Banned Policy Provisions

IDAHO ADMINISTRATIVE CODE IDAPA 18.04.13 Department of Insurance Individual Health Insurance Availability Act Rules Section 081 Page 10 01. Probationary or Waiting Period. A policy cannot contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy. (7-1-26) 02. Exclusions. A policy cannot limit or exclude coverage by type of illness, accident, treatment or medical condition, except that a policy may include one or more of the following limitations or exclusions: (3-31-22) a. Illness, treatment or medical condition arising out of: (3-31-22) i. War or act of war (whether declared or undeclared); participation in a felony, riot or insurrections; service in the armed forces or units auxiliary to it; (3-31-22) ii. Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury; and (3-31-22) iii. Professional aviation for wage or profit; (3-31-22) b. Cosmetic surgery, except that “cosmetic surgery” cannot include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part; reconstructive surgery because of congenital disease or anomaly of a covered dependent child; or involuntary complications related to a cosmetic procedure; (3-31-22) c. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet; (3-31-22) d. Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion, or subluxation in the human body for purposes of removing nerve interference and the effects of it, where the interference is the result of or related to distortion, misalignment or subluxation of, or in the vertebral column; (3-31-22) e. Benefits in excess of Medicare eligible expense, if enrolled in Medicare or other governmental program (except Medicaid), or benefits provided under a state or federal worker's compensation law, employers liability or occupational disease law, or motor vehicle no-fault law unless the motor vehicle no-fault plan provides for coordination of benefits; services performed by a member of the covered person's immediate family; and services for which no charge is normally made in the absence of insurance; (3-31-22) f. Dental care or treatment; (3-31-22) g. Eye glasses and the examination for the prescription or fitting of them; (3-31-22) h. Rest cures, custodial care, transportation, and routine physical examinations; (3-31-22) i. Territorial limitations; (3-31-22) j. 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 during the first twelve (12) months after delivery of the covered device; (3-31-22) k. Missed or cancelled appointments; completion of claim forms or records copying; failure to vacate a room on or before the facility's established discharge hour; educational and training services except as provided by the policy; over the counter medical supplies, consumable or disposable supplies, including but not limited to elastic stockings, ace bandages, gauze, alcohol swabs or dressings; (3-31-22) l. Treatment, services or supplies not prescribed by or upon the direction of a licensed provider, acting within the scope of his or her license; (3-31-22) IDAHO ADMINISTRATIVE CODE IDAPA 18.04.13 Department of Insurance Individual Health Insurance Availability Act Rules Section 082 Page 11 m. Services rendered prior to the effective date of coverage or after termination of coverage, except as provided by an extension of benefits provision; and (3-31-22) n. The reversal of an elective sterilization procedure, including but not limited to vasovasostomy or salpingoplasty. (3-31-22)