Covered Expenses, General Exclusions and Limitations

Transcription

Section 13:
Covered Expenses, General
Exclusions and Limitations
The following chapter is an excerpt from our Oregon
standard Group Health Insurance Contract. It is
included in this manual to give providers an idea of
the services PacificSource generally does and does
not cover.
neurodevelopmental problems and other problems
associated with pervasive developmental disorders
for which rehabilitative services would be appropriate
for children under 18 years of age) may be considered
for additional benefits, not to exceed 30 visits per
condition, when criteria for supplemental services are
met.
Please keep in mind that not all of the information in this
chapter applies to every PacificSource plan. Differences exist
by state, and some group clients choose to customize their
benefits.
Speech therapy services are only covered when
medically necessary and due to the following:
A. Voice deficits related to the peripheral speech
mechanism (larynx, palate, etc.), whether
congenital or acquired.
If you have questions about our coverages, exclusions,
or limitations, you are welcome to contact our Customer
Service Department by phone at (541) 684-5582 or toll-free
at (888) 977-9299, or by email at cs@pacificsource.com.
B. Phonological and language deficits due to hearing
loss (not including recurrent otitis media unless
chronic significant hearing loss is documented).
COVERED EXPENSES
C. Stuttering.
Subject to all terms and provisions of this policy, incurred
expenses for the following services and supplies are
covered according to the Schedule:
D. Phonological and language deficits arising from
neurological disease or injury of known cause
(stroke, brain trauma, cerebral palsy, encephalitis,
lead poisoning, irradiation, etc.)
PROFESSIONAL SERVICES
1.
Speech and/or cognitive therapy for acute illnesses
and injuries are covered up to one year post injury
when the services do not duplicate those provided
by other eligible providers, including occupational
therapists or neuropsychologists.
Services of a physician for medically necessary
diagnosis or treatment of illness or injury of a
member.
2. Services of a licensed physician assistant under the
supervision of a physician.
3. Services of a certified surgical assistant, surgical
technician, or registered nurse (R.N.) when
providing medically necessary services as a surgical
first assistant.
Outpatient pulmonary rehabilitation programs
are covered when prescribed by a physician. To be
eligible for benefits, there must be severe chronic
lung disease that interferes with normal activities
of daily living despite optimal management with
medications.
4. Services of a nurse practitioner, including certified
registered nurse anesthetist (C.R.N.A.) and certified
nurse midwife (C.N.M.) for medically necessary
diagnosis or treatment of illness or injury.
5. Services of the following providers for medically
necessary physical, occupational, or speech
therapy: a licensed physical therapist, occupational
therapist, speech language pathologist, physician,
or other practitioner licensed to provide physical,
occupational, or speech therapy. These services must
be prescribed in writing by a licensed physician,
dentist, podiatrist, nurse practitioner, or physician
assistant. The prescription must include site, modality,
duration, and frequency of treatment. Benefits for
physical therapy, occupational therapy, and/or speech
therapy are limited to a combined maximum of 20 30
visits per calendar year subject to preauthorization
and concurrent review by PacificSource for medical
necessity. Only treatment of neurologic conditions
(e.g. stroke, spinal cord injury, head injury, pediatric
Revised March 27, 2013. Replaces all prior versions
For related provisions, see General Exclusions –
Motion Analysis, General Exclusions – Rehabilitation,
General Exclusions – Speech Therapy, and General
Exclusions – Temporomandibular Joint.
6. Services of a physician or a licensed certified
nurse midwife (C.N.M.) for pregnancy. Benefits are
subject to the same payment amount, conditions, and
limitations that apply to similar expenses incurred
for illness except that pregnancy does not constitute
a pre-existing condition. Benefits for pregnancy are
provided for the subscriber, subscriber’s spouse or
domestic partner, or subscriber’s dependent child
only when expense is incurred while covered under
this policy.
7.
Services of a licensed audiologist for medically
necessary audiological testing.
PacificSource Health Plans
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8. Services of a state-licensed dentist and/or
physician for treatment of the jaw or natural teeth
only as follows:
o Treatment of injury to the jaw or natural teeth, provided services are rendered within 18 months after the injury.
o Orthognathic surgery when necessary due to an accidental injury, provided services are rendered within one year after the injury.
o Orthognathic surgery when necessary for removal
of a malignancy and the subsequent reconstruction,
provided services are rendered within one year.
Except for the initial examination, services for the
treatment of injury to the jaw or natural teeth require
prior approval by PacificSource to qualify for benefits.
9. Supplies, equipment, and diabetes selfmanagement programs associated with
the treatment of insulin-dependent diabetes,
insulin-using diabetes, gestational diabetes, and
noninsulin-using diabetes prescribed by a healthcare
professional legally authorized to prescribe such
items.
“Diabetes self-management program” means
one program of assessment and training after
diagnosis and no more than three hours per year of
assessment and training upon a material change of
condition, medication, or treatment. Services must
be provided by an education program credentialed
or accredited by a state or national entity accrediting
such programs, or by a physician, a registered nurse,
a nurse practitioner, a certified diabetes educator, or
a licensed dietitian with demonstrated expertise in
diabetes.
10. Services of a genetic counselor for evaluation
of known or suspected genetic disease when
referred by a physician or nurse practitioner. To be
eligible for coverage, the genetic counselor must be
board-certified by the American Board of Genetic
Counseling, or be board-eligible.
11. Medically necessary telemedical health services for
health services covered by this policy when provided
in person by a healthcare professional when the
telemedical health service does not duplicate or
supplant a health service that is available to the
patient in person. The location of the patient receiving
telemedical health services may include, but it not
limited to: hospital; rural health clinics; federally
qualified health center; physician’s office; community
mental health center; skilled nursing facility; renal
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dialysis center; or site where public health services
are provided. Coverage of telemedical health services
are subject to the same deductible, copayment, or
coinsurance requirements that apply to comparable
health services provided in person.
PREVENTIVE CARE
Services of a physician, nurse practitioner, or physician’s
assistant for the following preventive care services:
1. Routine physical examinations, including
appropriate screening radiology and laboratory tests
and other screening procedures, for each member
age 22 or older according to the following schedule:
o Ages 22 through 34:
One exam every four years
o Ages 35 through 59:
One exam every two years
o Ages 60 and older:
One exam per year
Only laboratory tests and other diagnostic testing
procedures ordered in conjunction with a routine
physical examination are covered by this benefit.
Charges for physical examinations and any
associated testing are subject to the deductible,
copayment and/or benefit percentage stated in the
Schedule.
One gynecological examination each calendar
year including a blood pressure check and weight
check. Covered laboratory services are limited to
occult blood, urinalysis, and complete blood count.
Each gynecological examination is subject to the
deductible, copayment and/or benefit percentage
stated in the Schedule. Mammograms, pelvic exams,
Pap smear exams, and breast exams are allowed
according to the following:
o Mammograms for women at any time with or
without referral from a women’s healthcare
provider.
o Pelvic exams and Pap smear exams at any
time upon referral of a women’s healthcare
provider; and pelvic exams and Pap smear exams
annually for women 18 to 64 years of age with or
without a referral from a women’s healthcare
provider.
o Breast exams annually for women 18 years of
age or older or at anytime when recommended
by a women’s healthcare provider for the purpose
of checking for lumps and other changes for early
detection and prevention of breast cancer.
2. Colorectal cancer screening examinations and
laboratory tests including the following:
o Hemophilus influenza B vaccine
o A fecal occult blood test
o Hepatitis A vaccine
o A flexible sigmoidoscopy
o Hepatitis B vaccine
o A colonoscopy (The deductible, copayment, and/
or benefit percentage shown on the Schedule for
“Preventive Care – Routine Colonoscopy” applies to
routine colonoscopies. The deductible, copayment,
and/or benefit percentage shown on the Schedule for
“Outpatient Services—Outpatient Surgery/Services”
applies to medically necessary colonoscopies.)
o Human papillomavirus (HPV) vaccine
o Influenza virus vaccine
o Measles, mumps, and rubella (MMR) vaccines, given separately or together
o Pneumococcal vaccine
o A double contrast barium enema
3. Prostate cancer screening, including a digital
rectal examination and a prostate-specific antigen
test.
4. Well baby/child care examinations including
appropriate screening radiology and laboratory tests
and other screening procedures, for each member
age 21 or younger according to the following
schedule.
o At birth: One standard in-hospital exam
o Ages 0 through 3: 12 additional exams during the first 36 months of life
o Ages 3 through 21: One exam per year
Only laboratory tests and other diagnostic testing
procedures related to a routine physical examination
are covered by this benefit. Charges for routine
physical examinations and related testing are
subject to the deductible, copayment, and/ or benefit
percentage stated in the Schedule. Any laboratory
tests and other diagnostic testing procedures
ordered during, but not related to, a routine physical
examination are not covered by this preventive care
benefit (see Covered Expenses – Outpatient Services –
Diagnostic Radiology and Laboratory Procedures).
5. Standard age-appropriate childhood and adult
immunizations for primary prevention of infectious
diseases as recommended by and adopted by the
Centers for Disease Control and Prevention, American
Academy of Pediatrics, American Academy of Family
Physicians, or a similar standard-setting body.
Benefits do not include immunizations for more
elective, investigative, unproven, or discretionary
reasons (e.g. travel). Covered immunizations include,
but may not be limited to the following:
o Diphtheria, tetanus, and pertussis (DPT) vaccines, given separately or together
o Polio vaccine
o Varicella (chicken pox) vaccine
o Meningococall (meningitis) vaccine
6. Tobacco use cessation program services
are covered 100 percent when provided by a
PacificSource approved program. Coverage is limited
to a maximum lifetime benefit of two quit attempts.
Approved programs are limited to members age 15 or
older. Specific nicotine replacement therapy will only
be covered according to the program’s description.
If this policy includes benefits for prescription drugs,
tobacco use cessation related medication prescribed
in conjunction with an approved tobacco use
cessation program will be covered to the same extent
this policy covers other prescription medications.
7.
Any plan deductible, copayment, and/or coinsurance
amounts stated in the Schedule are waived for
the following recommended preventive care
and screenings when provided by a participating
provider:
o Services that have a rating of “A” or “B” from the U.S. Preventive Services Task Force (USPSTF);
o Immunizations recommended by the Advisory
Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC);
o Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA);
o Preventive care and screening for women supported by the HRSA that are not included in the USPSTF recommendations.
Links to the lists of recommended preventive care
and screenings from the USPSTF, CDC, and HRSA can
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be found on the PacificSource website, PacificSource.
com. Current USPSTF recommendations include the
September 2002 recommendations regarding breast
cancer screenings, mammography, and prevent, not
the November 2009 recommendations.
HOSPITAL, SKILLED NURSING FACILITY, HOME
HEALTH, AND HOSPICE SERVICES
1.
