Limitations and Exclusions
Your coverage in this health plan is limited or excluded as described in this part. Other limits or restrictions and exclusions on your coverage may be found in Parts 3, 4, 5, 7, and 8 of this benefit booklet. You should be sure to read all of the provisions that are described in this benefit booklet, your Schedule of Benefits, and any riders that apply to your coverage in this health plan.
Admissions That Start Before Effective Date
This health plan provides coverage only for those covered services that are furnished on or after your effective date. If you are already an inpatient in a hospital (or in another covered health care facility) on your effective date, you or your health care provider must call Blue Cross and Blue Shield. (See Part 4.) This health plan will provide coverage starting on your effective date but only if Blue Cross and Blue Shield is able to coordinate your care. This coverage is subject to all of the provisions that are described in this benefit booklet, your Schedule of Benefits, and any riders that apply to your coverage in this health plan.
Benefits From Other Sources
No benefits are provided for health care services and supplies to treat an illness or injury for which you have the right to benefits under government programs. These include the Veterans Administration for an illness or injury connected to military service. They also include programs set up by other local, state, federal, or foreign laws or regulations that provide or pay for health care services and supplies or that require care or treatment to be furnished in a public facility. No benefits are provided by this health plan if you could have received governmental benefits by applying for them on time. This exclusion does not include Medicaid or Medicare.
Cosmetic Services and Procedures
No benefits are provided for cosmetic services that are performed solely for the purpose of making you look better. This is the case whether or not these services are meant to make you feel better about yourself or to treat your mental condition. For example, no benefits are provided for: acne related services such as the removal of acne cysts, injections to raise acne scars, cosmetic surgery, and dermabrasion or other procedures to plane the skin; electrolysis; hair removal or restoration (except as described in Part 5 for scalp hair prostheses); and liposuction. (See Part 5 for your coverage for reconstructive surgery.)
No benefits are provided for custodial care. This type of care may be furnished with or without routine nursing or other medical care and the supervision or care of a physician.
Except as described otherwise in this benefit booklet or your Schedule of Benefits, no benefits are provided for treatment that Blue Cross and Blue Shield determines to be for dental care. This is the case even when the dental condition is related to or caused by a medical condition or medical treatment. There is one exception. This health plan will cover facility charges when you have a serious medical condition that requires that you be admitted to a hospital as an inpatient or to a surgical day care unit of a hospital or to an ambulatory surgical facility in order for your dental care to be safely performed. Some examples of serious medical conditions are: hemophilia; and heart disease.
Educational Testing and Evaluations
No benefits are provided for exams, evaluations, or services that are performed solely for educational or developmental purposes. The only exceptions are for: covered early intervention services; treatment of mental conditions for enrolled dependents who are under age 19; and covered services to diagnose and/or treat speech, hearing, and language disorders. (See Part 5.)
Exams or Treatment Required by a Third Party
No benefits are provided for physical, psychiatric, and psychological exams or treatments and related services that are required by third parties. Some examples of non-covered services are: exams and tests that are required for recreational activities, employment, insurance, and school; and court-ordered exams and services, except when they are medically necessary services. (But, certain exams may be covered when they are furnished as part of a covered routine physical exam. See Part 5.)
Experimental Services and Procedures
This health plan provides coverage only for covered services that are furnished according to Blue Cross and Blue Shield medical technology assessment criteria. No benefits are provided for health care charges that are received for or related to care that Blue Cross and Blue Shield considers experimental services or procedures. The fact that a treatment is offered as a last resort does not mean that this health plan will cover it. There are two exceptions. As required by law, this health plan will cover:
- One or more stem cell (“bone marrow”) transplants for a member who has been diagnosed with breast cancer that has spread.
- Certain drugs that are used on an off-label basis. Some examples of these drugs are: drugs used to treat cancer; and drugs used to treat HIV/AIDS.
Except as described otherwise in this benefit booklet, no benefits are provided for eyeglasses and contact lenses.
Medical Devices, Appliances, Materials, and Supplies
No benefits are provided for medical devices, appliances, materials, and supplies, except as described otherwise in Part 5. Some examples of non-covered items are:
- Devices such as: air conditioners; air purifiers; arch supports; bath seats; bed pans; bath tub grip bars; chair lifts; computerized communication devices (except for those that are described in Part 5); computers; computer software; dehumidifiers; dentures; elevators; foot orthotics; hearing aids (unless they are described as a covered service in your Schedule of Benefits and/or riders); heating pads; hot water bottles; humidifiers; orthopedic and corrective shoes that are not part of a leg brace; raised toilet seats; and shoe (foot) inserts.
- Special clothing, except for: gradient pressure support aids for lymphedema or venous disease; clothing needed to wear a covered device (for example, mastectomy bras and stump socks); and therapeutic/molded shoes and shoe inserts for a member with severe diabetic foot disease.
- Self-monitoring devices, except for certain devices that Blue Cross and Blue Shield decides would give a member having particular symptoms the ability to detect or stop the onset of a sudden life-threatening condition.
