Limitations and Exclusions

The following are the most common exclusions and limitations that apply to our plans.

Exclusion periods

  • Pre-existing condition: Members age 19 and older 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 in 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).

Limited Covered Services

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

  • Inpatient rehabilitation: 30 visits per calendar year
  • Outpatient rehabilitation: 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 member, per calendar year
  • Removable custom shoe orthotics: $200 per calendar year
  • Emergency transportation: $2,000 per calendar year
  • Mental health treatment
    • Optimum and Value plans: 15 outpatient visits per calendar year
    • Prime and HSA plans: 10 outpatient visits per calendar yea

Alcohol treatment: 2 days detox and 20 outpatient visits every two calendar years

Essential health benefits: A $1,250,000 plan year aggregate limit applies to essential health benefit