Wellpoint Anthem Blue Standard small business plan5 (see Appendix E for more detail on the latter), and the Medicare program.6,7 The FEHB program develops a short list of general exclusions for both its fee-for-service and managed care plans (see, for example, Chapter 5, Box 5-2), which individual insurers can expand upon.
1 Personal communication, Charles Bevilacqua, Kaiser Permanente; the list of industry-wide practices are not necessarily specific to Kaiser but identified across many insurers as typical.
2 These are specific to Blue Cross and Blue Shield (BCBS) fee-for-service benefit plan under the FEHBP program (http://www.fepblue.org/benefitplans/2011-sbp/bcbs-2011-RI71-005.pdf).
3 Personal communication, Rosemary Lester, CIGNA Product, September 9, 2011.
4 Personal communication, Sam Ho, UnitedHealthcare, September 13, 2011.
5 Personal communication, Ruth Raskas, WellPoint, September 9, 2011.
7 Responses were compiled exactly as submitted, explaining any variance in style (e.g., X = excluded; X for Cigna = explicitly excluded or otherwise not a covered benefit; Y = excluded; N = not excluded).
|Sample Industry Variation in Exclusion Language||Industry Typicala||FEHB-BCBS||CIGNAb||United Healthcare||WellPointc||Medicare|
|Service, drugs, or supplies you receive while you are not enrolled in this plan||X||X||X||Y||Not Covered|
|Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice in the United States||X||X||Y||Not Covered|
|Services, drugs, or supplies billed by Preferred and Member facilities for inpatient care related to specific medical errors and hospital-acquired conditions known as never eventsa||X||X||N||Not addressed in contracts|
|Services not specifically/explicitly listed as covered||X||X||Y||Not Covered|
|All services, drugs, or supplies related to the non-covered service are excluded from coverage, except services we would otherwise cover to treat complications of the non-covered service||X||X||Y||Not Covered|
|Services, drugs, or supplies not required to prevent, diagnose, or treat a medical condition||X||X||Y||Not Covered|
|Services for conditions that a plan physician determines are not responsive to therapeutic treatment||X||X||Y||Not Covered|
|Services or supplies for which no charge would be made if the covered individual had no health insurance coverage||X||X||Y||Not Covered|
|Services related to and required as a result of services which are not covered under Medicare||N||Not addressed in contracts||Y|
|Medical Necessity||Not Coverede|
|Services deemed not medically necessary||X||Y|
|Services, drugs, or supplies that are not medically necessary||X||X||Y|
|Services not reasonable and necessary||X||N, eligible expense||Y|
|Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest||X||f||Y||Varies across plans|
|Active Military Service|
|Services, drugs, or supplies you receive without charge while in active military service||X||X||Y||Not Covered|
|Automobile. No Fault, Any Liability Insurance or Workers’ Compensation||Not Covered by most planse|
|Care for any condition or injury recognized or allowed as a compensable loss through any Workers' Compensation, occupational disease or similar lawg||X||X||Y|
|Services reimbursable under automobile, no fault, any liability insurance workers' compensation||X||Nh||Y|
|The cost of whole red blood or red blood cells when they are donated or replaced or billedi||X||Y||Not Covered by some plans|
|Charges for Administrative Services|
|Exclude services, supplies, or devices if they are not prescribed, performed, or directed by a provider or facility not defined by us as such, or not licensed to do so||X||Y||Not Covered|
|Research costs (costs related to conducting a clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes)||X||Not a Benefit unless mandated||Y||Not Covered|
|Extra care costs related to taking part in a clinical trial such as additional tests that a patient might may need as part of the trial, but not as part of the patient’s routine care||Not a Benefit unless mandated||Y||Not Covered|
|Cosmetic Services||Not Coverede|
|Cosmetic servicesj X||X||X||Y|
|Services, drugs, or supplies you receive for cosmetic purposes||X||X||Y|
|Cosmetic surgery or other procedures performed solely for beautification or to improve appearance||X||Y|
|Surgical treatments of gynecomastia (male breast reduction) for cosmetic purposes||X||Y|
|Religious, personal growth counseling or marriage counseling including services and treatment related to religious, personal growth counseling or marriage counseling, unless the primary patient has a DSM IV diagnosis||X||X||Y, except DSM diagnosis also Excluded||Not Covered by most plans|