No benefits are provided for charges for appointments that you do not keep. Physicians and other health care providers may charge you if you do not keep your scheduled appointments. They may do so if you do not give them reasonable notice. You must pay for these costs. Appointments that you do not keep are not counted against any benefit limits that apply to your coverage in this health plan.
No benefits are provided for any services and supplies that are furnished by the kinds of health care providers that are not covered by this health plan. This benefit booklet describes the kinds of health care providers that are covered by the health plan. (See “covered providers” in Part 2 of this benefit booklet.)
No benefits are provided for:
- A service or supply that is not described as a covered service. Some examples of non-covered services are: acupuncture (unless it is described as a covered service in your Schedule of Benefits and/or riders); private duty nursing; and reversal of sterilization.
- A service or supply that is furnished along with a non-covered service.
- A service or supply that does not conform to Blue Cross and Blue Shield medical policies.
- A service or supply that does not conform to Blue Cross and Blue Shield medical technology assessment criteria.
- A service or supply that is not considered by Blue Cross and Blue Shield to be medically necessary for you. The only exceptions are for: certain routine or other preventive health care services or supplies; certain covered voluntary health care services or supplies; and donor suitability for bone marrow transplant.
- A service or supply that is furnished by a health care provider who has not been approved by Blue Cross and Blue Shield for payment for the specific service or supply.
- A service or supply that is furnished to someone other than the patient, except as described in this benefit booklet for: hospice services; and the harvesting of a donor’s organ (or tissue) or stem cells when the recipient is a member. This coverage includes the surgical removal of the donor’s organ (or tissue) or stem cells and the related medically necessary services and tests that are required to perform the transplant itself.
- A service or supply that you received when you were not enrolled in this health plan. (The only exception is for routine nursery charges that are furnished during an enrolled mother’s maternity admission and certain other newborn services.)
- A service or supply that is furnished to all patients due to a facility’s routine admission requirements.
- A service or supply that is related to achieving pregnancy through a surrogate (gestational carrier).
- A service or supply that is related to sex change surgery or to the reversal of a sex change.
- Refractive eye surgery for conditions that can be corrected by means other than surgery. This type of surgery includes radial keratotomy.
- Whole blood; packed red blood cells; blood donor fees; and blood storage fees.
- A health care provider’s charge for shipping and handling or taxes.
- A health care provider’s charge to file a claim for you. Also, a health care provider’s charge to transcribe or copy your medical records.
- A separate fee for services furnished by: interns; residents; fellows; or other physicians who are salaried employees of the hospital or other facility.
- Expenses that you have when you choose to stay in a hospital or another health care facility beyond the discharge time that is determined by Blue Cross and Blue Shield.
Personal Comfort Items
No benefits are provided for items or services that are furnished for your personal care or for your convenience or for the convenience of your family. Some examples of non-covered items or services are: telephones; radios; televisions; and personal care services.
Private Room Charges
While you are an inpatient, this health plan covers room and board based on the semiprivate room rate. At certain times, this health plan may cover a private room charge. PCP/Plan Approved Benefits may be provided only when Blue Cross and Blue Shield determines that a private room is medically necessary for you. If a private room is used but not approved in advance by Blue Cross and Blue Shield, you must pay all costs that are more than the semiprivate room rate.
Services and Supplies Furnished After Termination Date
No benefits are provided for services and supplies that are furnished after your termination date in this health plan. There is one exception. This will occur if you are admitted as an inpatient in a hospital before your termination date and payment to the hospital is based on a “Diagnosis Related Grouping” (DRG). In this case, the hospital’s DRG payment that is approved by Blue Cross and Blue Shield will be paid to the hospital. This amount will be paid by Blue Cross and Blue Shield even when your coverage in this health plan ends during your admission. No benefits are provided for other services and/or supplies that are furnished during that same inpatient admission, unless you are enrolled in a New England health plan. In this case, coverage will continue for covered services that are furnished during that same inpatient admission until all the benefits allowed by your health plan have been used up or the date of discharge, whichever comes first. But, this does not apply if your coverage in this health plan is canceled for misrepresentation or fraud.
Services Furnished to Immediate Family
No benefits are provided for a covered service that is furnished by a health care provider to himself or herself or to a member of his or her immediate family. The only exception is for drugs that this health plan covers when they are used by a physician, dentist, or podiatrist while furnishing a covered service. “Immediate family” means any of the following members of a health care provider’s family:
- Spouse or spousal equivalent.
- Parent, child, brother, or sister (by birth or adoption).
- Stepparent, stepchild, stepbrother, or stepsister.
- Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law. (For purposes of providing covered services, an in-law relationship does not exist between the provider and the spouse of his or her wife’s (or husband’s) brother or sister.)
- Grandparent or grandchild.
(For the purposes of this exclusion, the immediate family members listed above will still be considered immediate family after the marriage which had created the relationship is ended by divorce or death.)