Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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Appendix F: General Exclusions
Appendix F: General Exclusions
Pages 209-224
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From page 209... ...
, 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.
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From page 210... ...
TABLE F-1 General Exclusions of Health Plans 210 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare General Exclusions 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 X X Y Not Covered medical, dental, or psychiatric practice in the United States Services, drugs, or supplies billed by Preferred and Member facilities X X N Not addressed for inpatient care related to specific medical errors and hospital-acquired in contracts conditions known as never eventsd Services not specifically/explicitly listed as covered X X Y Not Covered All services, drugs, or supplies related to the non-covered service are X X Y Not Covered excluded from coverage, except services we would otherwise cover to treat complications of the non-covered service Services, drugs, or supplies not required to prevent, diagnose, or treat a X X Y Not Covered medical condition Services for conditions that a plan physician determines are not responsive to X X Y Not Covered therapeutic treatment Services or supplies for which no charge would be made if the covered X X Y Not Covered individual had no health insurance coverage Services related to and required as a result of services which are not covered N Not addressed Y under Medicare in contracts 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 Y expense Abortion f Services, drugs, or supplies related to abortions, except when the life of the X Y Varies across mother would be endangered if the fetus were carried to term, or when the plans pregnancy is the result of an act of rape or incest Active Military Service Services, drugs, or supplies you receive without charge while in active military X X Y Not Covered service
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From page 211... ...
for cosmetic X Y purposes Cosmetic surgery X Y Y Counseling Religious, personal growth counseling or marriage counseling including X X Y, except Not Covered services and treatment related to religious, personal growth counseling or DSM by most plans marriage counseling, unless the primary patient has a DSM IV diagnosis diagnosis also Excluded 211 continued
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From page 212... ...
k Custodial care means assistance with activities of daily living (e.g., walking, X X Y 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 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, X X Y the teeth, dental implants, periodontal disease, or preparing the mouth for the fitting or continued use of denturesm Orthodontic care for malposition of the bones of the jaw or for X X Y temporomandibular joint (TMJ)
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From page 213... ...
These services are dental and nature and not covered under medicalo Extractions, treatment of cavities, care of the gums or structures directly X X Y supporting the teethp,q Treatment of periodontal abscess, removal of impacted teeth, orthodontia X X Y (including braces) , false teeth, or any other dental services or supplies, except as otherwise covered under the plan Items and services in connection with the care, treatment, filling, removal, or X Y Y replacement of teeth, or structures supporting the teethr Any dental procedures involving orthodontic care, inlays, gold or platinum X Y 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 Educational Services; Self-Training; Vocational Services Not Coverede Self-care or self-help training X Not a Benefit Y unless mandated Educational services, self management/help training services, and vocational Not a Benefit Y services except where mandated for diabetes and asthma, or where explicitly unless covered by another benefit mandated Any educational services and programs or therapies for behavioral/conduct Not a Benefit Y problemss unless mandated Coverage does not include services other than self management of a medical X Not a Benefit Y condition as determined by the Health Plan to be primarily educational in unless nature mandated Equipment Equipment that basically serves comfort or convenience functions or is X X Y Not Covered 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.
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From page 214... ...
X X Y Food and Dietary Supplements Benefits for food or food supplements, except formulas and/or food products Not a Benefit Y Not Covered that are prescribed, ordered or supervised by a physician and medically unless necessary as defined by medical policy mandated Nutritional supplements and formulae needed for the treatment of inborn X Not a Benefit Y Coveredu errors of metabolism unless mandated Foot Care Foot carev X N See below Y Routine or palliative foot care (comfort or cosmetic) unless medically X Y Not Covered necessary Shoe inserts, orthotics (except for care of the diabetic foot)
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From page 215... ...
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 Items and services furnished, paid for or authorized by governmental X N Y entities -- Federal, state, or local governments 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 aidsw X Y Hearing aids, hearing devices and related examinations and services X X Y Hearing aids and auditory implants Y Y Hypnotherapy Hypnotherapy (hypnosis)
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From page 216... ...
