HSA Oregon: Health Savings Accounts in Oregon

Providence HSA Plan Exclusions

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Medical & Rx Limitations and Exclusions

Exclusion Periods

Pre-existing condition: You must be covered on our plan for six months before a pre-existing condition will be covered. A pre-existing condition is a medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the effective date of coverage.
Elective procedures: An elective procedure is one that can be postponed for treatment such as allergy testing or knee surgery. You must be on our plan for 12 months before treatment for elective services will be covered.
Organ transplant: You must be on our plan for 24 months before we pay benefits for organ transplants.
Newborns: Exclusion periods are waived for a newborn or adopted child if the child is enrolled on the plan within 60 days of birth or adoption placement.

Creditable Coverage

If you were covered on another health plan within 63 days before your effective date of coverage, you may have “creditable coverage.” Your creditable coverage will be applied day for day toward the plan exclusion periods. You will need to provide us with a copy of your Certificate of Creditable Coverage (obtain from your prior health carrier).

Certain covered services have limitations. Once the plan maximum is met, you will be responsible for costs until a new limitation period begins. The following services are subject to limitations and maximum coverage amounts:

Cover service	Plan Maximum
Rehabilitative Inpatient Care	30 days per calendar year
Rehabilitative Outpatient Care	30 visits per calendar year
Skilled Nursing Facility Care	60 visits per calendar year
Home Health Care	180 visits per calendar year
Durable Medical Equipment	$2,500 per calendar year
Removable custom shoe orthotics	$200 per calendar year
Emergency transportation	$2,000 per calendar year
Mental Health Treatment	$2,000 per calendar year
Alcohol Treatment	$4,500 per 2 calendar years
Transplant services	$250,000 lifetime maximum
Lifetime maximum coverage for all benefits	$2,000,000

Medical Exclusions

The following is an overview of the most common exclusions that apply to our plans. This list is not complete. Please refer to the Plan Contract for a complete listing and additional information.

Chiropractic, alternative care, massage, acupuncture and naturopathic care
Chemical dependency, except as noted for alcohol treatment
Cosmetic surgery.
Dental care
Hearing aids/devices, screening and exams
Home births and all related services
Certain mental health services
Physical exams primarily for camps, sports, insurance, licensing, employment, or other third-party purposes
Voluntary sterilization or termination of pregnancy
Temporomandibular joint (TMJ) services
Treatment for tobacco addiction, including prescription drugs
Obesity or weight control treatment, including surgery and prescription drugs
Services covered by motor vehicle insurance or other liability insurance
Drugs not listed in our plan formulary
Drugs not directly related to treatment of a covered illness or injury
Over-the-counter (OTC) drugs, medications, or vitamins
Amphetamines and derivatives, except for narcolepsy or hyperactivity treatment
Drugs used to treat shift-sleep disorder, drug induced fatigue or general fatigue
Fluoride for members over the age of 10 years old
Drugs to stimulate hair growth