Limitations And Exclusions

01. Allowances. A health benefit plan will not limit or exclude coverage by type of illness, accident, treatment, or medical condition, except as follows: (3-31-22) a. Any service not medically necessary or appropriate unless specifically included within the coverage provisions. (3-31-22) b. Custodial, convalescent or intermediate level care or rest cures. (3-31-22) c. Services that are experimental or investigational. (3-31-22) d. Services eligible for coverage by Workers' Compensation, Medicare or CHAMPUS. (3-31-22) e. Services for which no charges are made or for which no charges would be made in the absence of insurance or for which the insured has no legal obligation to pay. (3-31-22) f. Services for weight control, nutrition, and smoking cessation, including self-help and training programs as well as prescription drugs, used in conjunction with such programs and services. (3-31-22) g. Cosmetic surgery and services, except for treatment or surgery for congenital anomaly and mastectomy reconstruction as described in the Women's Health and Cancer Rights Act. (3-31-22) h. Artificial insemination, infertility treatment, and the treatment of sexual dysfunction not related to organic disease. (3-31-22) i. Services for reversal of elective, surgically or pharmaceutically induced infertility. (3-31-22) j. Vision therapy, tests, glasses, contact lenses and other vision aids. Radial keratotomy, myopic keratomileusis and any surgery involving corneal tissue to alter or correct myopia, hyperopia or stigmatic error. Vision tests and glasses will be covered for children under the age of twelve (12), except in catastrophic health benefit plans. (3-31-22) k. For treatment of weak, strained, or flat feet, including orthopedic shoes or other supportive devices, or for cutting, removal, or treatment of corns, calluses, or nails other than corrective surgery, or for metabolic or peripheral vascular disease. (3-31-22) l. One thousand dollars ($1,000) per year limit, subject to the policy deductible, coinsurance, or copayment, on manipulative therapy and related treatment, including heat treatments and ultrasound, of the musculoskeletal structure for other than fractures and dislocations of the extremities. (3-31-22) m. Dental care or treatment, except for injury sustained while insured under this policy, or as a result of nondental disease covered by the policy. (3-31-22) n. Hearing or speech tests without illness being suspect. (3-31-22) o. Hearing aids, auditory osseointegrated (bone conduction) devices, cochlear implants and examination for or fitting of them -- except for congenital or acquired hearing loss that without intervention may result in cognitive or speech development deficits of a covered dependent child -- covering not less than one (1) device every thirty-six (36) months per ear with loss and not less than forty-five (45) language/speech therapy visits IDAHO ADMINISTRATIVE CODE IDAPA 18.04.12 – Small Employer Department of Insurance Health Insurance & Availability Act Rules Section 081 Page 14 during the first twelve (12) months after delivery of the covered device. (7-1-26) p. Private room accommodation charges in excess of the institution's most common semi-private room charge except when prescribed as medically necessary. (3-31-22) q. Services performed by a member of the insured's family or of the insured's spouse's family. Family includes parents or grandparents of the insured or spouse and any descendants of such parents or grandparents. (3-31-22) r. Care incurred before the effective date of the person's coverage. (3-31-22) s. Immunizations and medical exams and tests of any kind not related to treatment of covered injury or disease, except as specifically stated in the policy. (3-31-22) t. Injury or sickness caused by war or armed international conflict. (3-31-22) u. Sex change operations and treatment in connection with transsexualism. (3-31-22) v. Marriage and family and child counseling except as specifically allowed in the policy. (3-31-22) w. Acupuncture. (3-31-22) x. Private duty nursing except as specifically allowed in the policy. (3-31-22) y. Services received from a medical or dental department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group. (3-31-22) z. Services incurred after the date of termination of a covered person's coverage except as allowed by any extension of benefits provision of the policy. (3-31-22) aa. Expenses for personal hygiene and convenience items such as air conditioners, humidifiers, and physical fitness equipment. (3-31-22) bb. Charges for failure to keep a scheduled visit, charges for completion of any form, and charges for medical information. (3-31-22) cc. Charges for screening examinations except as otherwise provided in the policy. (3-31-22) dd. Charges for wigs or cranial prostheses, hair analysis, hair loss and baldness. (3-31-22) ee. Pre-existing conditions, except as provided by Section 41-4708, Idaho Code. (7-1-26) 082. -- 999. (RESERVED)