|Treatment of injuries sustained while committing a crime||X||(X in plans for individuals)||Y||Not Covered by most plans|
|Custodial care (such as feeding, dressing, bathing, transferring, and activities of daily living)k||X||Y|
|Custodial care means assistance with activities of daily living (e.g., walking, getting in and out of bed, bathing, dressing, feeding, toileting, and taking medicine), or care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates or the presence of a supervising licensed nursel||X||X||Y|
|Dental/Oral Services||Dental services Not Covered with some variation across plans for surgical extraction of impacted teeth and for TMJ treatment and appliancese|
|Any dental or oral surgical procedures or drugs involving orthodontic care, the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of denturesm||X||X||Y|
|Orthodontic care for malposition of the bones of the jaw or for temporomandibular joint (TMJ) syndrome||X||X||Y|
|Dental procedures and appliances to correct disorders of the temporomandibular (jaw) joint (also known as TMD or TMJ disorders)||X||X||Y, except surgery is covered|
|Routine dental services, including topical and oral fluoride preparations, from standard medical and pharmacy benefits except where mandated (does not apply to products with embedded dental coverage)n||X||Y|
|Teeth extractions, surgical removal of impacted teeth, and other oral surgical services (not to include pharmacy services) for care of the teeth or of the bones and gums directly supporting the teeth. These services are dental and nature and not covered under medicalo||X||Y|
|Extractions, treatment of cavities, care of the gums or structures directly supporting the teethp,q||X||X||Y|
|Treatment of periodontal abscess, removal of impacted teeth, orthodontia (including braces), false teeth, or any other dental services or supplies, except as otherwise covered under the plan||X||X||Y|
|Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures supporting the teethr||X||Y||Y|
|Any dental procedures involving orthodontic care, inlays, gold or platinum fillings, bridges, crowns, pin/post reduction, dental implants, surgical periodontal procedures, or the preparation of the mouth for the fitting or continued use of dentures||X||Y|
|Educational Services; Self-Training; Vocational Services||Not Coverede|
|Self-care or self-help training||X||Not a Benefit unless mandated||Y|
|Educational services, self management/help training services, and vocational services except where mandated for diabetes and asthma, or where explicitly covered by another benefit||Not a Benefit unless mandated||Y|
|Any educational services and programs or therapies for behavioral/conduct problemss||Not a Benefit unless mandated||Y|
|Coverage does not include services other than self management of a medical condition as determined by the Health Plan to be primarily educational in nature||X||Not a Benefit unless mandated||Y|
|Equipment that basically serves comfort or convenience functions or is primarily for the convenience of a person caring for you or your dependent, i.e., exercycle or other physical fitness equipment, elevators, hoyer lifts, shower/bath bench. Air conditioners, air purifiers and filters, batteries and charges, dehumidifiers, humidifiers, air cleaners and dust collection devices||X||X||Y||Not Covered|
|Experimental/Investigational Procedures||Not Coverede|
|Experimental or investigational servicest||X||X||Y|
|Experimental or investigational procedures, treatments, drugs, or devices||X||X||Y|
|Services related to complications resulting or arising from excluded services except where mandated or where DOI agreements have been made to cover||X||N|
|Services deemed to be experimental or investigational unless specifically covered (e.g., Clinical Cancer Trials)||X||Y|
|Expenses in excess of usual, customary and reasonable fees||X||X||N, eligible expense|
|Free care (no charge items)||X||X||Y|
|Food and Dietary Supplements|
|Benefits for food or food supplements, except formulas and/or food products that are prescribed, ordered or supervised by a physician and medically necessary as defined by medical policy||Not a Benefit unless mandated||Y||Not Covered|
|Nutritional supplements and formulae needed for the treatment of inborn errors of metabolism||X||Not a Benefit unless mandated||Y||Coveredu|
|Foot carev||X||N||See below||Y|
|Routine or palliative foot care (comfort or cosmetic) unless medically necessary||X||Y||Not Covered|
|Shoe inserts, orthotics (except for care of the diabetic foot), and orthopedic shoes (except when an orthopedic shoe is joined to a brace)||X||X||N, we cover one pair foot orthotics||Not Covered by most plans|