Hospital inpatient services. Any part of a hospital
room and board charge that is more than the hospital
charges for a semi-private room is not a covered
expense unless the attending physician orders
hospitalization in an intensive care unit, coronary
care unit, or private room for medically necessary
isolation.
The member must be living at home;
•
A nonsalaried primary caregiver must be available
and willing to provide custodial care to the member
on a daily basis; and
•
The member must not be undergoing treatment of
the terminal illness other than for direct control of
adverse symptoms.
Only the following hospice services are covered:
•
Home nursing visits.
•
Home health aides when necessary to assist in
personal care.
•
Home visits by a medical social worker.
•
Home visits by the hospice physician.
•
Prescription medications for the relief of symptoms
manifested by the terminal illness.
•
Medically necessary physical, occupational, and
speech therapy provided in the home.
3. Home health services for medically necessary skilled
nursing services performed by a registered nurse
(RN) or licensed practical nurse (LPN); rehabilitative
therapy performed by a physical, occupational, and
speech therapist; and in-home services provided for
a homebound patient by a medical social worker
or Medicare-certified or state-certified home health
agency. Private-duty nursing is not a covered benefit.
All home health services must be preauthorized by
PacificSource to be covered.
•
Home infusion therapy.
•
Durable medical equipment, oxygen, and medical
supplies.
•
Respite care provided in a nursing facility to provide
relief for the primary caregiver, subject to a maximum
of five consecutive days and to a lifetime maximum
benefit of 30 days. A member must be enrolled in
a hospice program to be eligible for respite care
benefits.
4. Home infusion services for parenteral nutrition,
medications, and biologicals (except immunizations)
that cannot be self-administered. Benefits are paid at
the contract percentage for home healthcare, and all
such services require preauthorization.
•
Inpatient hospice care when provided by a Medicarecertified or state-certified program when admission to
an acute care hospital would otherwise be medically
necessary.
•
Pastoral care and bereavement services.
2. Skilled nursing care services in a licensed skilled
nursing facility for up to 60 days per calendar
year. Services must be medically necessary and
preauthorized by PacificSource. Confinement for
custodial care is not covered.
5. Hospice services provided by a Medicare-certified
or state-certified hospice program. Hospice services
are defined as those intended to meet the physical,
emotional, and spiritual needs of the patient and
family unit during the final stages of illness and
dying, while maintaining the patient in the home
setting. Services are intended to supplement the
efforts of a nonsalaried primary caregiver, and are not
intended to provide custodial care of the patient other
than regular home visits as indicated by the hospice
team. Hospice benefits do not cover services of a
primary caregiver or private duty nursing. All hospice
services must be preauthorized by PacificSource to be
covered.
To qualify for hospice services:
•
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•
The member’s physician must certify that the
member is terminally ill with a life expectancy of less
than six months;
The member retains the right to all other services
provided under this contract, including active treatment
of nonterminal illnesses, except for services of another
provider that duplicate the services of the hospice team.
6. Inpatient rehabilitative care. Services must be preauthorized by PacificSource. Recreation therapy is only covered as part of an inpatient rehabilitation admission.
OUTPATIENT SERVICES
Surgery and other outpatient services performed by a
professional provider for medically necessary treatment of
illness or injury. Benefits for surgery and other outpatient
services are determined by the setting, as follows:
Surgeries or outpatient services performed in a physician’s office are subject to the deductible, copayment,
and/or benefit percentage shown on the Schedule for “Professional Services—Office Procedure and Supplies.”
including radiology, laboratory work, CT scans, and
MRIs, unless stated otherwise on the Schedule.
Surgeries or outpatient services performed in an ambulatory surgery center or outpatient hospital setting
are subject to the deductibles, copayments, and/or benefit
percentages shown on the Schedule for both “Professional
Services—Surgery” and “Outpatient Services—Outpatient
Surgery/Services.”
The copayment does not cover subsequent treatment
or diagnostic services provided on referral from
the emergency room. If a patient is admitted to a
nonparticipating hospital after emergency treatment
and stabilization, PacificSource may require that the
patient be transferred to a participating facility in
order to receive the highest level of plan benefits.
1.
Services or materials provided or ordered by a
physician, nurse practitioner, or physician assistant
for diagnostic radiology and laboratory
procedures. This benefit includes services performed
or provided by laboratories, radiology facilities,
hospitals, and physicians (including services in
conjunction with office visits). All such services are
subject to the deductible, copayment, and/or benefit
percentage shown on the Schedule for “Outpatient
Services—Diagnostic and Therapeutic Radiology and
Lab” regardless of the setting where services are
provided.
2. Services or materials provided or ordered by a
physician for therapeutic radiology services,
chemotherapy, or renal dialysis. Covered
services include a prescribed, orally administered
anticancer medication used to kill or slow the growth
of cancerous cells. This benefit includes services
performed or provided by physicians (including
services in conjunction with office visits) and
other facilities. All such services are subject to the
deductible, copayment, and/or benefit percentage
shown on the Schedule for “Outpatient Services—
Diagnostic and Therapeutic Radiology and Lab”
regardless of the setting where services are provided.
3. Advanced imaging procedures that are medically
necessary for the diagnosis of illness or injury.
For purposes of this benefit, advanced imaging
procedures include CT scans, PET scans, CATH
labs, and MRIs. These services are subject to the
deductibles, copayments, and/or benefit percentages
Advanced Imaging” regardless of the setting where
services are provided.
4. Services and supplies furnished in an emergency
room, and all ancillary services routinely available
to an emergency department to the extent they are
required for the stabilization of a patient with an
emergency medical condition. Services are subject to
applicable deductibles, copayments, and/or benefit
percentages shown on the Schedule for “Outpatient
Services—Emergency Room Visits.”
The emergency room copayment covers emergency
medical screening and emergency services, including
any diagnostic tests necessary for emergency care,
If a member needs immediate assistance for a
medical emergency, the member should call 911 or
go directly to an emergency room.
5. Other medically necessary diagnostic services
provided in a hospital or outpatient setting, including
testing or observation to diagnose the extent of a
medical condition. Such services are subject to the
deductible, copayment, and/or benefit percentage
Outpatient Surgery/Services.”
MENTAL HEALTH AND CHEMICAL
DEPENDENCY SERVICES
Subject to all terms and provisions of this policy including
deductibles, copayments, and/or benefit percentages
shown on the Schedule, benefits are provided for medically
necessary services for the treatment of mental and nervous
conditions and chemical dependency according to the
following:
1.
Related definitions. As used in this section:
a. Mental or nervous conditions health
means all disorders listed in the “Diagnostic
and Statistical Manual of Mental Disorders,
DSM-IV-TR, Fourth Edition” except for: Mental
Retardation (diagnostic codes 317, 318.0, 318.1,
318.2, 319); Learning Disorders (diagnostic codes
315.00, 315.1, 315.2, 315.9) Paraphilias (diagnostic
codes 302.4, 302.81, 302.89, 302.2, 302.83, 302.84,
302.82, 302.9); Gender Identity Disorders in
Adults (diagnostic codes 302.85, 302.6, 302.9 this exception does not extend to children and
adolescents 18 years of age or younger); and “V”
codes (diagnostic codes V15.81 through V71.09—
this exception does not extend to children five
years of age or younger for diagnostic codes
V61.20, V61.21, and V62.82).
b. Chemical dependency means the addictive
physical and/or psychological relationship with
any drug or alcohol that interferes with the
individual’s social, psychological, or physical
adjustment to common problems on a recurring
basis. Chemical dependency does not include
addiction to, or dependency on, tobacco products
or foods.
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c. Facility means a corporate or governmental
entity or other provider of services for the
treatment of chemical dependency or for the
treatment of mental or nervous conditions.
Board of Psychologists’ Examiners;
f.
g. A clinical social worker (LCSW) licensed by the
State Board of Clinical Social Workers;
d. Program means a particular type or level of
service that is organizationally distinct within a
facility.
h. A Licensed Professional Counselor (LPC)
licensed by the State Board of Licensed
Professional Counselors and Therapists;
e. Provider means a person who meets the
credentialing requirements of PacificSource,
is otherwise eligible to receive reimbursement
under the policy, and is:
i.
A healthcare facility;
ii. A residential program or facility;
iii. A day or partial hospitalization program;
iv. An outpatient service; or
4.
v. An individual behavioral health or medical
professional authorized for reimbursement
under state law.
2. Provider eligibility. A provider is eligible for
reimbursement if:
b. The provider is accredited for the particular
level of care for which reimbursement is
being requested by the Joint Commission on
Accreditation of Hospitals or the Commission on
Accreditation of Rehabilitation Facilities; or
e. The provider meets the credentialing
requirements of PacificSource.
3. Eligible providers are:
a. A program licensed, approved, established,
maintained, contracted with, or operated by the
Mental Health Division for Alcoholism;
b. A program licensed, approved, established,
Mental Health Division for Drug Addiction;
c. A program licensed, approved, established,
Mental Health Division for Mental or Emotional
Disturbance;
d. A medical or osteopathic physician licensed by
the State Board of Medical Examiners;
e. A psychologist (Ph.D.) licensed by the State
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A Licensed Marriage and Family Therapist
(LMFT) licensed by the State Board of Licensed
Professional Counselors and Therapists; and
j.
A hospital or other healthcare facility licensed
for inpatient or residential care and treatment
of mental health conditions and/or chemical
dependency.
Limitations.
b. Benefits for a long-term residential mental
health program are limited to 45 days of
treatment in a calendar year. This limitation does
not apply to group health plans that are subject
to the Mental Health Parity and Addiction
Equality Act of 2008.
a. The provider is approved by the Department of
Human Services;
d. The provider is providing a covered benefit
under this policy; and
i.
a. Services of a specialized treatment facility,
such as inpatient, residential, and/or intensive
outpatient treatment must be preauthorized by
PacificSource.
c. The patient is staying overnight at the facility
and is involved in a structured program at least
eight hours per day, five days per week; or
A nurse practitioner registered by the State
Board of Nursing;
c. Treatment of substance abuse and related
disorders is subject to placement criteria
established by the American Society of
Addiction Medicine.
For related provisions, see General Exclusions–Mental
Health/Chemical Dependency.
DURABLE MEDICAL EQUIPMENT
Subject to the limitations contained in this section, and
to the terms of exclusions relating to durable medical
equipment in the General Exclusions section, benefits are
provided for durable medical equipment, prosthetic and,
orthotics devices, and medical supplies according to the
following:
Related definitions as used in this section:
•
Durable medical equipment means equipment
that can withstand repeated use; is primarily and
customarily used to serve a medical purpose rather
than convenience or comfort; is generally not useful
to a person in the absence of an illness or injury; is
appropriate for use in the home; and is prescribed by
a physician. Examples of durable medical equipment
include but are not limited to: hospital beds,
wheelchairs, crutches, canes, walkers, nebulizers,
commodes, suction machines, traction equipment,
respirators, TENS units, and hearing aids.
