Plan Limitations and Exclusions
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- Asher Maxwell
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1 Plan Limitations and Exclusions These medical plans do not cover all health care expenses and they all include limitations and exclusions. The following material is for informational purposes only and it contains a partial and general description of services and supplies that are generally not covered under this type of coverage. Because this a partial and general description your plan documents can differ and include as cover some of the exclusions included in this material or as excluded or with different limitations some services not mentioned in this material. Members should refer to their plan documents to determine which health care services are covered and to what extent. Services and supplies that are generally not covered include, but are not limited to: Charges for services rendered by Relatives Charges for professional services received from a person who lives in the Member s home or who is related to the Member by blood, marriage or adoption. Charges for Unlisted Services Charges for services and supplies not specifically listed in this Booklet-Certificate as Covered Medical Expenses. Charges for Ambulance Services For routine transportation to receive outpatient, inpatient or professional services. Charges for Court ordered services Charges for court ordered services or those required by court order as a condition of parole or probation, other than for medically Necessary services provided by Preferred Care Providers. Charges for routine immunizations Charges for routine immunizations, unless otherwise specified in this Booklet-Certificate. Charges for immunizations Charges for immunizations, including those required by foreign travel for covered persons of any age, except as otherwise described in this Booklet-Certificate. Cosmetic Surgery Cosmetic surgery or other services that are performed to alter or reshape normal structures of the body in order to improve appearance. Cosmetic surgery does not include reconstructive breast surgery following a mastectomy, including (1) all stages of reconstruction of the breast on which the mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and treatment of physical complications at all stages of mastectomy, including lymphedemas, in a manner determined by the attending physician and patient to be appropriate.
2 Custodial Care Custodial care is care that does not require the services of trained medical or health professionals, such as, but not limited to, help in walking, getting in and out of bed, bathing, dressing preparation and feeding of special diets, and supervision of medications which are ordinarily self-administered. Domiciliary, or rest cures for which facilities, and/or services of a general acute hospital are not medically required including resident treatment centers are also excluded. Dental Services Dental services, including dentures, bridges, crowns, caps, clasps, habit appliances, partials, or other dental prostheses, dental services, extraction of teeth or treatment to the teeth or gums. Dental Implants: materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of implants. Orthodontic Services: Braces, other orthodontic treatment appliances, orthodontic services. Diagnostic Admissions Diagnostic admissions, inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Educational Services Educational services, except as specifically provided or arranged by Aetna. Excess Amounts Any amounts in excess of the maximum amounts shown in the Summary of Coverage. Experimental Any medical, surgical and /or other procedures, services, products, drugs or devices including implants, whose use is mainly limited to laboratory and /or animal research. Aetna has the sole discretion to make this determination. Food or Dietary Supplements Food or dietary supplements, except for formulas and special food products as specifically stated under the section Phenylketonuria (PKU) in this Booklet-Certificate. They must be prescribed by a physician in consultation with a metabolic disease specialist and deemed Necessary to prevent complications of PKU. Coverage is only to the extent that the prescribed formulas and special food products exceeded the cost of a normal diet. Genetic Testing Charges for counseling or services. Government Services Any services provided by a local, state or federal government agency except when payment under this Plan is expressly required by federal or state law.
3 Hearing Tests (Routine) Routine hearing tests except where provided for under this Booklet-Certificate. Infertility Treatment Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including but not limited to, diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal, and gamete intrafallopian transfer. Investigational Any medical, surgical and /or other procedures, services, products, drugs or devices (including implants): (a) which do not have final approval from the appropriate governmental regulatory body; or (b) which are not supported by scientific evidence which permits conclusions concerning the effect of the service, drug or device on health outcomes; or (c) which do not improve the health outcome of the patient treated; or (d) which are not beneficial as any established alternative; or (e) whose results outside the investigational setting cannot be demonstrated or duplicated; or (f) which are not generally approved or used by physicians in the medical community. Aetna has the sole discretion to make this determination. Mental or Nervous Disorders and Substance Abuse Treatment of Mental or Nervous Disorders and Substance Abuse, including nicotine use or psychological testing, except as specified in this Booklet-Certificate with respect to treatment of Serious Mental Illness and related alcoholism and drug dependency. Non-Duplication of Medicare Any services to the extent that you are entitled to receive Medicare benefits for those services, whether or not Medicare benefits are actually paid. Any services for which payment may be obtained from any local, state or federal government agency. If you are eligible for Part B of Medicare and do not enroll in it, we will still reduce the benefits payable under this Plan as if you were enrolled in Part B, and Medicare Part B benefits were paid. Veteran s Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation. Not Medically Necessary Charges for services or supplies that are not defined as medically Necessary. Nutritional Counseling, except for Diabetes. Orthotics Outpatient Speech Therapy Outpatient speech therapy, except following surgery, injury or non-congenital organic disease.
4 Personal Comfort Items Items which are furnished primarily for your personal comfort or convenience, air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators, and supplies for comfort, hygiene or beautification. Pre-existing Conditions No payment will be made for services or supplies for the treatment of a Pre-Existing Condition during a period of twelve (12) months following your effective date, (six [6] months in the state of California). However, this limitation does not apply to a child born to or newly adopted by an enrolled subscriber or spouse. Also, if you were covered under Creditable Coverage as defined by the regulations within 63 days of becoming covered under this Plan, the time spent under the Qualifying Prior Coverage will be used to satisfy, or partially satisfy, the twelve (12) month period, (six [6] month period in the state of California). Private Duty Nursing. S.A.D. Seasonal Affective Disorder Light treatment for Seasonal Affective Disorder (S.A.D.) Sex Changes Charges for procedures or treatments, to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex changes. Telephone and Facsimile Consultations Charges for consultations provided by telephone, or facsimile machines. Vision Care Charges for optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams and routine eye refractions, except as specifically stated under the benefit sections of this Booklet Certificate. Certain Eye Surgeries: Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia), astigmatism and /or farsightedness (presbyopia). Lasik surgery and any other procedures designed to surgically correct refractory conditions. War Conditions caused by an act of war, including those caused by the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy. Weight Reduction Charges for services primarily for weight reduction, treatment of obesity, or any care which involves weight reduction as a main method of treatment except medically Necessary treatment of morbid obesity with Aetna's prior authorization.
5 Worker s Compensation Any condition for which benefits are recovered or can be recovered, either by any workers compensation law, employer s liability law or work related disease law. Not Covered Charges for Covered Medical Expenses incurred before the Member's Effective Date or during an inpatient stay that began before the Member's Effective Date. Charges for Covered Medical Expenses incurred after the Member's coverage ends. Charges in excess of any Negotiated Charge for a service or supply. Charges for services exceeding the amount of benefits available for a particular service. Charges for services provided when a premium is past due, and the payment has not been received. Charges for services received by an individual who is not eligible for benefits.
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