Expenses That Are Not Eligible
The Plan does not cover expenses for the following services and supplies:
Excluded Hospital Care Expenses
- Inpatient care and services solely for observation, diagnostic testing, or physical therapy (see the medically necessary provision)
- Any inpatient care and services, including rehabilitation care and services, that can or could have been safely and adequately rendered to you as an outpatient
- Convenience items, such as guest meals, telephones, and televisions
Excluded Expenses for Reproductive Services
Any services, supplies, or drugs that in any way are intended to diagnose, restore, augment, or enhance reproductive ability, including but not limited to:
- Artificial insemination, in vitro fertilization, or similar services
- Reversal of sterilization
- Surgical sex transformation
- Treatment of sexual dysfunction not related to organic disease
- Recurrent pregnancy loss
Excluded Hearing, Prescription Drug, Dental, and Vision Expenses
- Hearing aids (except as specifically listed in "Eligible Expenses"), tinnitus maskers, or examinations for prescribing or fitting them.
- Any expenses eligible for reimbursement under the Prescription Drug Plan, Dental Plan, or Vision Plan
- Any dental treatment or vision care other than as specifically listed in "Eligible Expenses"
- Dental implants, including preparation for implants
- Stem cell tooth regeneration
- Inpatient treatment of any non-covered dental procedure, except as specified in "Eligible Expenses" for "Dental-Related Services for a Member with Special Needs"
- Eyeglasses, contact lenses, or examinations for prescribing or fitting them, except for aphakic patients (including lenses required after cataract surgery) and soft lenses or sclera shells to treat disease or injury. Vision examinations not related to the prescription or fitting of lenses will be an eligible expense only when performed in connection with the diagnosis or treatment of disease or injury.
- Eye surgery such as radial keratotomy, when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness), or astigmatism (blurring)
- Cochlear (ear) implants that are not performed at a Center of Expertise
Exclusions Related to Fraud, Waste, and Abuse
The Plan excludes any charges related to fraud, waste, and abuse.
- Fraud generally means filing a claim, causing a claim to be submitted, or making a statement that contains any materially false information, or fails to disclose material information, for the purpose of obtaining a benefit under the Plan.
- Waste generally means practices that result in unnecessary costs to the Plan, such as misuse or overutilization of services or supplies.
- Abuse generally means any practice not consistent with providing or receiving services that are medically necessary, consistent with professionally recognized standards, and priced fairly.
The following are some examples of fraud, waste, and abuse. The Plan will not cover any charges resulting from or related to these or similar practices:
- Alteration of records to receive coverage for services
- Any charges for which claim documentation is incomplete or for which the Plan or claims administrator cannot identify or understand the item(s) being billed
- Billing for more units than rendered
- Billing for non-covered services using an incorrect CPT, HCPCS, and/or diagnosis code to receive coverage for services
- Billing for services at a frequency or price per unit that is excessive or disproportionately high, relative to claims submitted to the Plan by similar providers (In all cases, for an implant or device, the Plan considers charges above 110% of the original manufacturer’s invoice price to be excessive and thus excluded. The Plan reserves the right to review the original invoices for implants or devices.)
- Billing for services that are actually performed by another provider (for example, when services were performed by an unlicensed provider but billed under a licensed provider's name)
- Billing for unnecessary services
- Billing for care, supplies, treatment, drugs and/or services that are not actually rendered
- Duplicate services and charges
- Falsifying an illness or injury
- Inappropriate or incorrect billing
- Kickbacks or any other payments for referrals of patients
- Knowingly requesting preauthorization for a different level of service than intended to avoid preauthorization or utilization review requirements (for example, requesting outpatient surgery preauthorization for a procedure that will actually be performed on inpatient basis)
- Lack of documentation in the records to support the services billed
- Modifier misuse
- Providing any false or misleading information to the Plan
- Providing false or misleading information in connection with enrollment in the Plan
- Submitting a claim for benefits or attempting to fill a prescription for a person who is not an eligible member
- Unbundling (charging for any items separately that are customarily included in a global billing procedure code)
- Upcoding (assigning an inappropriate billing code to a medical procedure or treatment), or billing for services at a level of complexity higher than actually rendered
Fraud, waste, or abuse committed by a member (or a member’s knowledge of such actions being taken by another person or a provider) will result in denial of claims, and may result in retroactive termination of all coverage under the Plan for the member’s entire family.
In addition, fraud, waste, or abuse committed by a health care provider will result in denial of claims.
It is important to note that committing a fraudulent act may also be subject to prosecution by the United States Department of Labor, and punishable by a substantial fine, imprisonment, or both.
