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Benefit Limitations and Exclusions
Some benefit limitations and exclusions apply to all of our plans. Benefit plans typically have exclusions and limitations – what the plans do not cover. The following is an overview of the most common exclusions and limitations that apply to our plans. Upon enrollment, you will be given a Plan Contract with a complete description of your coverage.
Exclusion period
An exclusion period is the period of time specific treatments and services are not covered by the health plan.
- Pre-existing condition: 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. You must be on our plan for six months before treatment and services for a preexisting condition will be covered.
- Elective procedures: An elective procedure is one that can be postponed for treatment during the limitation period. You must be on our plan for 12 months before treatment and 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 month for month 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 a coverage maximum for a set period of time. Limitations are set by either a maximum dollar or day/visit amount. Once the plan maximum is met, you will be responsible for costs until a new limitation period begins. The services below are subject to limitations and maximum coverage amounts.
| Covered service | Plan Maximum |
|---|---|
|
Inpatient Rehabilitation Outpatient Rehabilitation |
30 days per calendar year |
| Skilled Nursing Facility Care | 60 days per calendar year |
| Home Health Care | 180 visits per calendar year |
| Durable medical equipment | $2,500 per member, per year |
| Removable shoe orthotics | $200 per calendar year |
| Ambulance Services | $2,000 per calendar year |
| Mental Health Treatment | $2,000 per calendar year for all services, inpatient or outpatient |
| Alcohol Treatment | $4,500 per 2 calendar years |
| Transplant services | $250,000 lifetime maximum |
| Lifetime maximum coverage for all benefits | $2,000,000 |
Exclusions
Our Individual & Family Plans have exclusions – or what our plans do not cover. Below is a list of the exclusions that apply to all of our plans, as described in our Plan Contract. Upon enrollment, you will be given a full Plan Contract with a complete description of your coverage.
If you have questions about any of these exclusions, call our Individual & Family Plans Sales Team at 503-574-5000 or 1-800-988-0088.
Providence RN
Medical Advice Line where you can call 24-hours a day, seven days a week.