TABLE F-1 Continued 216 Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Services for which the member has no liability to pay in the absence of this X Y plan's coverage. This includes, but is not limited to: government programs; incarceration; workers compensation; and free clinics No legal obligation to pay for or provide services X N Y Location Coverede,u Services, other than Emergency Services, received outside the United States X X Y whether or not the services are available in the United States Services not provided within the United States Y Y Massage Therapy Massage therapyx X X Y Not Covered by most plans Medical Reports Completion of specific medical reports, including those not directly related X X Y Not Covered to treatment of the Participant, e.g., employment or insurance physicals, and reports prepared in connection with litigation 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 X X Y Generally Not dietary control, except for office visits and diagnostic tests for the treatment Covered by of morbid obesityy; gastric restrictive procedures, gastric malabsorptive plans unless procedures, and combination restrictive and malabsorptive procedures mandated Nutritional counseling when billed by a covered provider such as a physician, X X Y Coveredu as part nurse, nurse practitioner, licensed certified nurse, nurse practitioner, licensed of Preventative certified nurse midwife, dietician or nutritionist, who bills independently for services for nonnutritional counseling services grandfathered plans after 9/23/2010 if services are rendered by a covered provider.
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From page 217... ...
TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Commercial weight loss programs from core medical benefit X Y Not Covered Weight reduction programs: fees and charges relating to fitness programs, X X Y Not Covered weight loss, or weight control programs Gastric bypass and bariatric surgery except where mandated Not a Y Generally Not Benefit Covered by unless plans unless Mandated mandated Outpatient Prescription Drugsz Compounded products unless the drug is listed on our drug formulary or one X X Y Compound of the ingredients requires a prescription by law 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 X X Y Not Covered strength may be realized by the over the counter product by most plans Experimental or investigational drugs X X Y Not Covered If a service is not covered, any drugs or supplies needed in connection with X X Y Not Covered that service are 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 X N Not applicable standard packaging) 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, X X Y or telephone 217 continued
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From page 218... ...
Close relative means wife or husband, parent, child, brother or by most plans sister, by blood, marriage or adoption Charges imposed by immediate relatives of the patient or members of the X Y Not Covered Y patient's households by most plans Services or supplies furnished or billed by a noncovered facility, except that X Y, except Not Covered medically necessary prescription drugs; oxygen; and physical, speech and speech and occupational therapy rendered by a qualified professional therapist on an occupational outpatient basis are covered subject to plan limits therapy Excluded in most cases Services, drugs, or supplies you receive from noncovered providers except in X Y, except Not Covered medically underserved areasaa we do not allow in underserved areas either Services you receive from a provider that are outside the scope of the X X Y Not Covered provider's licensure or certification 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
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From page 219... ...
TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Care by non-plan providers except for authorized referrals, emergencies and X Y Not Covered out of area urgent care 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 X Y Not Covered nursing facility) cc by some plans Private duty nursing as a registered bed patient unless a plan physician X X Y Not Covered determines medical necessity 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 X Y Not Covered by a provider or facility not defined by us as such, or not licensed to do so Inpatient hospital or SNF services not delivered directly or under arrangement N Not addressed Y by the provider in contracts Care in halfway house X Y Not Covered Private room unless medically necessary or if a semi-private room is not X X Y Generally Not available Covered Recreational Therapy/Activities Not Coverede Recreational or educational therapy and any related diagnostic testing, except X X Y as provided by a hospital during a covered inpatient stay Recreational, diversional and play activities X X Y Reproductive Services 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 X X Y Not Covered sterilization by most plans except as required by mandate 219 continued
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From page 220... ...
) 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 X X Y Not Covered but not limited to in vitro fertilization (IVF)
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From page 221... ...
TABLE F-1 Continued Industry FEHB- United Sample Industry Variation in Exclusion Language Typicala BCBS CIGNAb Healthcare WellPointc Medicare Routine services, such as periodic physical examinations; screening X N examinations; immunizations; and services or tests not related to a specific diagnosis, illness, injury, set of symptoms, or maternity caredd Sexual Transformations/Dysfunction/Inadequacy 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, X X Y See above and or sexual inadequacy (except for surgical placement of penile prostheses to below treat erectile dysfunction) Drugs and devices used for the treatment of sexual dysfunction X Y Not Covered by some plans Shift Differentials Professional charges for shift differentials X X Y Not addressed in contract Smoking Cessation 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 Surrogate parenting X Y Services related to surrogacy X Y Services related to conception, pregnancy or delivery in connection with a X X Y surrogate arrangement.
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From page 222... ...
X Not a N Not addressed Benefit in contract Travel or Transportation Travel or transportation (other than a state licensed professional ambulance X X Y Generally not service) expenses even though prescribed by a physician, except as noted addressed in under transplants contract Treatment of Dementia, Amnesia, or Mental Retardation Treatment of dementia, amnesia or mental retardation, except for treatment of X Y, no mental Not Covered psychological symptoms related to these conditions covered by some plans unless optional is purchased Vein Surgery 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.
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From page 223... ...
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 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.
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From page 224... ...
, 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.
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