General Exclusions

General exclusions and limitations

 

You are not covered for the following services. These are in addition to the individual exclusions listed in the Description of benefits section of this handbook; however, this is not an exhaustive list.

If you have any questions about your benefits, please contact Customer Service at 1-800-868-5200 (TTY users please call TRS Relay 711).

  1. Services or supplies that are not described as covered in this Member Handbook
  2. Any service or supply related to or furnished along with a non-covered service or condition
  3. Acne-related services, including the removal of acne cysts, cosmetic surgery or dermabrasion. (Benefits are provided for outpatient medical care to diagnose or treat the underlying condition identified as causing the acne.)
  4. ALCAT test for food sensitivity
  5. All medical, hospital, or other health care services or supplies provided by an non-plan provider, unless approved by a plan provider and FCHP in accordance with FCHP policies and rules. FCHP will cover services or supplies rendered by non-plan providers in cases of an emergency medical condition. See Emergency and urgent care.
  6. Alternative therapies (also known as complimentary and alternative medicine) including but not limited to acupuncture, biofeedback, massage therapy, craniosacral therapy, hippotherapy, etc.
  7. Ancillary services such as vocational rehabilitation, behavioral training, sleep therapy, employment or vocational counseling and training, or educational therapy for learning disabilities
  8. Any and all costs associated with any form of surrogacy, specifically including, but not limited to, costs of prenatal, delivery-related and postnatal professional and facility-related care of gestational carriers.
  9. Any experimental procedure or service that is not generally accepted medical practice. (This does not include the off-label uses of covered prescription drugs used in the treatment of HIV/AIDS or cancer, nor to bone marrow transplants for breast cancer as required by state law.)
  10. Any services furnished by any provider not having a license or approval, under applicable state law, to furnish that type of service
  11. Any services provided by the Veterans Administration for service-connected disabilities to which members are legally entitled and for which facilities are reasonably available
  12. Any services that are the legal liability of workers’ compensation insurance or other third party insurer; any illness or injury that FHLAC determines arose out of or in the course of your employment
  13. Auditory integration therapy, such as Berard auditory integration therapy
  14. Autologous blood donation or storage for use during surgery or other medical procedures
  15. Care from a non-plan or out-of-area provider once you are medically able to return to the service area.
  16. Care that FHLAC determines is custodial. Custodial care is defined as a level of care which: (a) is chiefly designed to assist a person with the activities of daily life; and (b) cannot reasonably be expected to greatly improve a medical condition.
  17. Charges after the date on which your membership ends
  18. Clinical or laboratory research
  19. Contact lenses are covered only for: cataract after extraction; keratoconus; aphakia; or following a cornea transplant, for up to one year, if medically necessary. A lens applied as a bandage lens following an eye injury or to treat a diseased cornea is covered. Multifocal and presbyopiacorrecting lenses are not covered.
  20. Cosmetic or beautifying surgeries, procedures, drugs, services, or appliances
  21. Dental treatments and appliances for the treatment of temporomandibular joint (TMJ) disorder or other conditions. Dental treatment of TMJ is defined as conservative, nonsurgical intervention. This may include, but is not limited to: therapeutic splints, oral appliances and corrective dental treatments (for example, crowns, bridges, braces and/or prosthetic appliances).
  22. Dermatoscopy for detection of melanoma
  23. Diagnostic tests analyzed in functional medicine laboratories such as Genova Diagnostics
  24. Elective long-term psychotherapy
  25. Elective treatment or surgery not required by your medical condition, according to the judgment of the plan
  26. Extracorporeal Shock Wave Therapy (ESWT) for chronic plantar fasciitis
  27. Gender reassignment operations and treatments
  28. Holistic treatments
  29. Home video EEG monitoring
  30. Housekeeping services and/or homemaking services, including meals
  31. Interspinous process decompression (or the X-Stop® interspinous process decompression device).
  32. Maintenance treatment or services
  33. Medical care that FCHP determines is experimental, investigational, or not generally accepted in the medical community. Experimental means any medical procedure, equipment, treatment or course of treatment, or drugs or medicines that are considered to be unsafe, experimental, or investigational. This is determined by, among other sources, formal or informal studies, opinions and references to or by the American Medical Association, the Food and Drug Administration, the Department of Health and Human Services, the National Institutes of Health, the Council of Medical Specialty Societies, experts in the field, and any other association or federal program or agency that has the authority to approve medical testing or treatment.
  34. Medical expenses incurred in any government hospital or facility or for services of a government doctor or other government health professional
  35. Out-of-area care or services that could have been anticipated before leaving the FCHP Select Care service area
  36. Over-the-counter birth control preparations or devices
  37. Procedures or services related to dental care.
  38. Provider charges for shipping or copying medical records, or for failing to keep an appointment. You must pay for these charges.
  39. Psychological testing or neuropsychological assessments unless determined to be medically necessary
  40. Replacement of lost or stolen Weight Watchers® coupons
  41. Rest care or long-term care
  42. Routine circumcision performed after an infant’s discharge from a maternity hospital admission (unless determined to be medically necessary prior to discharge)
  43. Routine foot care. This includes, but is not limited to:
    • Cutting or removal of corns, calluses and plantar keratoses
    • Trimming, cutting and clipping of nails
    • Treatment of weak, strained, flat, unstable or unbalanced feet
    • Other hygienic and preventive maintenance care considered self-care (i.e., cleaning and soaking the feet, and the use of skin creams to maintain skin tone)
    • Any service performed in the absence of localized illness, injury or symptoms involving the foot
  44. Sclerotherapy, joint and ligamentous injections (prolotherapy) for non-symptomatic varicose veins
  45. Sensory integration therapy
  46. Services and supplies received for reasons of preference or convenience, including a preference to have services provided by a non-plan provider due to personal preference
  47. Services and treatment not in keeping with national standards of practice, as determined by FCHP, including, but not limited to: nutritional-based therapies, non-abstinence-based substance abuse care, crystal healing therapy, Rolfing®, regressive therapy, EST, and herbal therapy.
  48. Services authorized to be provided under MGL Chapter 71B in Massachusetts (referred to as “Chapter 766”). These services include, for example:
    • Adaptive physical education
    • Physical and occupational therapy
    • Psychological counseling
    • Speech and language therapy
    • Transportation

