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.

Exclusion period

An exclusion period is the period of time in which specific treatments and services are not covered by the health plan.

  • Elective procedures: An elective procedure is one that can be postponed for treatment during the limitation period. You must be on our plan for 12 months before treatment and services will be covered (does not apply to Standard plans).
  • Newborns: Exclusion and open enrollment periods are waived for a newborn or adopted child if the child is enrolled on the plan within 60 days of birth or adoption placement.

Creditable coverage

If you were covered on another health plan within 63 days before your effective date of coverage, you may have “creditable coverage.” Your creditable coverage will be applied month for month toward the plan exclusion periods. You will need to provide us with a copy of your Certificate of Creditable Coverage (obtain from your prior health carrier).

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 10 visits per lifetime

Exclusions

Our individual & 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 1-800-988-0088.