Exclusions Related to Durable Medical Equipment (DME)
The Plan excludes certain charges related to DME:
- Cleaning supplies
- Cold therapy and ice machines
- Equipment, or electrical or mechanical features to enhance basic equipment, that serves as a comfort or convenience (such as a computer)
- Equipment used for environmental setting or surroundings of an individual, such as:
- Air conditioners
- Air filters
- Portable bath jet pumps
- Modifications to the individual’s home or vehicle
- Fees charged to fill oxygen containers
Other Exclusions That Apply to Expenses for All Services or Supplies
- Amounts in excess of the Allowable Charge for any service (including any amounts that are "balance billed" by a provider)
- Any charges by a provider sanctioned under a federal program for reason of fraud, waste, abuse, or medical competency
- Any charges by a resident in a teaching hospital where a faculty physician did not supervise services
- Any expenses related to a claim where the provider or manufacturer did not require the member to pay the required deductibles, copays, coinsurance, and/or benefit penalties in full. The member is required to pay these out-of-pocket expenses under the terms of the Plan. This requirement cannot be waived by a provider or manufacturer under any “fee forgiveness,” “no out-of-pocket,” “coupon,” or similar arrangement. If a provider or manufacturer waives the required out-of-pocket expenses, the member’s claim may be denied, or benefits reduced, and the member will be responsible for payment of the remaining balance. The claim(s) may be reconsidered if the member provides satisfactory proof to the Plan Administrator that he or she paid the out-of-pocket expenses under the terms of the Plan. In any case, the Plan has the right to require receipts or other satisfactory proof that the member paid the out-of-pocket expenses required under the terms of the Plan
- Any service or supply that is determined to be experimental or investigational in nature
- Any service or supply that is not medically necessary
- Care, supplies, treatment, and/or services for illnesses or injuries resulting from error, negligence, misfeasance, malfeasance, nonfeasance, or malpractice on the part of any provider
- Charges for administrative activities, such as preparation of medical records and itemized bills
- Charges for any care, supplies, treatment, and/or services of an injury or illness not payable by virtue of the Plan’s subrogation, reimbursement, and/or third-party responsibility provisions
- Charges for care, supplies, treatment, and/or services for any injury or sickness which is incurred while taking part or attempting to take part in an illegal activity, including but not limited to misdemeanors and felonies. It is not necessary that an arrest occur, criminal charges be filed, or, if filed, that a conviction result. Proof beyond a reasonable doubt is not required to be deemed an illegal act. This exclusion does not apply if the injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions).
- Charges for exercise programs for treatment of any condition, except for occupational or physical therapy covered by the Plan
- Charges for which there is not a procedure code or diagnosis code, or for which the procedure code is considered “unlisted”
- Charges for which you have no legal obligation to pay in the absence of this or like coverage
- Contraceptive drugs or devices which are sold without a physician's prescription (including condoms; contraceptive foam, sponges, or cream; or other spermicides)
- Cosmetic surgery or complications, including surgery to improve or restore your appearance, unless it is:
- Needed to repair conditions directly resulting from an accidental injury, taking into account the nature of the surgery, the intended result of the surgery, and the proximity in time of the surgery to the accidental injury,
- Preauthorized as meeting the medical-necessity requirements for 50% coverage for certain cosmetic treatments to restore normal physical function (see "Eligible Expenses"), or
- For the improvement of the physiological functioning of a malformed body member.
- In no event will any care and services for breast reconstruction or implantation or removal of breast prostheses be an eligible expense unless such care and services are performed solely and directly as a result of mastectomy, which is medically necessary.
- In no event will circumcision for adults (age 18 or older) or labiaplasty be an eligible expense.
- Covered facility services during a temporary leave of absence from the facility
- Custodial care
- Devices used specifically as safety items for, or to affect performance in, sports-related activities
- Dorsal rhizotomy for treatment of spasticity
- Ductal lavage of the mammary ducts
- Educational, behavioral, vocational, recreational, or coma stimulation therapy
- Except as provided in "Eligible Expenses," charges for telephone consultations, email or other electronic consultations, missed appointments, or completion of a claim form
- Extracorporeal shock wave treatment, also known as orthotripsy, using either a high- or low-dose protocol, for treatment of plantar fasciitis and all other musculoskeletal conditions
- Health services for treatment of military service-related illnesses, injuries, or disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you (for example, if you are entitled to receive care from a Veterans Administration hospital for a military-service related injury), unless payment is legally required
- Hippotherapy, equine-assisted learning, or other therapeutic riding programs
- Medical or surgical care that is not performed according to generally accepted professional standards, or that is provided by a provider acting outside the scope of his or her license
- Personal hygiene and convenience items, regardless of whether or not recommended by a physician or other provider. Examples include computers; air conditioners, air purifiers or filters; humidifiers; physical fitness equipment, including exercise bicycles or treadmills; or modifications to your home or vehicle
- Photodynamic therapy to treat any organ other than skin
- Physical, psychiatric, or psychological exams, testing, or treatments (unless provided at an on-site clinic) when (i) required solely for purposes of career, sports, or camp, employment, insurance, marriage, or adoption; (ii) related to judicial or administrative proceedings or orders; (iii) conducted for purposes of medical research; or (iv) required to obtain or maintain a license of any type
- Physician-standby services
- Platelet-rich plasma injections
- Preventive care services exceeding the frequencies explained in "Eligible Expenses"
- Private-duty nursing