|Furniture (other than medically necessary durable medical equipment) such as commercial beds, mattresses, chairs||X||X||Y||Not Covered|
|Government Programs||Xe||Not Covered by most plans except as required by mandatee|
|Treatment where payment is made by any local, state, or federal government (except Medicaid), or for which payment would be made if the Participant had applied for such benefits. Services that can be provided through a government program for which you as a member of the community are eligible for participation. Such programs include, but are not limited to, school speech and reading programs||X||X||N|
|Items and services furnished, paid for or authorized by governmental entities‖Federal, state, or local governments||X||N||Y|
|Health Club Memberships||Xe||Not Covered by most planse|
|Health club memberships from core medical benefit||X||Y|
|Membership costs or fees associated with health clubs, weight loss programs||X||X||Y|
|Hearing Aids and Routine Hearing Tests||Generally Not Covered by plans unless mandatede|
|Hearing aids, hearing devices and related examinations and services||X||X||Y|
|Hearing aids and auditory implants||Y||Y|
|Hypnotherapy (hypnosis)||X||X||Y||Not Covered|
|See Reproductive Services||See Reproductive Services|
|Legal Liability||Not Coverede|
|Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B, doctor's charges exceeding the amount specified by the HHS when benefits are payable under Medicare, or State premium taxes however applied||X||X||Y|
|Services for which the member has no liability to pay in the absence of this plan’s coverage. This includes, but is not limited to: government programs; incarceration; workers compensation; and free clinics||X||Y|
|No legal obligation to pay for or provide services||X||N||Y|
|Services, other than Emergency Services, received outside the United States whether or not the services are available in the United States||X||X||Y|
|Services not provided within the United States||Y||Y|
|Massage therapyx||X||X||Y||Not Covered by most plans|
|Completion of specific medical reports, including those not directly related to treatment of the Participant, e.g., employment or insurance physicals, and reports prepared in connection with litigation||X||X||Y||Not Covered|
|Medical Supplies||Criteria for coverage varies across planse|
|Disposable supplies for home use||X||X||Y|
|Obesity/Weight Loss Services|
|Services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for office visits and diagnostic tests for the treatment of morbid obesityy; gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures||X||X||Y||Generally Not Covered by plans unless mandated|
|Nutritional counseling when billed by a covered provider such as a physician, nurse, nurse practitioner, licensed certified nurse, nurse practitioner, licensed certified nurse midwife, dietician or nutritionist, who bills independently for nutritional counseling services||X||X||Y||Coveredu as part of Preventative services for non-grandfathered plans after 9/23/2010 if services are rendered by a covered provider. Otherwise, Not Covered for most plans|
|Commercial weight loss programs from core medical benefit||X||Y||Not Covered|
|Weight reduction programs: fees and charges relating to fitness programs, weight loss, or weight control programs||X||X||Y||Not Covered|
|Gastric bypass and bariatric surgery except where mandated||Not a Benefit unless Mandated||Y||Generally Not Covered by plans unless mandated|
|Outpatient Prescription Drugsz|
|Compounded products unless the drug is listed on our drug formulary or one of the ingredients requires a prescription by law||X||X||Y||Compound Coveredu only if one of ingredients requires a prescription|
|Drugs prescribed for cosmetic purposes||X||X||Y||Not Covered|
|Drugs that shorten the duration of the common cold||X||N||Coveredu if a prescription is required|
|Drugs used to enhance athletic performance||X||X||Y||Not Covered|
|Drugs which are available over the counter and prescriptions for which drug strength may be realized by the over the counter product||X||X||Y||Not Covered|
|Experimental or investigational drugs||X||X||Y||Not Covered|
|If a service is not covered, any drugs or supplies needed in connection with that service are not covered||X||X||Y||Not Covered|
|Prescription drugs for which there is an over the counter drug equivalent||X||X||Y||Not Covered|
|Replacement of lost, damaged or stolen drugs||X||X||N||Not Covered by most plans|
|Special packaging (packaging of prescription medications may be limited to standard packaging)||X||N||Not applicable|
|Drugs and supplies needed solely for travel||X||X||N||Not Covered by most plans|
|Personal Care Items||Not Coverede|
