Limitations and exclusions
Benefit plans typically have exclusions, what the plans do not cover, and limitations. Some benefit limitations and exclusions apply to all of our plans. The following is an overview of the most common exclusions and limitations that apply to our plans. Upon enrollment, you will be given a plan contract with a complete description of your coverage.
Limited covered services
Certain covered services have a coverage maximum for the calendar year. Limitations are set at a day/visit amount. Once the plan maximum is met, you will be responsible for costs until a new limitation period begins. The services below are subject to limitations and maximum coverage amounts.
| Covered Service |
Plan Maximum |
| Inpatient Rehabilitation |
30 days per calendar year, 60 days per calendar year for head/spinal injuries |
| Inpatient Habilitation |
30 days per calendar year, 60 days per calendar year for head/spinal injuries |
| Outpatient Rehabilitation |
30 visits per calendar year. Up to 30 additional visits per specified condition |
| Outpatient Habilitation |
30 visits per calendar year. Up to 30 additional visits per specified condition |
| Skilled Nursing Facility Care |
60 days per calendar year |
| Removable Custom Shoe Orthotics |
$200 per calendar year |
| Biofeedback for specified diagnosis |
10 visits per lifetime |
Exclusions
Our individual and family plans have exclusions – or what our plans do not cover. View a complete list of exclusions that apply to all of our plans, as described in our plan contract. Upon enrollment, you will be given a full plan contract with a complete description of your coverage.
If you have questions about any of these limitations and exclusions, call our individual and family plans sales team at 503-574-5000 or 800-988-0088.