- Professional services billed by a provider or nurse who is an employee of a hospital or skilled nursing facility and paid by the hospital or facility for the service
- Self-administered services or procedures that can be done by the member without the presence of medical supervision
- Services and supplies provided by trainers, doctors, therapists, and other service providers employed or engaged by a school, college, institution, sports team, or other organization to treat injuries incurred by students, parents, volunteers, or staff of such organization
- Services billed as an outpatient that are listed on the most recent Medicare “Inpatient Only” List at www.cms.gov
- Services or supplies for diseases contracted, or injuries sustained, as a result of voluntary participation in a war (declared or undeclared), act of war, riot, or civil disobedience
- Services or supplies for holistic or homeopathic medicine, hypnosis, hydrotherapy, aromatherapy, naturopathy, massage therapy (even if performed by a physical therapist), or other alternative or complementary treatment that is not accepted medical practice as determined by the Plan
- Services or supplies for injuries or diseases that are work-related, or for which the member has received compensation from an employer or compensation as a result of self-employment
- Services or supplies for or related to transplantation of donor organs, tissues, or bone marrow, except as specified in "Human Organ, Tissue, and Bone Marrow Transplant Services"
- Services or supplies for which a charge is not usually made
- Services or supplies not prescribed by or performed by or upon the direction of a physician or other provider
- Services or supplies provided by a member of the patient's family (including but not limited to spouse, child, step-child, parent, sibling, in-law, aunt, uncle, niece, or nephew)
- Services or supplies received before the effective date or after termination of a person's coverage under the Plan
- Services or supplies rendered to a dependent child for pregnancy, childbirth, related medical condition(s) (including complications of pregnancy), or prenatal or postnatal care of the mother, or routine care or other care of a newborn infant born to a dependent child (except for applicable preventive care services for a dependent child or as otherwise required by applicable law)
- Services provided in a community-based residential facility or group home
- Services provided in any facility that is not licensed to provide such services by the state (or other jurisdiction, if applicable) in which it is operating
- Services to the extent available or covered under workers' compensation
- Services to the extent available under federal, state, or local laws and regulations, including Medicare and other services available through the Social Security Act of 1965, as amended, except as otherwise required by law (this limitation applies even if the member is not enrolled in all coverage for which he or she is eligible)
- Services, drugs, or supplies billed by providers for inpatient, outpatient, or surgical care related to medical errors and facility-acquired conditions (sometimes referred to as "never events"), including but not limited to the conditions listed by the Centers for Medicare & Medicaid Services and any resulting complications. These 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 conditions that are acquired during a hospital stay or provider treatment, such as severe bed sores or infections.
- Services, supplies, care, or treatment arising from taking part in any activity made illegal due to the use of alcohol. Expenses will be covered for the injured members other than the person partaking in an activity made illegal due to the use of alcohol (subject to other Plan exclusions), and expenses may be covered for substance abuse treatment as specified in this Plan, if applicable. This exclusion does not apply (a) if the injury resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions).
- Services, supplies, care, or treatment for injury or sickness resulting from that member being under the influence of any controlled substance, drug, hallucinogen, or narcotic not administered on the advice of a physician. Expenses will be covered for injured members other than the person using the substances.
- This exclusion does not apply if the injury (a) resulted from being the victim of an act of domestic violence, or (b) resulted from a medical condition (including both physical and mental health conditions).
- This exclusion does not apply to eligible substance abuse treatment.
- Services, supplies, care, or treatment in connection with chelation therapy
- Stem cell therapy for treatment of joint disease
- Thermal capsulorrhaphy as a treatment of joint instability, including but not limited to instability of shoulders, knees, and elbows
- Tobacco-cessation aids, clinical services to stop smoking or any other services, treatment, or supplies related to addiction to or dependency on nicotine, unless received at an on-site clinic (prescription drugs to stop smoking may be covered under the Prescription Drug Plan)
- Transcutaneous electrical nerve stimulator (TENS)
- Travel, whether or not recommended by a provider, except as specifically described in "Travel Benefit"
- Treatment of conditions related to autism
- Treatment of obesity (except obesity counseling is covered as described in “Eligible Expenses”; also, prescription drugs to treat obesity may be covered under the Prescription Drug Plan); the following are examples of services and supplies that are not covered:
- Any equipment or device designed to promote weight loss
- Bariatric surgery, gastric bypass surgery, mini gastric bypass, lap band procedures, and other weight loss surgeries, and any preoperative visits, testing, routine adjustments, follow-ups, or treatment of complications from such surgery
- Diet foods, supplements, books, videos, home programs, etc.
- Gym memberships
- Intensive inpatient or outpatient weight loss programs
- Vocational and educational services rendered primarily for training or education purposes
- Wilderness or outdoor treatment programs (whether or not the program is part of a Residential Treatment Facility or otherwise licensed institution), therapeutic day or overnight camping, educational services, schooling or any such related or similar program, including therapeutic programs within a school setting
If a payment of benefits is made under the Medical Plan and later determined to be excluded under the terms provided above or elsewhere under the Plan, the Plan is entitled to recover the amount that has been incorrectly paid. See "Recovering Overpayments" in the Health Care Program Participation section. Any such incorrect payment shall not constitute a waiver of or exception to any Medical Plan provision for the payment recipient or any other member.