|Personal comfort items||X||Y||Y|
|Personal comfort items such as beauty and barber services, radio, television, or telephone||X||X||Y|
|Personal comfort items such as those that are furnished primarily for your personal comfort or convenience, including those services and supplies not directly related to medical care, such as guest’s meals and accommodations, hospital admission kit, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, over the counter convenience items and take-home supplies||X||X||Y|
|Services, drugs, or supplies you receive from a provider or facility barred or suspended from the FEHB Program||X||Y||Not applicable|
|Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption||X||X||Y||Not Covered by most plans|
|Services (applies to medical and pharmacy services) performed by a provider who is a family member by birth, marriage, or adoption, or by the provider to self||X||Y||Not Covered by most plans|
|Services rendered by a provider who is a close relative or member of your household. Close relative means wife or husband, parent, child, brother or sister, by blood, marriage or adoption||X||X||Y||Not Covered by most plans|
|Charges imposed by immediate relatives of the patient or members of the patient’s households||X||Y||Not Covered by most plans||Y|
|Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs; oxygen; and physical, speech and occupational therapy rendered by a qualified professional therapist on an outpatient basis are covered subject to plan limits||X||Y, except speech and occupational therapy Excluded in most cases||Not Covered|
|Services, drugs, or supplies you receive from noncovered providers except in medically underserved areasaa||X||Y, except we do not allow in underserved areas either||Not Covered|
|Services you receive from a provider that are outside the scope of the provider's licensure or certification||X||X||Y||Not Covered|
|Services/service charges of standby physicians||X||X||Y||Not Covered by some plans|
|Care by non-plan providers except for authorized referrals or emergenciesbb||Y||Not Covered under certain plan types|
|Care by non-plan providers except for authorized referrals, emergencies and out of area urgent care||X||Y||Not Covered under certain plan types|
|Private duty nursing||X||Y||Not Covered by some plans|
|Private duty nursing provided in an inpatient setting (acute care or skilled nursing facility)cc||X||Y||Not Covered by some plans|
|Private duty nursing as a registered bed patient unless a plan physician determines medical necessity||X||X||Y||Not Covered by some plans|
|Private duty nursing in home or long term facility||X||X||Y||Not Covered by some plans|
|Services, supplies, or devices if they are not prescribed, performed, or directed by a provider or facility not defined by us as such, or not licensed to do so||X||Y||Not Covered|
|Inpatient hospital or SNF services not delivered directly or under arrangement by the provider||N||Not addressed in contracts||Y|
|Care in halfway house||X||Y||Not Covered|
|Private room unless medically necessary or if a semi-private room is not available||X||X||Y||Generally Not Covered|
|Recreational Therapy/Activities||Not Coverede|
|Recreational or educational therapy and any related diagnostic testing, except as provided by a hospital during a covered inpatient stay||X||X||Y|
|Recreational, diversional and play activities||X||X||Y|
|Fetal reduction surgery||X||Y||Generally not addressed in contracts|
|The reversal of voluntary/elective sterilization||X||X||Y||Not Covered|
|Infertility services when the infertility is caused by or related to voluntary sterilization||X||X||Y||Not Covered by most plans except as required by mandate|
|All assisted reproductive technologies (ART) and the associated diagnostic testing and Rx treatments to support ART (e.g., artificial insemination, in-vitro fertilization, ZIFT [zygote intrafallopian transfer], GIFT [gamete intrafallopian transfer])||X||Y||Not Covered by most plans except as required by mandate|
|In vitro fertilization services||X||Y||Not Covered by most plans except as required by mandate|
|Infertility services related to advanced reproductive technologies including but not limited to in vitro fertilization (IVF); gamete intrafallopian transfer (GIFT); zygote intrafallopian transfer (ZIFT) and variations of these procedures||X||X||Y||Not Covered by most plans except as required by mandate|
|Donor charges and services||X||X||Y||Not Covered by most plans except as required by mandate|
|Cryopreservation of donor sperm and eggs||X||X||Y||Not Covered by most plans except as required by mandate|
|Any experimental, investigational or unproven infertility procedures or therapies||X||X||Y||Not Covered|