•
•
•
Prosthetic devices (excluding dental) means
artificial limb devices or appliances designed to
replace in whole or part an arm or leg. Benefits for
prosthetic devices include coverage of devices that
replace all or part of an internal or external body
organ, or replace all or part of the function of a
permanently inoperative or malfunctioning internal
or external organ, and are furnished on a physician’s
order. Examples of prosthetic devices include but are
not limited to: artificial limbs, cardiac pacemakers,
prosthetic lenses, breast prosthesis (including
mastectomy bras), and maxillofacial devices.
Orthotics devices means rigid or semirigid devices
supporting a weak or deformed leg, foot, arm, hand,
back or neck or restricting or eliminating motion in
a diseased or injured leg, foot, arm, hand, back or
neck. Benefits for orthotic devices include orthopedic
appliances or apparatus used to support, align,
prevent, or correct deformities or to improve the
function of movable parts of the body. An orthotic
device differs from a prosthetic in that, rather than
replacing a body part, it supports and/or rehabilitates
existing body parts. Orthotic devices are usually
customized for an individual’s use and are not
appropriate for anyone else. Examples of orthotics
devices include but are not limited to: Ankle Foot
Orthosis (AFO), Knee Ankle Foot Orthosis (KAFO),
Lumbosacral Orthosis (LSO), and foot orthotics.
Medical supplies means items of a disposable
nature that may be essential to effectively carry out
the care a physician has ordered for the treatment or
diagnosis of an illness or injury. Examples of medical
supplies include but are not limited to: syringes
and needles, splints and slings, ostomy supplies,
sterile dressings, elastic stockings, enteral foods, and
drugs or biologicals that must be put directly into
durable medical equipment in order to achieve the
therapeutic benefit of the equipment or to assure the
proper functioning of this equipment (e.g. Albuterol
for use in a nebulizer).
Coverage of prosthetic and orthotic devices
This policy covers prosthetic and orthotic devices that are
medically necessary to restore or maintain the ability to
complete activities of daily living or essential job-related
activities and that are not solely for comfort or convenience.
Benefits include coverage of all services and supplies
medically necessary for the effective use of a prosthetic or
orthotic device, including formulating its design, fabrication,
material and component selection, measurements, fittings,
static and dynamic alignments, and instructing the patient in
the use of the device. Benefits also include coverage for any
repair or replacement of a prosthetic or orthotic device that
is determined medically necessary to restore or maintain
the ability to complete activities of daily living or essential
job-related activities and that is not solely for comfort or
convenience.
Limitations
1.
Covered expenses for durable medical equipment
are limited to a $5,000 maximum per calendar year.
Exceptions to this limitation are essential health
benefits, such as prosthetics, and orthotic devices,
oxygen and oxygen supplies, diabetic supplies, and
wheelchairs. Medical foods for the treatment of
inborn errors of metabolism are also exempt from
this limitation.
2. Durable medical equipment, prosthetic devices,
orthotics, and medical equipment must be prescribed
in writing by a licensed M.D., D.O., N.P., P.A., D.D.S.,
D.M.D., or D.P.M.
3. Expenses exceeding $800 for the purchase, rental,
repair, lease, or replacement of durable medical
equipment must be preauthorized for benefits by
PacificSource. Reimbursement is limited to either
purchase or rental for the period required, at the
option of PacificSource.
4. Benefits include repair of equipment only if such
repair is necessary to return it to or maintain a
functional state and only if the equipment was,
or would have been, a covered expense under
this policy. Benefits for repair are limited to the
replacement cost.
5. Benefits for the purchase, rental, repair, lease,
or replacement of a power-assisted wheelchair
(including batteries and other accessories) requires
preauthorization of PacificSource and is payable
only in lieu of benefits for a manual wheelchair. For
members age 19 or older, this benefit is limited to a
lifetime maximum of one power-assisted wheelchair.
6. Expenses for lenses required to correct a specific
vision defect resulting from a severe medical or
surgical problem (e.g., stroke, other vascular or
neurological disease, trauma, or eye surgery other
than eye refraction procedures intended to correct
refractive error) are covered subject to the following
limitations:
a. The medical or surgical problem must cause
visual impairment or disability due to loss of
binocular vision or visual field defects (not
merely a refractive error or astigmatism) and
requires lenses to restore some normalcy to
vision.
b. The maximum allowance for lenses and frames
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is limited to $200 per initial case. “Initial case”
is defined as the first time surgery or treatment
is performed on either eye. Other policy
limitations, such as exclusions for extra lenses,
other hardware, tinting of lenses, eye exercises,
or vision therapy, also apply. (See General
Exclusions.)
c. Benefits for subsequent medically necessary
vision corrections to either eye (including an eye
not previously treated) are limited to the cost of
lenses only.
d. Reimbursement is subject to the deductible,
copayment, and/or benefit percentage stated
in the Schedule for durable medical equipment
and is in lieu of, and not in addition to, benefits
payable under any vision endorsement that may
be added to this policy.
7. Benefits for breast pumps are limited to a maximum
of three months’ rental or up to a lifetime maximum
of $200 toward rental and/or purchase.
8. Benefits for hearing aids are limited to members
under 18 years of age, and dependent children
18 years of age or older who are enrolled in an
accredited educational institution, up to a maximum
benefit of $4,000 every 48 months. The benefit
amount shall be adjusted on January 1 of each year
to reflect the U.S. City Average Consumer Price Index.
9. Treatment for sleep apnea and other sleeping
disorders, including equipment, appliances, and
surgery, requires preauthorization. Coverage of
oral devices, including tongue-retaining appliances,
includes charges for consultation, fitting, adjustment,
and follow-up care. The appliance must be
prescribed by a physician specializing in evaluation
and treatment of obstructive sleep apnea and the
condition must meet criteria for obstructive sleep
apnea.
Provider Eligibility
Only expenses for durable medical equipment or
prosthetic and orthotic devices that are provided by a
PacificSource contracted provider or a provider that
satisfies the criteria in the Medicare Quality Standards for
Suppliers or Medical Equipment, Prosthetics, Orthotics,
Supplies (DMEPOS) and Other Items and Services
handbook are eligible for reimbursement. Mail order or
Internet/Web-based providers are not eligible providers.
(See General Exclusions—Providers services.)
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TRANSPLANTATION SERVICES
Subject to the limitations contained in this section, and to
terms of the exclusion relating to transplants in the General
Exclusions section of the policy, benefits are provided for
transplantation of human organs, tissues, bone marrow,
and peripheral blood stem cells only for those items listed
below.
Eligible transplants. Transplant benefit requests are
reviewed on a case by case basis to determine if the
transplant is medically necessary and reasonable by
nationally recognized standards in reputable transplant
centers.
•
Kidney
•
Kidney—Pancreas
•
Pancreas—whole organ transplantation (subject to
disease-specific criteria)
•
Heart
•
Heart—Lung
•
Lung
•
Liver (subject to disease specific criteria)
•
Bone marrow and peripheral blood stem cell
transplantation
•
Pediatric bowel
Limitations
1.
To access benefits for evaluation for transplantation
(including tissue typing, stem cell collection, or bone
marrow harvest), the recipient of the transplant
must have been under coverage with PacificSource
for at least 24 consecutive months or since birth
(see General Limitations–Exclusion Period for
Transplantation Benefits).
2. Only expenses incurred by a member for the
transplantation of human body organs and/or
tissue are considered eligible as covered expenses.
Expenses incurred for the transplantation of artificial,
animal, or other non-human body organs or tissue
are not approved as eligible expenses.
3. Expenses for the acquisition of organs or tissues
for transplantation are covered only when the
transplantation itself is covered under this contract,
and is subject to the following limitations:
a. Testing of related or unrelated donors for a
potential living related organ donation is payable
at the same percentage that would apply to the
same testing of an insured recipient.
b. Expense for acquisition of cadaver organs is
covered, payable at the same percentage and
subject to the same maximum dollar limitation, if
Transplant Services—If services are available through
contractual agreement but are not performed at a
contracted facility, benefits are paid at the lesser
of 60% of the billed amount or $100,000, and are
otherwise subject to plan deductibles, copayments,
coinsurance, out-of-pocket, and lifetime maximum
provisions stated in the Schedule. Incurred expense in
excess of 60% of the billed amount or $100,000 does
not accumulate toward any stop-loss or out-of-pocket
maximum.
any, as the transplant itself.
c. Medical services required for the removal and
transportation of organs or tissues from living
donors are covered. Coverage of the organ
or tissue donation is at the same percentage
payable for the transplant itself, and applies to
the maximum dollar limitation for the transplant,
if any.
i.
If the donor is not a PacificSource member,
only those complications of the donation
that occur during the initial hospitalization
are covered, and such complications are
covered only to the extent that they are
not covered by another health plan or
government program. Coverage is at the
same percentage payable for the transplant
itself, and also applies to the maximum
dollar limitation, if any, for the transplant.
ii. If the donor is a PacificSource member,
complications of the donation are covered as
any other illness would be covered.
d. Travel and housing expenses for the donor are
not covered.
4. Transplant related services, including HLA typing,
sibling tissue typing, and evaluation costs, are
considered transplant expenses and accumulate
toward any transplant benefit limitations and are
subject to PacificSource’s provider contractual
agreements (see Payment of transplantation benefits,
below.)
5. Subject to approval by PacificSource, reasonable
travel and housing expenses for the transplant
recipient and one caregiver are eligible for coverage
up to a maximum of $5,000 per transplant.
6. Preauthorization of benefits is required for any and
all services, treatments, and supplies related to a
transplantation procedure.
3. Physician and Professional Fees—For services of a
physician or other professional provider that are not
included in a contractual agreement of a participating
provider, PacificSource will pay according to the
regular provisions of this policy, subject to the
maximum amount allowed for the transplant as
stated in item 2 above.
OTHER COVERED SERVICES, SUPPLIES, AND
TREATMENTS
1.
2. Biofeedback to treat migraine headaches and
urinary incontinence, limited to a maximum lifetime
benefit of ten sessions, when provided by an
otherwise eligible provider.
3. Blood transfusions, including the cost of blood or
blood plasma when not available from a free blood
bank or from voluntary donors. Benefits include
reimbursement of administrative charges for the
handling of blood and blood plasma.
4. Breast reconstruction is covered only as follows:
a. With or without prosthesis following medically
necessary mastectomy, including reconstruction
of the opposite breast to achieve cosmetic
symmetry.
Payment of transplantation benefits
1.
Participating Provider with Contractual Agreement
for Transplant Services—A contracting transplant
facility is a Center of Excellence facility with which
PacificSource has contracted or arranged to
provide transplantation services. Benefits for the
services, treatment, and supplies provided under
the contractual arrangement are subject to plan
deductibles and the lifetime maximum stated in the
Schedule. Coinsurance and copayment amounts after
deductible are waived.
