Medical Plan Limitations & Exclusions
Dependent Eligibility
Dependents are lawful spouse and unmarried children younger than age 23.
Out-of-Area Dependent Children Coverage
If your enrolled dependent child(ren) resides outside the service area, we will extend benefits for treatment of an illness or injury, and women’s routine healthcare (or preventive healthcare if available in the plan) and maternity services, as if care were rendered by a participating physician or provider. Out-of-area dependents must access benefits within a 30-mile radius of their residence in order for the PPO benefit level to apply.
Limitations
Six-month exclusion period applies to the following:
- Myringotomy with tubes
- Removal of tonsils or adenoids
- Allergies
- Sterilization
- Elective procedures (procedures that can be reasonably postponed for the exclusion period)
- Pre-existing conditions even if they worsen or recur.
- All medical and surgical admissions must be authorized by ODS.
- Mental illness paid up to a $2,500 maximum in a 12-month period.
- Alcohol treatment up to a $4,500 maximum in a 24-month period.
- A 24-month exclusion period for transplants.
- ODS will not pay benefits for covered expenses to the extent that you have any other coverage for those expenses.
- Inpatient rehabilitation benefits are limited to 30 days per plan year (up to 60 days for head and spinal cord injuries); outpatient rehabilitation benefits are limited to 30 sessions per plan yearThe 12-month period commencing on the effective date and each 12-month period thereafter. (up to 60 sessions for head and spinal cord injuries).
- Transplant benefits are limited to an aggregate lifetime maximum benefit of $250,000.
- Hospice benefits are limited to $20,000 for home care; 12 days of inpatient care; 170 hours/3 months respite care.
Note: Your plan's six-month pre-existing exclusion period will be shortened one day for each day you had "creditable coverage" under another health plan, provided you do not have a 63-day lapse (or longer) in coverage immediately prior to your enrollment date in our plan, or, if earlier, the first day of the waiting period for such enrollment.
Exclusions
- Services provided by a member of the patient’s immediate family.
- Services or supplies that are not medically necessary.
- Services and supplies for reversal of sterilization or infertility.
- Services and supplies for obesity, including complications arising out of such treatment.
- Surgery to alter the refractive character of the eye.
- Dental examinations and treatment, except as specifically listed.
- Massage or massage therapy.
- Services or supplies for the treatment of sexual dysfunction or inadequacy, or those related to sex change procedures.
- Treatment of personality disorders.
- Experimental or investigational treatment.
- Services or supplies available in whole, or in part, under any city, county, state or federal law, except Medicaid.
- Charges above those considered the maximum plan allowance.
- Services or supplies for which an employer is required by law to provide benefits even if you choose not to accept those benefits.
- Instruction programs, including, but not limited to, those to learn to self-administer drugs or nutrition, except as specifically provided for under the outpatient diabetic instruction benefit of this plan.
- Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control or education.
- Cosmetic/reconstructive services and supplies.
- Services and supplies associated with orthognathic surgery.
- Drugs for treatment of mental illness.
- Chemical dependency treatment, except for alcohol treatment.
This is a benefit summary only. For a complete description of benefits, limitations and exclusions, refer to your member handbook.