|Routine Services||Not Covered under some grandfathered planse|
|Routine services and appliances||Unable to determine definition of category, therefore no comment||N||Y|
|Routine services, such as periodic physical examinations; screening examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity caredd||X||N|
|Sexual reassignment surgery||X||X||Y||Not Covered|
|Services related to sexual transformations||X||Y||Not Covered|
|Services, drugs, or supplies related to sex transformations||X||Y||Not Covered|
|Services, drugs, or supplies related to sex transformations, sexual dysfunction, or sexual inadequacy (except for surgical placement of penile prostheses to treat erectile dysfunction)||X||X||Y||See above and below|
|Drugs and devices used for the treatment of sexual dysfunction||X||Y||Not Covered by some plans|
|Professional charges for shift differentials||X||X||Y||Not addressed in contract|
|Smoking cessation programs||X||Y,||Programs not affiliated with WellPoint Not Covered in most plans|
|Surrogacy||Services provided to an individual not covered under the plan are Not Coverede|
|Services related to surrogacy||X||Y|
|Services related to conception, pregnancy or delivery in connection with a surrogate arrangement. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the childee||X||X||Y|
|Testing for ability, aptitude, intelligence or interest||X||X||Y||Not Covered by some plans|
|Third-party Requests or Requirements|
|Physical examinations and other services, and related reports and paperwork, in connection with third-party requests or requirements, such as those for: employment, participation in employee programs, insurance, disability, licensing, or on court order or for parole or probation||X||X||Y||Generally Not Covered with some nuances across plans|
|Topical Hyperbaric Oxygen Therapy (THBO)|
|Topical Hyperbaric Oxygen Therapy (THBO)||X||Not a Benefit||N||Not addressed in contract|
|Travel or Transportation|
|Travel or transportation (other than a state licensed professional ambulance service) expenses even though prescribed by a physician, except as noted under transplants||X||X||Y||Generally not addressed in contract|
|Treatment of Dementia, Amnesia, or Mental Retardation|
|Treatment of dementia, amnesia or mental retardation, except for treatment of psychological symptoms related to these conditions||X||Y, no mental covered unless optional is purchased||Not Covered by some plans|
|Treatments of all varicose and spider vein surgeries for cosmetic purposes||X||Y||Not Covered|
|Vision Services||Vision services generally Not Covered with some nuances across planse|
|Eye glasses and contact lenses for individuals at least 18 years of age.||X||Y, excluded any age|
|Vision correction surgery (e.g., Lasik, radial keratotomy) to correct refractive error, including near sightedness, far sightedness, and/or astigmatism; orthoptics and vision therapy/training; prescription and non-prescription eyewearff||X||Y|
|Radial keratotomy; and surgery, services, evaluations or supplies for the surgical correction of near sightedness and/or astigmatism or any other correction of vision due to a refractive problem||X||X||Y|
|Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision) or visual training||X||X||Y|
|Vision-medical benefits for low vision aids, eyeglasses, contact lenses for prescription or fitting and follow-up care thereof, except that covered expenses will include the purchase of the first pair of eyeglasses, lenses, frames or contact lenses that follows cataract surgery or loss of lens due to eye disease for aphakia or aniridia||X||X||Y|
|War||Not Covered by most planse|
|Any disease or injury resulting from a war, declared or not, or any military duty or any release of nuclear energy. Also excluded are charges for services directly related to military service provided or available from the Veterans’ Administration or military medical facilities as required by law||X||X||Y|
|Services resulting from war||X||Y||Y|
a Approximately 25 percent of customers will accept these exclusions as listed. About 50 percent of customers will add exclusions to the list, while the other 25 percent will remove some exclusions. Those customers who add or remove exclusions typically only make changes to a small number of services. This list of exclusions is typical for both self-funded plans as well as traditionally insured plans. Self-funded plans, however, tend to customize this list more than fully insured plans.
b This table reflects exclusions for CIGNA’s Typical Small Group Employer Plan.
c This table reflects exclusions for Anthem/Blue Standard Coverage/Typical small group and individual plans.