2. Provider Without a Contractual Agreement for
Services of a state-certified ground or air
ambulance when private transportation is medically
inappropriate because the acute medical condition of
the member requires paramedic support. Coverage
is provided for emergency ambulance service and/
or transport to the nearest facility capable of treating
the medical condition. Air ambulance service is
covered only when ground ambulance is medically or
physically inappropriate.
b. All stages of a planned multistage reconstruction
associated with the medically necessary
mastectomy, if authorized in advance by
PacificSource.
5.
Removal, repair, and/or replacement of internal
breast prosthesis is covered only when the original
placement surgery was for a medically necessary
mastectomy, and when due to a contracture or
rupture of the prosthesis according to the following
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criteria:
a. The contracture or rupture must be clinically
evident by a physician’s physical examination,
imaging studies, or findings at surgery.
b. This policy covers removal, repair, and/
or replacement of the prosthesis; a new
reconstruction is not covered.
c. Removal, repair, and/or replacement of the
prosthesis is not covered when recommended
due to an autoimmune disease, connective
tissue disease, arthritis, allergenic syndrome,
psychiatric syndrome, fatigue, or other systemic
signs or symptoms.
d. Coverage is only provided if PacificSource
has received a properly signed loan receipt/
subrogation agreement from the member in
accordance with the provisions of this policy’s
General Limitations—Third Party and Motor
Vehicle Liability section.
6. Cardiac rehabilitation (see Definitions–Cardiac
rehabilitation) is covered as follows:
a. Phase I services are covered under inpatient
hospital benefits.
b. Phase II services are covered under outpatient
hospital benefits. Benefits are limited to
services provided in connection with a cardiac
rehabilitation exercise program that does not
exceed 36 sessions and that are considered
reasonable and necessary.
c. Phase III services are not a covered expense
under this policy.
7. Corneal transplants.
8. Cosmetic or reconstructive surgery is covered
only as follows:
a. Reconstructive surgery done primarily to correct
a functional disorder; or
b. Reconstructive surgery necessitated by an
accidental injury, or by a scar or defect resulting
from the initial repair of an accidental injury; or
c. Surgery to correct a scar or defect of the head or
neck resulting from medically necessary surgery
that was covered, or would have been covered,
under this policy.
d. Benefits are limited to only one attempt
at reconstruction (including all stages of a
planned multistage reconstruction if authorized
in advance by PacificSource) unless further
reconstructive surgery is necessary to correct
a functional disorder and reconstruction is
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undertaken within 18 months of the original
surgery or injury.
For related provisions on breast reconstruction and removal,
repair, or replacement of breast prosthesis, see “breast
reconstruction” and “breast prosthesis” in this section.
9. Dietary or nutritional counseling when provided
by a registered dietitian, only in the following
circumstances:
a. As part of the diabetic education benefit;
b. When medically necessary for management
of inborn errors of metabolism (not including
obesity);
c. When medically necessary for the management
of anorexia nervosa or bulimia nervosa up to a
lifetime maximum benefit of five visits.
10. Routine foot care, but only for patients being treated
for diabetes mellitus.
11. Hospitalization for dental procedures is covered
when the patient has another serious medical
condition that may complicate the dental procedure,
such as serious blood disease, unstable diabetes,
or severe cardiovascular disease, or the patient is
physically or developmentally disabled with a dental
condition that cannot be safely and effectively treated
in a dental office. Preauthorization by PacificSource
is required, and only charges for the facility,
anesthesiologist, and assistant physician are covered.
Hospitalization because of a patient’s apprehension or
convenience is not covered.
12. Treatment is covered for inborn errors of
metabolism involving amino acid, carbohydrate,
and fat metabolism and for which medically standard
methods of diagnosis, treatment, and monitoring
exist, including quantification of metabolites in blood,
urine or spinal fluid or enzyme or DNA confirmation
in tissues. Coverage includes expenses for
diagnosing, monitoring and controlling the disorders
by nutritional and medical assessment, including
but not limited to clinical visits, biochemical analysis
and medical foods used in the treatment of such
disorders. Reimbursement for covered nutritional
supplies is subject to the deductible, copayment,
and/or benefit percentage stated in the Schedule for
durable medical equipment.
13. Expense for injectable drugs and biologicals
medically necessary for the diagnosis or treatment of
illness or injury when administered by a physician in
an office or home setting. This benefit does not apply
to immunizations (see Covered Expenses–Preventive
Care), or to drugs and biologicals that can be selfadministered or that are purchased by or dispensed
to a member.
14. Expense for maxillofacial prosthetic services
when prescribed by a physician as necessary for
adjunctive treatment. Coverage is limited to the least
costly clinically appropriate alternative treatment as
determined by a physician. For the purpose of this
provision, adjunctive treatment is the restoration
and management of head and facial structures
that cannot be replaced with living tissue and that
are defective because of disease, trauma, or birth
and developmental deformities. Restoration and
management must be performed for the purpose of:
a. Controlling or eliminating infection;
b. Controlling or eliminating pain; or
c. Restoring facial configuration or functions
such as speech, swallowing or chewing, but
not including cosmetic procedures rendered to
improve on the normal range of conditions.
Prosthetic devices not covered by this provision
include dentures, prosthetic devices for the treatment
of temporomandibular joint conditions, artificial
larynx, or prosthetic devices primarily used for
cosmetic purposes that are not necessary to control
or eliminate infection, relieve pain, or restore
functions such as speech, swallowing, or chewing.
15. Expense for non-prescription elemental enteral
formula for home use if:
a. The formula is medically necessary for the
treatment of severe intestinal malabsorption; and
b. A physician has issued a written order for the
formula; and
c. The formula comprises a predominant or
essential source of nutrition.
Reimbursement for covered elemental enteral
formula is subject to the deductible, copayment,
and/or benefit percentage stated in the Schedule for
durable medical equipment.
16. Facility charges of a hospital or ambulatory surgery
center for pediatric dental care requiring general
anesthesia, up to a lifetime maximum benefit
of $2,000. Services must be preauthorized by
PacificSource to be covered.
17. Outpatient pulmonary rehabilitation programs
are covered when prescribed by a physician, to a
lifetime maximum benefit of $1,000. To be eligible for
benefits, there must be severe chronic lung disease
that interferes with normal daily activities despite
optimal management with medications.
18. Routine costs of clinical trials are covered (see
Definitions–Routine costs of care). Benefits are only
provided for routine costs of care associated with
qualifying clinical trials. Expenses for services or
supplies that are not considered routine costs of care
are not covered. PacificSource is not, based on the
coverage provided, liable for any adverse effects of a
clinical trial.
19. Sleep studies when ordered by a pulmonologist,
neurologist, otolaryngologist, or certified sleep
medicine specialist and performed at a certified sleep
laboratory.
20. Medically necessary therapy and services for the
treatment of traumatic brain injury.
GENERAL EXCLUSIONS
This policy does not provide benefits in any of the
following circumstances or for any of the following
conditions:
Abdominoplasty: for any indication.
Acupuncture: except as may be provided for by
endorsement to this policy.
Admission prior to coverage: Services and supplies
for an admission to a hospital, skilled nursing facility or
specialized facility that began before the patient’s coverage
under this policy.
Benefits not stated: Services and supplies not specifically
described as benefits under this policy and/or any
endorsement attached hereto.
Charges over the allowable fee: Any amount in excess
of the allowable fee for a given service or supply.
Chelation therapy: including associated infusions
of vitamins and/or minerals, except as preauthorized
by PacificSource for the treatment of selected medical
conditions and medically significant heavy metal toxicities.
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Chiropractic care except as may be provided for by
Contraceptive drugs and devices: for any diagnosis,
except as may be provided for by endorsement to this
policy.
Cosmetic/reconstructive services and supplies: Except
as specified in the Covered Expenses—Other Covered
Services, Supplies, and Treatments section of this contract,
services and supplies, including drugs, rendered primarily
for cosmetic/reconstructive purposes and any complications
as a result of noncovered cosmetic/reconstructive surgery.
Cosmetic/reconstructive services and supplies are those
performed primarily to improve the body’s appearance
and not primarily to restore impaired function of the body,
regardless of whether the area to be treated is normal or
abnormal.
Criminal conduct: Illness or injury in which a contributing
cause was the member’s commission of or attempt to
commit a felony, including illness or injury in which
a contributing cause was being engaged in an illegal
occupation.
Custodial care: Care and related services designed
essentially to assist a person in maintaining activities of
daily living, e.g. services to assist with walking, getting in/
out of bed, bathing, dressing, feeding, preparation of meals,
homemaker services, special diets, rest cures, day care, and
diapers. Custodial care is only covered in conjunction with
respite care allowed under this policy’s hospice benefit. (See
Covered Expenses - Hospital, Skilled Nursing Facility, Home
Health, and Hospice Services.)
Dental examinations and treatment: For the purpose
of this exclusion, the term “dental examinations and
treatment” means services or supplies provided to prevent,
diagnose, or treat diseases of the teeth and supporting
tissues or structures. This includes services, supplies,
hospitalization, anesthesia, dental braces or appliances, or
dental care rendered to repair defects that have developed
because of tooth loss, or to restore the ability to chew,
or dental treatment necessitated by disease. For related
provisions, see Covered Expenses–Other Covered Services,
Supplies, and Treatments–Hospitalization for Dental
Procedures.
Drugs or medications: that can be self-administered
(including prescription drugs, injectable drugs, and
biologicals), unless given during a visit for outpatient
chemotherapy or dialysis or during a medically necessary
hospital, emergency room or other institutional stay, except
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as may be provided by endorsement to this policy.
Electronic Beam Tomography (EBT):
Equipment: commonly used for nonmedical purposes,
marketed to the general public and available without a
prescription, intended to alter the physical environment,
or used primarily in athletic or recreational activities.
Items such as the following are specifically excluded from
coverage:
•
Adjustable power beds sold as furniture
•
Air conditioners
•
Air purifiers
•
Blood pressure monitoring equipment
•
Compression/cooling combination units
•
Computer or electronic devices
•
Computer software for monitoring (including
coagulation monitoring), recording, or reporting
asthmatic, diabetic, or similar clinical tests or data
•
Conveyances (including scooters) other than
conventional wheelchairs
•
Cooling pads
•
Equipment purchased on the Internet
•
Exercise equipment for stretching, conditioning,
strengthening, or relief of musculoskeletal symptoms
•
Heating pads
•
Humidifiers, except as part of CPAP apparatus
•
Light boxes
•
Mattress or mattress pads, except for healing of
pressure sores
•
Orthopedic shoes
•
Pillows
•
Replacement costs for worn or damaged durable
medical equipment that would otherwise be
replaceable without charge under warranty or other
agreement
•
Spas
•
Saunas
•
Shoe modifications, except when incorporated into a
brace or prosthesis
•
Structural alterations in order to prevent, treat, or
accommodate a medical condition (including, but not
limited to, grab bars and railings)
•
Vehicle alterations in order to prevent, treat, or
accommodate a medical condition
•
Whirlpool baths
•
Female: The inability to conceive or carry a pregnancy
to 12 weeks.
