Plan Limitations & Exclusions
Total Page：16
File Type：pdf, Size：1020Kb
PLAN LIMITATIONS & EXCLUSIONS GHC-SCW Individual Plans This is an outline of the Limitations and Exclusions for the Group Health Cooperative of South Central Wisconsin (GHC-SCW) group and individual health plans. It is designed for reference only. Consult the Policy, Policy Amendments, Certificate of Our plans are further organized into “Metals” based on the percentage of health care costs shared Coverage and Benefits Summary for a complete list of Limitations and Exclusions. The following services and expenses are between you and GHC-SCW. not covered, and no benefits will be payable unless stated otherwise for expenses arising from: Medical care or services provided by a Complications, consultations, services Keratorefractive surgery specifically included under the Policy Platinum Plans GHC-SCW pays 90% of health Bronze Plans GHC-SCW pays 60% of health non-GHC-SCW Provider, whether or not and procedures related to a non-covered or Certificate of coverage), telephonic care costs; you pay 10%. Associated with the care costs; you pay 40%. Associated with the under contract with GHC-SCW. Using a non- procedure Surrogate maternity services and midwife mental health care therapy session, GHC-SCW Provider or an Out-of-Plan Provider services sexual dysfunction therapy, financial and highest monthly premiums and the lowest out of lowest monthly premiums and the highest out of is not covered and the Member will be Cosmetic services occupational counseling, and therapies Medical Supplies, including durable and financially responsible for full payment of care beyond the services specified in the Policy or Custodial care disposable medical equipment, supplies and pocket expenses. Includes Essential Health Benefits. pocket expenses. Includes Essential Health Benefits. and services unless: written approval for Out- Certificate of coverage prosthetic appliances not specifically covered of-Plan care and services has been obtained Dental services not specifically covered under under the Policy or Certificate of coverage Therapies for the diagnosis and treatment of from GHC-SCW’s Care Management the Policy or Certificate of coverage chronic brain injury, including augmentative Gold Plans 80% Catastrophic Plans Department prior to obtaining the medical Mental Health and Substance Use Disorder GHC-SCW pays of health care This plan includes all the communication devices, and speech therapy care or service; is for an Emergency Condition Developmental delay (unless specifically services beyond the services specified in the for the treatment of stuttering, developmental costs; you pay 20%. Associated with high monthly Essential Health Benefits, but is only available to or an Urgent Condition when the Member is included under the Policy or Certificate of Policy or Certificate of coverage outside of the GHC-SCW Service Area; or, the coverage) including: nonmedical services delay, mental retardation or cerebral palsy, premiums and low out of pocket expenses. Includes young adults 30 and under, or to people who plan provides for the use of non-GHC-SCW for the evaluation, diagnosis, testing or Coverage for medical problems which unless specifically included under the Policy Providers treatment of educational problems, behavior never would have occurred except through or Certificate of coverage Essential Health Benefits. qualify for a hardship exemption due to low income. modification or educational disorder services hospitalization, including but not limited to Third-party examinations Services that are not Medically Necessary, injuries or illnesses that could have been are experimental, investigative or for research Drug screening, except as specifically covered (This plan is only offered in the marketplace.) prevented such as certain infections, severe Tobacco cessation products, except as purposes under the Policy or Certificate of coverage bedsores, fractures, and medical errors specified in the Policy or Certificate of Silver Plans GHC-SCW pays 70% of health care coverage Billed amounts that are over and above the Electrolysis services Obesity-related services costs; you pay 30%. Associated with low monthly GHC-SCW Reasonable and Customary Fees Tongue thrust services or treatment and Charges for covered benefits Emergency Outpatient Services when a Personal comfort items premiums and high out of pocket expenses. Includes Member leaves the emergency room prior to Transplants, except for those specified in Items or services required as a result of war or seeing a physician Prescription drugs or contraceptive devices the Policy or Certificate of coverage and Essential Health Benefits. any act of war, insurrection, riot, terrorism, or unless specifically included under the Policy services, any organ or