d Never events are errors in medical care that are clearly identifiable, preventable, and serious in their consequences, such as surgery performed on a wrong body part, and specific conditions that are acquired during your hospital stay, such as severe bed sores.
e Respondents sometimes answered on the gray category line when specific wording choices did not match their own.
f Elective abortions are not a benefit in the individual plan products; maternity care is not a typical benefit in individual plans.
g Exception: Benefits are provided for actively employed partners and small business owners not covered under a Workers’ Compensation Act or similar law, if elected by the group and additional premium is paid. Services or supplies for injuries or diseases related to you or your dependent’s job to the extent you or your dependent is required to be covered by a workers’ compensation law.
h Coordination of benefits provided.
i Except expenses for administration and processing of blood and blood products (except blood factors) covered as part of inpatient and outpatient services.
j Except as otherwise specified for services covered under “reconstructive surgery.”
k Does not apply to hospice.
l This exclusion does not apply to services covered under “hospice care.”
m Except as specifically allowable under Oral and maxillofacial surgery.
n Exclusion does not apply to: anesthesia and associated facility charges as a result of age and/or disability criteria; dental accidents—treatment, sought within 12 months, of an injury to natural teeth and when a treatment plan submitted for prior approval. Injuries resulted from biting and/or chewing are not considered a dental accident; radiation—dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer.
o Other oral surgical services are covered, including treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; orthognathic surgery that is required because of a medical condition or injury which prevents normal function of the joint or bone and is deemed medically necessary to attain functional capacity of the affected part; oral/surgical correction of accident-related injuries; treatment of lesions, removal of tumors and biopsies; incision and drainage of infection of soft tissue not including teeth-related cysts or abscesses.
p Structures supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.
q This exclusion does not apply to accidental injury to sound and natural teeth.
r Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process.
s This exclusion does not apply to coverage for medication management.
t A Service is experimental or investigational if the health plan, in consultation with the medical group, determines that: generally accepted medical standards do not recognize it as safe and effective for treating the condition in question (even if it has been authorized by law for use in testing or other studies on human patients); it requires government approval that has not been obtained when Service is to be provided; it cannot be legally performed or marketed in the United States without FDA approval; it is the subject of a current new drug or device application on file with the FDA; it is provided as part of a research trial; (see specific section for clinical trials); it is provided pursuant to a written protocol or other document that lists an evaluation of the service’s safety, toxicity, or efficacy as among its objectives; it is subject to approval or review of an IRB or other body that approves or reviews research; it is provided pursuant to informed consent documents that describe the services as experimental or investigational, or indicate that the services are being evaluated for their safety, toxicity or efficacy; or the prevailing opinion among experts is that use of the services should be substantially confined to research settings or further research is necessary to determine the safety, toxicity, or efficacy of the service.
u Covered subject to terms and conditions of the contract. For example, there may be network limitations, medical policy limitations, cost-sharing requirements, dollar caps, visit limits, etc.
v Except when medically necessary.
w Cochlear implants are not necessarily included in the exclusion. Cover routine hearing screenings as a part of preventive care.
x Except when provided as a procedure during a covered therapy.
y A condition in which an individual has a BMI of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment.
z Insurer may outline drugs that should be reviewed based on employer selection: drugs used in the treatment of infertility, sexual dysfunction, weight control, smoking cessation, and growth hormone.
aa For 2011, for example: Alabama, Arizona, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri, Montana, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming.
bb A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care.
cc Nursing services in a home or hospice setting are covered as a part of home health care benefits and hospice benefits.
dd Certain services are exempted, including those preventive services specifically covered under preventive care (adult and child), preventive screenings specifically listed in the plan brochure; and certain routine services associated with covered clinical trials.
ee The plan might choose alternative wording for this exclusion: in situations where you receive monetary compensation to act as a surrogate, health plan will seek reimbursement of all charges for covered services you receive that are associated with conception, pregnancy and/or delivery of the child. A surrogate arrangement is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child.
ff Exclusion does not apply to medial and surgical services for the treatment of injuries and diseases affecting the eye (e.g., eye exams for diabetics, eyewear/contacts and related services to replace lenses following surgery or injury, etc.).