Experimental or investigational procedures: Services
that are experimental or investigational (see Definitions
– Experimental or investigational procedures). An
experimental or investigational service is not made eligible
for benefits by the fact that other treatment is considered by
the member’s healthcare provider to be ineffective or not as
effective as the service or that the service is prescribed as
the most likely to prolong life.
Jaw surgery: Procedures, services, and supplies for
developmental or degenerative abnormalities of the
jaw, malocclusion, or improving placement of dentures,
including dental implants. For related provisions,
see the exclusions for orthognathic surgery and
temporomandibular joint in this section, and Covered
Expenses–Professional Services.
Eye examinations (routine).
Massage or massage therapy, except as may be
provided for by endorsement to this policy.
Eye glasses and eye refraction: The fitting, provision, or
replacement of eye glasses, lenses, frames, contact lenses,
or subnormal vision aids; and eye exercises, orthoptics,
vision therapy, or eye refraction procedures intended to
correct refractive error, except as may be provided for by
Family planning: Services and supplies for artificial
insemination, in vitro fertilization, diagnosis and treatment
of infertility, erectile dysfunction, frigidity, surgery to reverse
voluntary sterilization, or removal of contraceptive devices.
For related provisions, see the exclusions for infertility and
sexual disorders in this section.
Foot care (routine): Services and supplies for corns and
calluses of the feet, conditions of the toenails other than
infection, hypertrophy or hyperplasia of the skin of the feet,
and other routine foot care, except in the case of patients
being treated for diabetes mellitus.
Genetic (DNA) testing: DNA and other genetic tests,
except for those tests identified as medically necessary for
the diagnosis and standard treatment of specific diseases.
Growth hormone: injections or treatments, except to treat
documented growth hormone deficiencies.
Immunizations: when recommended for or in anticipation
of exposure through travel or work.
Infertility: Services and supplies, diagnostic laboratory
and x-ray studies, surgery, treatment, or prescriptions to
diagnose, prevent, or cure infertility or to induce fertility
(including Gamete and/or Zygote Interfallopian Transfer; i.e.
GIFT or ZIFT), except for medically necessary medication
to preserve fertility during treatment with cytotoxic
chemotherapy. For related provisions, see the exclusions
for family planning and sexual disorders in this section. For
purposes of this policy, infertility is defined as:
•
Male: Low sperm counts or the inability to fertilize an
egg.
Mental health/chemical dependency: Treatment for
mental retardation; learning disorders; paraphilias; gender
identity disorders in adults (this exclusion does not apply to
children and adolescents 18 years of age or younger); and
diagnostic codes V15.81 through V71.09 (this exclusion does
not apply to diagnostic codes V61.20, V61.21, and V62.82 for
children five years of age or younger). This plan does not
cover educational or correctional services or sheltered living
provided by a school or halfway house, except outpatient
services received while temporarily living in a shelter;
psychoanalysis or psychotherapy received as part of an
educational or training program, regardless of diagnosis
or symptoms that may be present; a court-ordered sex
offender treatment program; a screening interview or
treatment program under ORS813.021; treatment of
caffeine-related disorders not related to caffeine-induced
anxiety disorder; or nicotine-related disorders.
The following treatment types are also excluded, regardless
of diagnosis: marital/partner counseling; support groups;
sensory integration training; biofeedback except to treat
migraine headaches or urinary incontinence; hypnotherapy;
academic skills training; equine/animal therapy;
narcosynthesis; aversion therapy; and social skill training.
Recreation therapy is only covered as part of an inpatient or
residential admission.
Motion analysis, including video taping and 3D kinematics, dynamic surface and fine wire
electromyography, including physician review.
Myeloablative high dose chemotherapy, except when
the related transplant is specifically covered under the
transplantation provisions of this policy (see Covered
Expenses–Transplantation Services).
Naturopathic/homeopathic services or supplies,
except as may be provided for by endorsement to this
policy.
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Obesity or weight control: Surgery or other related
services or supplies provided for weight control or obesity
(including all categories of obesity), whether or not there
are other medical conditions related to or caused by obesity.
This also includes services or supplies used for weight
loss, such as food supplementation programs and behavior
modification programs, regardless of the medical conditions
that may be caused or exacerbated by excess weight, and
self-help or training programs for weight control.
Orthognathic surgery: Services and supplies to augment
or reduce the upper or lower jaw, except as specified under
Covered Expenses—Professional Services–Jaw or Natural
Teeth. For related provisions, see the exclusions for jaw
surgery and temporomandibular joint in this section.
Osteopathic manipulation, except for treatment of
disorders of the musculoskeletal system.
Panniculectomy for any indication.
Physical examinations: Routine physical or eye
examinations required for administrative purposes such
as participation in athletics, admission to school, or by an
employer.
Providers (ineligible) – An individual, organization, facility,
or program is not eligible for reimbursement for services
or supplies, regardless of whether this policy includes
benefits for such services or supplies, unless the individual,
organization, facility, or program is licensed by the state in
which services are provided as an independent practitioner,
hospital, ambulatory surgical center, skilled nursing facility,
durable medical equipment supplier, or mental and/or
chemical healthcare facility. And, to the extent PacificSource
maintains credentialing requirements the practitioner or
facility must satisfy those requirements.
Rehabilitation: Functional capacity evaluations, work
hardening programs, vocational rehabilitation, community
reintegration services, and driving evaluations and training
programs.
Routine services and supplies: Services, supplies, and
equipment not involved in diagnosis or treatment but
provided primarily for the comfort, convenience, cosmetic
purpose, environmental control, or education of a patient
or for the processing of records or claims. These include but
are not limited to:
•
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Charges for telephone consultations, missed
appointments, completion of claim forms, or reports
requested by PacificSource in order to process
claims.
•
Appliances, such as air conditioners, humidifiers, air
filters, whirlpools, hot tubs, heat lamps, or tanning
lights.
•
Private nursing service, or personal items such as
telephones, televisions, and guest meals in a hospital
or skilled nursing facility.
•
Maintenance supplies and equipment not unique to
medical care.
Screening tests: Services and supplies, including imaging
and screening exams performed for the sole purpose of
screening and not associated with specific diagnoses and/or
signs and symptoms of disease or of abnormalities on prior
testing (including but not limited to total body CT imaging,
CT colonography and bone density testing), except to the
extent covered under the policy’s preventive care benefits
(see Covered Expenses—Preventive Care).
Services otherwise available: These include but are not
limited to:
• Services or supplies for which payment could be
obtained in whole or in part if the member applied
for payment under any city, county, state (except
Medicaid), or federal law; and
•
Services or supplies the member could have received
in a hospital or program operated by a federal
government agency or authority, except otherwise
covered expenses for services or supplies furnished
to a member by the Veterans’ Administration of the
United States that are not service-related.
Services or supplies for which no charge is made,
for which the member is not legally required to pay, or for
which a provider or facility is not licensed to provide even
though the service or supply may otherwise be eligible. This
exclusion includes services provided by the member, or by
an immediate family member.
Sexual disorders: Services or supplies for the treatment
of sexual dysfunction or inadequacy. For related provisions,
see the exclusions for family planning, infertility, and mental
health in this section.
Sex reassignment: Procedures, services, or supplies
(including gender-reassignment drug therapies in a presurgery situation) related to a sex reassignment. For related
provisions, see exclusions for mental health in this section.
Snoring: Services or supplies for the diagnosis or
treatment of snoring and/or upper airway resistance
disorders, including somnoplasty.
Speech therapy: Oral/facial motor therapy for
strengthening and coordination of speech-producing
musculature and structures.
Temporomandibular joint: Advice or treatment,
including physical therapy and/or oromyofacial therapy,
either directly or indirectly for temporomandibular joint
dysfunction, myofascial pain, or any related appliances. For
related provisions, see the exclusions for jaw surgery and
orthognathic surgery in this section, and Covered Expenses–
Professional Services.
Third party liability, motor vehicle liability, motor
vehicle insurance coverage, workers’ compensation:
Any services or supplies for illness or injury for which a
third party is responsible or which are payable by such
third party or which are payable pursuant to applicable
workers’ compensation laws, motor vehicle liability,
uninsured motorist, underinsured motorist, and personal
injury protection insurance and any other liability and
voluntary medical payment insurance to the extent of any
recovery received from or on behalf of such sources. For
related provisions see General Limitations—Third Party
and Motor Vehicle Liability: General Limitations—Motor
Vehicle Accidents; and General Limitations—Workers’
Compensation Benefits.
Training or self-help programs: General fitness exercise
programs, and programs that teach a person how to use
durable medical equipment or care for a family member.
Also excluded are health or fitness club services or
memberships and instruction programs, including but
not limited to those to learn to self-administer drugs or
nutrition, except as specifically provided for in this policy.
Transplants: Any services, treatments, or supplies for
the transplantation of bone marrow or peripheral blood
stem cells or any human body organ or tissue, except as
expressly provided under the provisions of this policy for
covered transplantation expenses. For related provisions
see Covered Expenses–Transplantation Services.
Treatment after insurance ends: Services or supplies
a member receives after the member’s coverage under
this policy ends. The only exception is that if this policy is
immediately, without lapse, replaced by a group health
policy issued by another insurer and the member is in the
hospital on the day this policy terminates, PacificSource
will continue to pay toward covered expenses for that
hospitalization until the member is discharged from the
hospital or until benefits have been exhausted, whichever
occurs first.
Treatment not medically necessary: Services or supplies
that are not medically necessary for the diagnosis or
treatment of an illness or injury. For related provisions see
Definitions–Medically Necessary and General Limitations–
Medical Necessity.
Treatment prior to enrollment: Services or supplies a
member received prior to enrolling in coverage provided by
this policy.
Treatment while incarcerated: Services or supplies a
member receives while in the custody of any state or federal
law enforcement authorities or while in jail or prison.
Unwilling to release information: Charges for services
or supplies for which a member is unwilling to release
medical or eligibility information necessary to determine the
benefits payable under this policy.
War-related conditions: The treatment of any condition
caused by or arising out of an act of war, armed invasion,
or aggression, or while in the service of the armed forces.
Work-related conditions: Services or supplies for
treatment of illness or injury arising out of or in the course
of employment or self-employment for wages or profit,
whether or not the expense for the service or supply is
paid under workers’ compensation, except in the case
of owners, partners, or principles injured in the course
of employment of the employer/policyholder and who
are otherwise exempt from, and not covered by, state or
federal workers’ compensation insurance.
GENERAL LIMITATIONS
PRE-EXISTING CONDITION EXCLUSION PERIOD
Coverage for pre-existing conditions is excluded according
to the following:
•
For a member, six months following the member’s
effective date of coverage, or if earlier, ten months
following the start of any required group eligibility
waiting period.