    Members who believe that their child may be handicapped (physical disability, mental retardation, learning problem, or behavioral problem) should seek a Chapter 766 evaluation. Members must make appropriate and reasonable efforts to obtain benefits available under state law.

  49. Services covered under the plan that are performed by a member of your family or household, unless that person is a licensed health care provider who would otherwise have been gainfully employed performing these services
  50. Services for cosmetic reasons
  51. Services for nonacute (chronic) conditions. Chronic conditions are those that exist for an extended time or continue past the expected recovery time for acute or short-term conditions. For example, the plan defines chronic pain as continuing for more than three months after the injury of illness causing the original pain.
  52. Services furnished to someone other than the member
  53. Services or supplies associated with care for military service connected disabilities for which you are legally entitled to services and for which facilities are reasonably available, or care for conditions that state and local law require be treated at a public facility
  54. Services or supplies related to a transsexual operation
  55. Services or supplies that are furnished or paid for, or with respect to which payments are actually provided, under any law of a government (national or otherwise) by reason of the past or present service of any person in the armed forces of a government
  56. Services or supplies that are not medically necessary for the prevention, detection or treatment of an illness, injury or disease as determined by a plan provider and the plan. Some examples include (but are not limited to): autopsies, routine circumcision performed after an infant’s discharge from a maternity admission, ear plugs to prevent fluid from entering the ear canal during water activities, and nutritional supplements or formulas for adults or children unless described under Special formulas as covered. Services or supplies that do not meet the plan’s medical criteria are not considered to be medically necessary.
  57. Services or supplies that are not provided by or authorized by a plan provider or the plan, except in the emergency situations described in Emergency and urgent care.
  58. Services or supplies, other than those referred to in item 51 above, that are paid for, or with respect to which benefits are actually provided, under any law of a government (national or otherwise) except where such payments are made or such benefits are provided under a plan specifically established by a government for its own civilian employees and their dependents
  59. Services received after the date that coverage ends
  60. Services that a third party or court order requires. Examples are employment, school, sports, premarital and/or summer camp examinations or tests; court-ordered treatment or evaluations; competency, adoption or child custody/visitation evaluations; and any immunizations required by an employer, related to your job and/or work conditions.
  61. Services that are considered experimental or which have not been approved by a plan medical director
  62. Services that are covered by another insurer
  63. Services that have not been authorized by the plan, including nonemergency services received out of the FCHP Select Care service area, or services beyond the plan benefit limits
  64. Services to reverse a voluntary sterilization
  65. Special duty or private duty nursing and attendant services
  66. Specialty clothing appropriate to specific medical conditions
  67. Tinnitus masker
  68. Total body photography
  69. Travel, transportation and lodging expenses for a member and/or a member’s family as a course of treatment or to receive consultation or treatment
  70. Treatment by telephone
  71. Transportation between hospitals when your medical condition does not warrant that you be transported to another facility
  72. Treatment for personal growth, or other treatment that is not medically necessary, or not in keeping with national standards of practice
  73. Unskilled nursing home care
  74. Visits to additional providers beyond a second opinion, or a second opinion with a non-plan provider
  75. Vocational rehabilitation, including job retraining, or vocational and driving evaluations focused on job adaptability, or therapy to restore function for a specific occupation
  76. Weight control programs
  77. White noise machines
Cosmetic Services

Cosmetic surgery, cosmetic treatments, cosmetic procedures, cosmetic medications and cosmetic supplies are not covered (even when intended to improve self-esteem or treat a mental health condition). In addition, drugs, biologicals, facility/hospital charges, laboratory and radiology charges, and charges for surgeons, assistant surgeons, anesthesiologists, and any other incidental services which are directly related to the cosmetic surgery/procedure are not covered. However, services required to treat a complication that arises as a result of a prior non-covered surgery/procedure, may be covered when medically necessary in all other respects.

Below are some examples of procedures that are considered cosmetic in nature and are not covered:

  • Botox injections for cosmetic purposes
  • Breast implants
  • Chemical exfoliation for acne
  • Chemical peel
  • Chin implant (unless for the correction of a deformity that is secondary to disease, injury or congenital defect)
  • Collagen implant (e.g., Zyderm)
  • Correction of diastasis recti abdominis
  • Cosmetic or beautifying surgeries, procedures, drugs, services, or appliances
  • Dermabrasion for removal of acne scars
  • Earlobe repair to close a stretched or torn ear pierce hole
  • Electrolysis for hirsutism
  • Excision of excessive skin on thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad, or other areas
  • Excision or repair of keloid
  • Grafts, fat
  • Otoplasty
  • Reduction of labia minora
  • Removal of spider angiomata
  • Rhytidectomy
  • Salabrasion
  • Scar revision
  • Suction-assisted lipectomy

This list is not exhaustive; any procedure considered cosmetic in nature will be excluded.