tissue which is sold sustained while performing military services End of Life Services not specifically included or Certificate of coverage under the Policy or Certificate of coverage rather than donated, involving non-human or Services provided at U.S. Government Health Private duty nursing services artificial organs and tissues, and human to Facilities Food/Infant Formula and enteral nutritional human organ or tissue transplant other than products (medical foods) Prolotherapy those specifically listed and specified within Services provided before the effective date the Policy or Certificate of coverage or after the termination date of the Policy or Functional capacity evaluations Scar revisions Terms to Know Certificate of coverage Transportation services and costs, except Gastro-intestinal surgical procedures for Sex change operations Medically Necessary ambulance services Co-Payment – A fixed amount (for example, $15) In-Network – The facilities, Providers, and Services related to an admission or purposes of weight loss Specialty medical care provided by a non- confinement which occurs prior to and Vocational Rehabilitation services you pay for a covered health care service. The suppliers your health insurer or plan has Growth Hormone for the treatment of GHC-SCW Provider, whether or not under continues on or after the Member’s effective idiopathic short stature contract with GHC-SCW, when the service Vision services, and eyewear for all date when GHC-SCW coverage replaces amount can vary by the type of covered health care contracted with to provide health care services. requested may be provided by a GHC-SCW Members (to include lenses, frames, contact other group coverage. Home modifications Specialty Provider lenses, contact lens prescriptions or contact service. Visit ghcscw.com and select “Find a Provider” to Services while incarcerated, except as lens fitting), unless specifically included under Housecleaning Sperm banking or egg harvesting specifically required by state or federal law the Policy or Certificate of coverage find In-Network facilities and Providers. Hospital services for a Skilled Nursing Facility Supportive care Workers’ Compensation items and services Deductible – The amount you owe for health care Charges for missed appointment(s) beyond the amount specified in the Policy or incidental to an injury or conditions covered Certificate of coverage Surgical Services and treatment to correct or Services for injuries incurred during the by any Workers’ Compensation law or services your health insurance or plan covers before HMO plans emphasize high-quality, preventive reverse complications and/or dissatisfaction commission of a crime occupational disease law Hypnotherapy services resulting from surgery, cosmetic treatment, or your health insurance or plan begins to pay. For health care with a strong relationship with a Primary reconstruction when no functional impairment Bilateral Cochlear Implants and Bilateral Bone Insulin injection pens not included in the GHC Out-of-Area Dependents (who do not reside exists, as determined by GHC-SCW example, if your deductible is $1000, your plan Care Provider and access to area Specialists. We Anchored Hearing Aid (BAHA) devices formulary. in the Service Area) are only eligible for Out-of-Area Services as specified in the Tattoos: services for the removal of tattoos or won’t pay anything until you’ve met your $1000 recommend this plan for members that live in Dane Blood donor services Infertility services not specifically covered Policy or Certificate of coverage, unless the complications related to tattoos under the Policy or Certificate of coverage, plan provides for the use of non-GHC-SCW Common use supplies deductible for covered health care services subject to County, WI and surrounding communities. and services beyond the Benefit Maximum Transplant donor services when the recipient Providers Complementary Medicine services not specified in the Benefits Summary is not a current Member under this certificate. the deductible. The deductible may not apply to all specifically covered under the Policy or Certificate of coverage Recreational and Educational therapy, services. HSA plans are accounts created for individuals therapy for congenital conditions (unless who are covered under high-deductible health Maximum Out-of-pocket – The most you pay plans (HDHPs) to save for medical expenses that during a policy period (usually a year) before your HDHPs do not cover. Contributions are made into Important: This plan summary provides Prior Authorization means advance This Policy will become effective as of the We define a “grievance” as meaning health insurance or plan begins to pay 100% of the account by the individual or the individual’s only a general description of benefits authorization for