•
For a late enrollee, six months following the effective
date of coverage.
Exemptions from pre-existing condition exclusion
period:
•
The exclusion period does not apply to members
under the age of 19.
EXCLUSION PERIOD FOR SPECIFIED
CONDITIONS
Specified conditions exclusion period: For a period of
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six months following a member’s effective date of coverage,
expenses for the following procedures are excluded as a
benefit of this policy:
•
Elective surgery or procedures. This refers to a
surgery or procedure for a condition that does not
require immediate attention and for which a delay
would not have a substantial likelihood of adversely
affecting the health of the patient. For the purpose
of this provision elective procedures include, but are
not limited to, sterilization when not performed in
conjunction with a newborn delivery.
•
Surgery for otitis media (inner or middle ear
infection).
•
Removal of tonsils or adenoids with or without
myringotomy.
EXCLUSION PERIOD FOR TRANSPLANTATION
BENEFITS
For a period of 24 months following a member’s effective
date of coverage, expense that might otherwise be
considered an eligible expense under the transplantation
benefits is excluded as a benefit of this policy. Note: This
exclusion does not apply to children under the age of 19.
CREDIT FOR PRIOR COVERAGE
Credit for prior coverage: Exclusion periods for
pre-existing conditions, specified conditions, and
transplantation benefits will be reduced by an amount of
time equal to the member’s or late enrollee’s aggregate
period of creditable coverage if the most recent period of
creditable coverage ended within 63 days of, or remains in
effect on, the effective date of coverage under this policy.
The credit for prior coverage will be applied without regard
to the specific benefits covered during the prior period.
Proof of creditable coverage: To demonstrate creditable
coverage, a member may provide PacificSource with a
Certificate of Creditable Coverage from a prior health benefit
plan. If, after making reasonable effort, a member is unable
to obtain a Certificate of Creditable Coverage, PacificSource
will attempt to assist in obtaining the certificate.
THIRD-PARTY AND MOTOR VEHICLE LIABILITY
Third party liability: A member covered by this policy
may have a legal right to recover benefits or healthcare
costs from another person, organization, or entity or an
insurance company (any of whom is a “Third-Party”) as a
result of an illness or injury for which benefits or healthcare
costs were paid under this policy. PacificSource is entitled
to be reimbursed in full for any benefits it pays that are
associated with any illness or injury that are or may be
recoverable from a third party or other source.
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A “third party” includes liability and casualty insurance, and
any other form of insurance that may pay money to or on
behalf of a member, including but not limited to uninsured
motorist coverage, under-insured motorist coverage,
premises med-pay coverage, PIP coverage, and workers’
compensation insurance.
Member responsibilities: A member shall promptly notify
PacificSource in writing when the member has incurred
an illness, or sustained an injury, for which one or more
Third-Parties may be responsible. The member must avoid
doing anything that would prejudice PacificSource’s right of
recovery. The member must cooperate with PacificSource in
its attempt to recover from Third-Parties.
Upon claiming or accepting payment, or the provision
of benefits under this policy, the member agrees that
PacificSource shall have the remedies and rights as stated in
this section. PacificSource may elect to seek recovery under
one or more of the procedures outlined in this section.
Under all of the procedures outlined in this section,
including Subrogation, Right of Recovery, and Motor Vehicle
Accidents, the reimbursement to PacificSource includes
the full amount of benefits paid, as well as any pending
payments. The reimbursement to PacificSource shall
be from the first dollars paid or payable to the member
(including to his or her legal representatives, estate or heirs,
or any trust established for the purpose of paying for the
future income, care or medical expense of the member),
regardless of the characterization of the recovery, whether
or not the member is made whole, or whether or not any
moments are paid or payable directly by the third party or
another source. The member agrees that the “made whole”
doctrine does not apply. Attorney’s fees and court costs are
the responsibility of the member, not PacificSource.
SUBROGATION
Upon payment for medical services or supplies,
PacificSource shall be subrogated to all of the member’s
rights of recovery therefore, and the member shall do what
ever is necessary to secure such rights and do nothing to
prejudice them.
Under this subsection, PacificSource may pursue the
Third-Party in its own name, or in the name of the member.
PacificSource is entitled to all subrogation rights and
remedies under the common and statutory law, as well as
otherwise provided for in this policy.
RIGHT OF RECOVERY
In addition to its subrogation rights, PacificSource may,
at its sole discretion and option, ask that the member,
and his or her attorney, if any, protect PacificSource’s
reimbursement rights. If PacificSource elects to proceed
under this subsection, the following rules apply:
1.
The member holds any right of recovery against the
other party in trust for PacificSource, but only for the
amount of benefits PacificSource pays for that illness
or injury.
2. PacificSource is entitled to receive the amount of
benefits it has paid for that illness or injury out of any
settlement or judgment that results from exercising
the right of recovery against the other party. This is so
regardless of whether the third party admits liability
or asserts that the member is also at fault. In addition,
PacificSource is entitled to receive the amount of
benefits it has paid whether the healthcare expenses
are itemized or expressly excluded in the third party
recovery.
3. PacificSource holds the option to subtract from
the money to be reimbursed to PacificSource a
proportionate share representing the member’s
reasonable attorney fees for collecting amounts paid
by PacificSource to a third party.
4. In addition, and as an alternative, if requested by
PacificSource, the member will take such action as
may be necessary or appropriate to recover such
benefits furnished as damages from the responsible
third party. Such action will be taken in the name
of the member. If requested by PacificSource,
such action will be prosecuted by a representative
designated by PacificSource who does not have a
conflict of interest with the member. In the event
of a recovery, PacificSource will be reimbursed
out of such recovery for the member’s share of
the expenses, costs, and attorney fees incurred by
PacificSource in connection with the recovery.
5. PacificSource may ask the member to sign an
agreement to abide by the terms of this Right of
Recovery subsection. If PacificSource elects to
proceed under this subsection, PacificSource will not
be required to pay benefits for the illness or injury
until the agreement is properly signed and returned.
MOTOR VEHICLE ACCIDENTS
Any expense for injury or illness which results from a motor
vehicle accident and which is payable under a motor vehicle
insurance policy is not a covered expense under this policy
and will not be paid by PacificSource.
If a claim for healthcare expenses arising out of a motor
vehicle accident is filed with PacificSource and motor
vehicle insurance has not yet paid, then PacificSource
may advance benefits, subject to the rights and remedies
outlined in the SUBROGATION and RIGHT OF RECOVERY
subsections stated above, and subject to the next
paragraph.
In addition to the rights and remedies outlined in the
Subrogation and Right of Recovery subsections stated
above, in third party claims involving the use or operation
of a motor vehicle, PacificSource, at its sole discretion and
option, is entitled to seek reimbursement under the Personal
Injury Protection statutes of the State of Oregon, including
ORS 742.534, ORS 742.536, or ORS 742.538. When liability
is not in question, PacificSource will seek reimbursement
under ORS 742.538.
MEMBER RESPONSIBILITY FOR FUTURE
MEDICAL EXPENSES
If the member incurs healthcare expenses for treatment of
the illness or injury after receiving a recovery from or on
behalf of a Third-Party, PacificSource will exclude benefits
for otherwise covered expenses until the total amount of
healthcare expenses incurred before and after the recovery
exceeds the amount of the total recovery from all ThirdParties and insurers, less reasonable attorney fees incurred
in connection with the recovery.
WORKERS’ COMPENSATION BENEFITS
Work-related conditions: Any expense for injury or
illness that arises out of or in the course of employment
or self-employment for wages or profit is not a covered
expense under this policy, regardless of the availability
of workers’ compensation benefits, except in the case of
owners, partners, or principles injured in the course of
employment of the employer/policyholder and who are
otherwise exempt from, and not covered by, state or federal
workers’ compensation insurance.
Right of Recovery: If the entity providing workers’
compensation coverage has not approved the member’s
claim and the member has filed an appeal, PacificSource
may advance benefits if the member agrees in writing to
hold any recovery the member obtains from the entity
providing workers’ compensation coverage in trust for
PacificSource up to the amount of benefits PacificSource
pays, and to reimburse PacificSource for all such benefits
advanced.
If PacificSource has already paid benefits, PacificSource is
entitled to full reimbursement of the benefits PacificSource
has paid from the proceeds of any recovery the member
receives from or on behalf of the entity providing
workers’ compensation coverage. This is so regardless of
99
whether the recovery is the result of an arbitration award,
compromise settlement, disputed claims settlement,
or any other arrangement. In addition, PacificSource is
entitled to reimbursement without regard to whether the
healthcare expenses are itemized or expressly excluded
in the recovery, or whether the entity providing workers’
compensation coverage admits or does not approve liability.
A deduction for the reasonable attorney fees incurred in
obtaining the recovery may be made from the amount to be
reimbursed to PacificSource.
Member responsibility for future medical expenses:
If the member incurs healthcare expenses for treatment of
the illness or injury after receiving a recovery, PacificSource
will exclude benefits for otherwise covered expenses until
the total amount of healthcare expenses incurred after the
recovery exceeds the total amount of all recoveries relating
to the injury or illness from any entity, less a proportionate
share of reasonable attorney fees incurred in obtaining the
recovery.
The order of benefit determination rules govern the order
in which each Plan will pay a claim for benefits. The Plan
that pays first is called Primary plan. The Primary plan must
pay benefits in accordance with its policy terms without
regard to the possibility that another Plan may cover some
expenses. The Plan that pays after the Primary plan is
the Secondary plan. The Secondary plan may reduce the
benefits it pays so that payments from all Plans do not
exceed 100 percent of the total Allowable expense.
Related definitions as used in this section:
1. A Plan is any of the following that provides benefits
or services for medical or dental care or treatments.
If separate contracts are used to provide coordinated
coverage for members of a group, the separate
contracts are considered parts of the same plan and
there is no COB among those separate contracts.
•
Plan includes: group insurance contracts, health
maintenance organization (HMO) contracts,
closed panel plans or other forms of group
or group-type coverage (whether insured
or uninsured); medical care components of
group long-term care contracts, such as skilled
nursing care; and Medicare or any other federal
government plan as permitted by law.
•
Plan does not include: hospital indemnity
coverage or other fixed indemnity coverage;
accident only coverage; specified disease or
specified accident coverage; limited benefit
health coverage, as defined by state law; school
accident type coverage; benefits for nonmedical
components of group long-term care policies;
Medicare supplements policies; Medicaid
policies; or coverage under other federal
governmental plans, unless permitted by law.
MEDICARE
When this plan is primary payer to Medicare: In certain
situations, this plan is primary payer to Medicare coverage
when the member is enrolled in the coverage of both
Medicare and this plan. Those situations are:
•
When the member is age 65 or over and by law
Medicare is secondary payer to this plan;
•
When the member incurs covered services for kidney
transplant or kidney dialysis and by law Medicare is
secondary payer to this plan; and
•
When the member is entitled to benefits under
Medicare disability and by law Medicare is secondary
payer to this plan.
Benefits payable by Medicare: This policy does not pay
benefits toward any part of a covered expense to the extent
the covered expense is paid under Medicare Part A or Part
B or would have been paid under Medicare Part B had the
Medicare-eligible member properly enrolled and applied
for benefits under Medicare. Benefits that are payable by
this policy are paid in accordance with federal and state
government rules and regulations on the coordination of
health plan benefits with Medicare that are in effect at the
time services are incurred.
COORDINATION OF THIS CONTRACT’S
BENEFITS WITH OTHER BENEFITS
The Coordination of Benefits (COB) provision applies when
a member has healthcare coverage under more than one
Plan. Plan is defined below.
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Each contract for coverage listed above is a separate
Plan. If a Plan has two parts and COB rules apply only
to one of the two, each of the parts is treated as a
separate Plan
2. This plan means, in a COB provision, the part of the
contract providing the healthcare benefits to which
the COB provision applies and which may be reduced
because of the benefits of other plans. Any other
part of the contract providing healthcare benefits is
separate from This Plan. A contract may apply one
COB provision to certain benefits, such as dental
benefits, coordinating only with similar benefits, and
may apply another COB provision to coordinate other
benefits.
allowable expense for all Plan. However if the
provider has contracted with the Secondary plan
to provide the benefit or service for a specific
negotiated fee or payment amount that is different
than the Primary plan’s payment arrangement and
if the provider’s contract permits, the negotiated
fee or payment shall be the allowable expense
used by the Secondary plan to determine its
benefits.
3. The order of benefit determination rules determine
whether This plan is a Primary plan or Secondary
plan when the person has healthcare coverage under
more than one Plan.
When This Plan is primary, it determines payment
for its benefits first before those of any other Plan
without considering any other Plan’s benefits. When
this plan is secondary, it determines its benefits after
those of another Plan and may reduce the benefits
it pays so that all Plan benefits do not exceed 100
percent of the total allowable expense.
4. Allowable expense is a healthcare expense,
including deductibles, coinsurance and copayments,
that is covered at least in part by any Plan covering
the member. When a Plan provides benefits in the
form of services, the reasonable cash value of each
service will be considered an allowable expense and
a benefit paid. An expense that is not covered by
any Plan covering the member is not an allowable
expense. In addition, any expense that a provider by
law or in accordance with a contractual agreement is
prohibited from charging a covered person is not an
allowable expense.
The following are examples of expenses that are not
allowable expenses:
•
•
The difference between the cost of a semi-private
hospital room and a private hospital room is not
an allowable expense, unless one of the Plans
provides coverage for private hospital room
expenses.
If a member is covered by two or more Plans
that compute their benefit payments on the basis
of usual and customary fees or relative value
schedule reimbursement methodology or other
similar reimbursement methodology, any amount
is excess of the highest reimbursement amount
for a specific benefit is not an allowable expense.
•
If a member is covered by two or more Plans
that provide benefits or services on the basis
of negotiated fees, an amount in excess of the
highest of the negotiated fees is not an allowable
expense.
•
If a member is covered by one Plan that calculates
its benefits or services on the basis of usual
and customary fees or relative value schedule
reimbursement methodology or other similar
reimbursement methodology and is also covered
by another Plan that provides its benefits or
services on the basis of negotiated fees, the
Primary plan’s payment arrangement shall be the
•
The amount of any benefit reduction by the
Primary plan because a covered member has
failed to comply with the Plan provisions is not
an allowable expense. Examples of these types of
plan provisions include second surgical opinions,
precertification of admissions, and preferred
provider arrangements.
5. Closed panel plan is a Plan that provides healthcare
benefits to covered members primarily in the form
of services through a panel of providers that have
contracted with or are employed by the Plan, and
that excludes coverage for services provided by other
providers, except in cases of emergency or referral by
a panel member.
6. Custodial parent is the parent awarded custody by
a court decree or, in the absence of a court decree,
is the parent with whom the child resides more
than one half of the calendar year excluding any
temporary visitations.
Order of benefit determination rules
When a member is covered by two or more Plans, the
rules for determining the order of benefit payments are as
follows:
•
The Primary Plan pays or provides its benefits
according to its terms of coverage without regard to
the benefits under any other Plan.
(1) Except as provided in Paragraph 2, a Plan that
does not contain a coordination of benefits
provision that is consistent with state insurance
regulations is always primary unless the
provisions of both Plans state that the complying
Plan is primary.
(2) Coverage that is obtained by virtue of
membership in a group that is designed to
supplement a part of a basic package of benefits
and provides that this supplementary coverage
shall be excess to any other parts of the Plan
provided by the policyholder. Examples of these
types of situations are major medical coverages
that are superimposed over base plan hospital
101
coverage and the Plan of that parent
has actual knowledge of those terms,
the Plan is primary. This rule applies to
plan years commencing after the Plan is
given notice of the court decree;
and surgical benefits, and insurance type
coverages that are written in connection with
a Closed panel plan to provide out-of-network
benefits.
•
•
A Plan may consider the benefits paid or provided
by another Plan in calculating payment of its benefits
only when it is secondary to that other Plan.
If a court decree states that both parents
are responsible for the dependent
child’s healthcare expenses or
healthcare coverage, the provisions of
Subparagraph (a) above shall determine
the order of benefits;
o
If a court decrees states that the parents
have joint custody without specifying
that one parent has responsibility for
the healthcare expenses or healthcare
coverage of the dependent child, the
provision of Subparagraph (a) above
shall determine the order of benefits; or
o
If there is no court decree allocating
responsibility for the dependent child’s
healthcare expenses or health coverage,
the order of benefits for the child are
as follows: 1) The Plan covering the
Custodial parent; 2) The Plan covering
the spouse of the Custodial parent; 3)
The plan covering the non-custodial
parent; and then 4) The Plan covering the
spouse of the non-custodial parent.
Each Plan determines its order of benefits using the
first of the following rules that apply:
(1)
(2)
Non-Dependent or Dependent. The Plan
that covers the person other than as a
dependent (for example as an employee,
member, policyholder, subscriber or retiree)
is the Primary plan. The Plan that covers the
person as a dependent is the Secondary plan.
However, if the person is a Medicare beneficiary
and, as a result of federal law, Medicare is
secondary to the Plan covering the person as
a dependent; and primary to the Plan covering
the person as other than a dependent (e.g. a
retired employee); then the order of benefits
between the two Plans is reversed so that the
Plan covering the person as an employee,
member, policyholder, subscriber or retiree is
the Secondary plan and the other Plan is the
Primary plan.
Dependent Child Covered Under More Than
One Plan. Unless there is a court decree stating
otherwise, when a dependent child is covered
by more than one Plan the order of benefits is
determined as follows:
(c)For a dependent child covered under more
than one Plan of individuals who are not
the parents of the child, the provisions
of Subparagraph (a) or (b) above shall
determine the order of benefits as if those
individuals were the parents of the child.
(a)For a dependent child whose parents are
married or are living together, whether or not
they have ever been married:
o
The Plan of the parent whose birthday
falls earlier in the calendar year is the
Primary Plan; or
o
If both parents have the same birthday,
the Plan that has covered the parent the
longest is the Primary plan.
(3)
Active Employee or Retired or Laid-off
Employee. The Plan that covers a person as an
active employee, this is, an employee who is
neither laid off nor retired, is the Primary Plan.
The Plan covering the same person as a retired
or laid-off employee and that same person is a
dependent of a retired or laid-off employee. If
the other Plan does not have this rule, and as
a result, the Plans do not agree on the order of
benefits, this rule is ignored. This rule does not
apply if the rule labeled “Non-Dependent or
Dependent” can determine the order of benefits.
(4)
COBRA or State Continuation Coverage. If a
person whose coverage is provided pursuant
(b)For a dependent child whose parents are
divorced or separated or not living together,
whether or not they have ever been married;
o
102
o
If a court decree states that one of the
parents is responsible for the dependent
child’s healthcare expenses or healthcare
to COBRA or under a right of continuation
provided by state or other federal law is covered
under another Plan, the Plan covering the
person as an employee, member, subscriber, or
retiree or covering the person as a dependent
of an employee, member subscriber, or retiree
is the Primary plan and the COBRA or state
or other federal continuation coverage is the
Secondary plan. If the other Plan does not have
this rule, and as a result, the Plans do not agree
on the order of benefits, this rule is ignored. This
rule does not apply if the rule labeled “NonDependent or Dependent” can determine the
order of benefits.
(5)
Longer or Shorter Length of Coverage. The
Plan that covered the person as an employee,
member, policyholder, subscriber or retiree
longer is the Primary plan and the Plan that
covered the person the shorter period of time is
the Secondary plan.
(6)
If the preceding rules do not determine the
order of benefits, the Allowable expenses shall
be shared equally between the Plans meeting
the definition of Plan. In addition, This plan will
not pay more than it would paid had it been the
Primary plan.
Effects on the benefits of this plan.
•
•
When this plan is secondary, it may reduce its
benefits so that the total of benefits paid or provided
by all Plans during a plan year are not more than
the total Allowable expenses. In determining the
amount to be paid for any claim, the Secondary plan
will calculate the benefits it would have paid in the
absence of other healthcare coverage and apply
that calculated amount to any Allowable expense
under its Plan that is unpaid by the Primary plan. The
Secondary plan may then reduce its payment by the
amount so that, when combined with the amount
paid by the Primary plan, the total benefits paid or
provided by all Plans for the claim do not exceed the
total Allowable expense for that claim. In addition, the
Secondary plan shall credit to its plan deductible any
amounts it would have credited to its deductible in
the absence of other healthcare coverage.
If a covered person is enrolled in two or more Closed
panel plans and if, for any reason, including the
provision of service by a non-panel provider, benefits
are not payable by one Closed panel plan, then COB
shall not apply between that Plan and other Closed
panel plans.
Right to receive and release necessary information.
Certain facts about healthcare coverage and services are
needed to apply these COB rules and determine benefits
payable under This plan and other Plans. PacificSource
may get the facts it needs from or give them to other
organizations or persons for the purpose of applying these
rules and determining benefits payable under This plan
and other Plans covering the person claiming benefits.
PacificSource need not tell, or get the consent of, any
person to do this. Each person claiming benefits under This
plan must give PacificSource any facts it needs to apply
those rules and determine benefits payable.
Facility of payment.
A payment made under another plan may include an
amount that should have been paid under This plan.
If it does, PacificSource may pay that amount to the
organization that made that payment. That amount will then
be treated as though it were a benefit paid under This plan.
PacificSource will not have to pay that amount again. The
term “payment made” includes providing benefits in the
form of services, in which case “payment made” means the
reasonable cash value of the benefits provided in the form
of services.
Right of recovery.
If the amount of the payment made by PacificSource is
more than it should have been under this COB provision,
PacificSource may recover the excess from one or more of
the persons it has paid or for whom it has paid, or from any
other person or organization that may be responsible for the
benefits or services provided for the covered person. The
“amount of the payments made” includes the reasonable
cash value of any benefits provided in the form of services.
MEDICAL NECESSITY
Medical necessity. Except for specified Preventive
Care services, the benefits of this group policy are paid
only toward the covered expense of medically necessary
diagnosis or treatment of illness or injury. All treatment is
subject to review for medical necessity. Review of treatment
may involve prior approval, concurrent review of the
continuation of treatment, post-treatment review or any
combination of these. Just because a physician may
prescribe, order, recommend, or approve a service or
supply does not, of itself, make the charge a covered
expense.
Second opinion. PacificSource has the right to arrange,
at its expense, a second opinion by a provider of its choice,
and is not required to pay benefits unless that opinion has
been rendered.
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PREAUTHORIZATION
Preauthorization process: Preauthorization is the
process by which providers verify coverage and receive a
benefit determination from PacificSource before services or
supplies are rendered. Preauthorization establishes covered
expenses based on benefits available, medical necessity,
appropriate treatment setting, and/or anticipated length
of stay. Failure to preauthorize could result in benefits not
being approved and the member unknowingly becoming
responsible for payment to a provider for services or
supplies not covered by this policy.
Preauthorization list: Because of the changing nature
of medicine, PacificSource continually reviews new
technologies and standards of medical practice. The list
of procedures and services requiring preauthorization is
therefore subject to revision and update. The following
list is not intended to suggest that all the items
included are necessarily covered by the benefits
of this policy. The most current preauthorization list
is available upon request or may be accessed on the
PacificSource website, PacificSource.com. The list of
procedures and services requiring preauthorization
includes, but is not limited to the following:
•
Advanced diagnosis imaging
•
Ambulance (air or ground) transports between
medical facilities, except in emergencies
•
Artificial intervertebral disc replacement
•
Back surgeries—instrumented
•
Breast brachytherapy (Accelerated Partial
Breast Irradiation (PBI)
•
Breast reconstruction, including breast reduction
and implants
•
Chelation therapy
•
Chondrocyte implants
•
Cochlear implants
•
Cosmetic and reconstructive procedures
including skin peels, scar revisions, facial plastic
procedures and/or reconstruction, and procedures
to remove superficial varicosities or other superficial
vascular lesions
•
104
Durable medical equipment expenses over
$800, including purchase, rental, repair, lease, or
replacement; or rental for longer than three months,
except for the initial purchase of CPAP/BiPAP
equipment, which does not require preauthorization.
•
Dynamic elbow/knee/shoulder flexion devices
•
Elective medical admissions, such as
preadmission, or admission to a hospital for
diagnostic testing or procedures normally
done in an outpatient setting, and transfers to
nonparticipating facilities
•
Enhanced external counterpulsation
•
Excimer laser for psoriasis
•
Experimental or investigational procedures or
surgeries
•
Extensions of previously authorized benefits, such
as extension of physical or occupational therapy
benefits, mental health treatment, or chemical
dependency treatment
•
Genetic (DNA) testing
•
Home health, outpatient and home IV infusion, and
enteral nutrition supplies, and hospice services
•
Hospitalization for dental procedures when
covered under this plan, including pediatric dental
procedures
•
Hyperbaric oxygen
•
Ingestible telemetric gastrointestinal capsule
imaging system (wireless capsule enteroscopy)
•
Intradiscal electrothermal therapy (IDET)
•
Kidney dialysis
•
Laparoscopies of the female reproductive system
and hysterosalpingograms, hysteroscopies and
chromotubations
•
Mental health and chemical dependency
inpatient or residential treatment including intensive
outpatient mental health treatment
•
obile cardiac outpatient telemetry (MCOT)
M
e.g., CardioNet Ambulatory ECG or HEARTlink
Telemetry
•
MRIs during an exclusion period
•
Multidisciplinary developmental pediatric
evaluations
•
Multidisciplinary pain management and
rehabilitation evaluations and programs
•
Neurostimulators—implantable
•
Parenteral Nutrition
•
Percutaneous vertebroplasty and balloon-assisted
vertebroplasty (kyphoplasty)
•
PET scans
•
Proton beam treatment delivery
•
Radiofrequency procedure including
radiofrequency neurotomy
•
Rehabilitation or skilled nursing facility admissions
•
Skin substitutes (e.g., Apligraf, Dermagraft, or other)
•
Surgical procedures and tongue-retaining orthodontic
appliances for sleep apnea and other sleeping
disorders
•
Stereotactic radiosurgery
•
Surgeries or procedures in a hospital or
ambulatory center during any exclusion period
on an outpatient basis (hospital outpatient department,
ambulatory surgical facility, physician’s office, or clinic)
are payable only to the extent they would be payable
on an outpatient basis. A reduction in benefits due to an
inappropriate setting will not exceed 30% or a maximum of
$2,500 for each occurrence.
•
Transmyocardial revascularization (TMR)
LEAST COSTLY SETTING
•
Transplantation of organ, bone marrow, and stem
cell, including evaluations, related donor services
and/or searches, and HLA tissue typing, except for
corneal transplants
•
Varicose vein procedures
Notification of determination. Notification of
PacificSource’s benefit determination will be communicated
by letter, fax, or electronic transmission to the hospital, the
provider, and the member. If time is a factor, notification will
be made by telephone and followed up in writing.
Length of time determinations are valid. A
preauthorization benefit determination relating to benefit
coverage and medical necessity is valid for 90 calendar
days. A preauthorization benefit determination relating
to the member’s eligibility is valid for five working days,
unless PacificSource states a shorter period because of
specific knowledge that the member’s coverage will end
within five days. These specified times are not binding on
PacificSource if there was misrepresentation on the part of
the policyholder, member, or provider that was relevant to
the preauthorization request.
Services of a third party. PacificSource reserves the
right to employ a third party to perform preauthorization
procedures on its behalf.
Preauthorization appeals. Any member or provider
whose request for treatment or payment for services was
not approved as not medically necessary or experimental
and/or investigational will be given an opportunity for timely
appeal before an appropriate medical consultant or peer
review committee.
Emergency services. In a medical emergency, services
and supplies necessary to determine the nature and extent
of the emergency condition and to stabilize the patient
are covered without preauthorization requirements.
PacificSource must be notified of an emergency admission
to a hospital or specialized treatment center as an inpatient
within two business days.
AMBULATORY SURGERY
Charges for procedures that can be performed safely
Benefits are eligible for payment only to the extent that
they are provided in the least costly setting that can
be safely provided and that does not adversely affect
the member’s condition or the quality of medical care.
A reduction in benefits due to an inappropriate setting
will not exceed 30% or a maximum of $2,500 for each
occurrence.
CASE MANAGEMENT
Case management process. Case management is a
service provided by registered nurses with specialized skills
to respond to the complexity of a member’s healthcare
needs. Case management services may be initiated by
PacificSource when there is high utilization of health
services or multiple providers, or for health problems such
as, but not limited to: transplantation; high-risk obstetric or
neonatal care; open heart surgery; neuromuscular disease;
spinal cord injury; mental and nervous conditions and/or
chemical dependency; or any acute or chronic condition that
may necessitate specialized treatment or care coordination.
When case management services are implemented, the
nurse case manager will work in collaboration with the
patient’s primary care provider and the PacificSource Chief
Medical Officer to enhance the quality of care and maximize
available health plan benefits. A case manager may
authorize benefits for supplemental services not otherwise
covered by this policy. (See Individual Benefits Management
below.)
Services of a third party. PacificSource reserves the
right to employ a third party to assist with, or perform the
function of, case management.
INDIVIDUAL BENEFITS MANAGEMENT
Individual benefits management. Individual benefits
management addresses, as an alternative to providing
covered services, PacificSource’s discretionary consideration
of economically justified alternative benefits. The decision
to allow alternative benefits will be made by PacificSource
in its sole discretion on a case-by-case basis. PacificSource’s
determination to cover and pay for alternative benefits for
an individual shall not be deemed to waive, alter or affect
PacificSource’s right to reject any other or subsequent
request or recommendation. PacificSource may elect
to provide alternative benefits if PacificSource and the
105
individual’s attending provider concur in the request for and
in the advisability of alternative benefits in lieu of specified
covered services. In addition, PacificSource may provide
alternative benefits if it concludes that substantial future
expenditures for covered services for the individual could
be significantly diminished by providing such alternative
benefits under the individual benefit management program
(see Case Management above).
OUT-OF-POCKET MAXIMUM
Annual out-of-pocket maximum: When the member
has incurred expense in the amount stated in the Schedule
for “Out-of-Pocket Limit” or “Stop-Loss,” the policy will
pay 100% of eligible charges of participating providers
or Network Not Available providers for the remainder of
the calendar year. See “Mid-year change in deductible,
stop-loss, or out-of pocket maximum” below. Unless the
Schedule states otherwise, once the nonparticipating stoploss or out-of-pocket limit is satisfied (if one is stated in the
Schedule), the policy will pay 100 percent of the allowable
fee to nonparticipating providers for the remainder of the
calendar year. See “Mid-year change in deductible, stoploss, or out-of pocket maximum” below.
Items not subject to out-of-pocket maximum: The
Schedule may state that the out-of-pocket limit or stoploss provisions apply to only certain benefits. Unless the
Schedule states otherwise, the out-of-pocket maximum or
stop-loss provisions do not apply to:
• Expense for prescription drugs.
106
•
Charges in excess of the allowable fee.
•
Benefits paid in full.
In addition, stop-loss applies only to those benefits subject
to an annual deductible. Any benefits not subject to the
annual deductible are not subject to the plan’s stop-loss
provisions. This means copayments and/or coinsurance for
those services continue even if the stop-loss is met.
Policy conditions and limitations apply. Payment for
covered expenses is subject to all conditions and limitations
of this policy including stated dollar limits on specific
services or supplies.
Mid-year changes in deductible, stop-loss, or outof-pocket maximums. Deductible, stop-loss, and out-ofpocket maximum provisions are calculated on a calendar
year basis. A calendar year is a 12-month period from
January 1 through December 31. This policy is renewed,
with or without changes, on a contract year. A contract
year is a 12-month period following either the date of initial
policy issuance, or the last policy renewal date. A contract
year may or may not coincide with a calendar year.
When this policy is renewed mid calendar year, any
previous satisfied deductible, stop-loss, and/or out-of-pocket
maximum amounts are credited toward similar provisions
in the renewed policy. If the deductible, stop-loss, and/or
out-of-pocket maximum amount increases mid calendar
year, the member must satisfy the new policy’s requirement
less the amount already satisfied during the current
calendar year under the previous policy.

Covered Expenses, General Exclusions and Limitations

Transcription

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