List of exclusions

 

The section numbers contained in the following refer to the Oregon Passport Individual and Family Plan contract.

General exclusions

We do not cover Services and supplies that:

  • Are not provided;
  • Are provided without charge or for which you would not be required to pay if you did not have this coverage;
  • Are received before the Effective Date of Coverage;
  • Are not a Covered Service or relate to complications resulting from a Non-Covered Service, except for Services provided as Emergency Care as described in section 4.5;
  • Are not furnished by a Qualified Practitioner or Qualified Treatment Facility;
  • Are provided by or payable under any health benefit plan or program established by a domestic or foreign government or political subdivision, unless such exclusion is prohibited by law;
  • Are provided while you are confined in a Hospital or institution owned or operated by the United States Government or any of its agencies, except to the extent provided by 38 U. S. C. § 1729 as it relates to non-military Services provided at a Veterans Administration Hospital or facility;
  • Are provided while you are in the custody of any law enforcement authorities or while incarcerated;
  • Are self-administered (except as provided in 4.8.14), are prescribed by you for your own benefit, or are provided or prescribed by a person who resides in your home or is a member of your family. “Member of your family” for this purpose means any person who could possibly inherit from you under the intestate succession law of any state, plus any in-law, step relative, foster parent, or domestic partner of you or of any such person;
  • Are provided for convenience, educational or vocational purposes including, but not limited to, videos and books, educational programs to which drivers are referred by the judicial system and volunteer mutual support groups;
  • Are provided to yield primarily educational outcomes.  An outcome is “primarily educational” if the outcome’s fundamental, first, or principal character is to provide you with enduring knowledge, skill, or competence through a process of repetitive positive reinforcement over an extended length of time.  An outcome is “enduring” if long-lasting or permanent;   
  • Are performed in association with a Service that is not covered under this Contract;
  • Are provided for any injury or illness that is sustained by any Member that arises out of, or as the result of, any work for wage or profit when coverage under any Workers' Compensation Act or similar law is required for the Member. This exclusion also applies to injuries and illnesses that are the subject of a disputed claim settlement or claim disposition agreement under a Workers’ Compensation Act or similar law. This exclusion does not apply to Members who are exempt under any Workers' Compensation Act or similar law;
  • Are payable under any automobile medical, personal injury protection (“PIP”), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance makes benefits or Services available to you, whether or not you make application for such benefits or Services and whether or not you are refused payment for failure to satisfy an term of such coverage.  If such coverage is required by law and you unlawfully fail to obtain it, benefits will be deemed to have been payable to the extent of that requirement. This exclusion also applies to charges applied to the deductible of such contract or insurance. Any benefits or Services provided under this Contract that are subject to this exclusion are provided solely to assist you and such assistance does not waive our right to reimbursement or subrogation as specified in section 6.3. This exclusion also applies to Services and supplies after you have received proceeds from a settlement as specified in section 6.3.3;
  • Are provided in an institution that specializes in treatment of developmental disabilities;
  • Are provided for treatment or testing required by a third party or court of law which is not Medically Necessary;
  • Are Experimental/Investigational; 
  • Are determined by us not to be Medically Necessary for diagnosis and treatment of an injury or illness;
  • Are received by a qualified Member under the Oregon Death with Dignity Act;
  • Have not been Prior Authorized as required by this Contract;
  • Relate to any condition sustained by a Member as a result of engagement in an illegal occupation or the commission or attempted commission of an assault or other illegal act by the Member if such Member is convicted of a crime on account of such illegal engagement or act. For purposes of this exclusion, “illegal” means any engagement or act that would constitute a felony or misdemeanor punishable by up to a year’s imprisonment under applicable law if such Member is convicted for the conduct. Nothing in this paragraph shall be construed to exclude Covered Services for a Member for injuries resulting from an act of domestic violence or medical condition (i.e. a physical or mental health condition); and
  • Relate to a civil revolution or riot, duty as a Member of the armed forces of any state or country, or a war or act of war which is declared or undeclared.

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We do not cover:
  • Charges that are in excess of the Usual, Customary and Reasonable (UCR) cost;
  • Custodial Care;
  • Transplants, except as described in the Benefit Summary and section 4.10;
  • Services for Medical Supplies, Medical Appliances, Prosthetic and Orthotic Devices, Durable Medical Equipment (DME) and Hearing Aids, except as described in section 4.7.;
  • Charges for Services that are primarily and customarily used for a non-medical purpose or used for environmental control or enhancement (whether or not prescribed by a physician) including, but not limited to, air conditioners, air purifiers, vacuum cleaners, motorized transportation equipment, escalators, elevators, tanning beds, ramps, waterbeds, hypoallergenic mattresses, cervical pillows, swimming pools, whirlpools, spas, exercise equipment, gravity lumbar reduction chairs, home blood pressure kits, personal computers and related equipment or other similar items or equipment;
  • Physical therapy, rehabilitative and habilitative Services, except as provided in sections 4.4.3, 4.8.2 and 4.8.3;
  • "Telephone visits" by a physician or "environment intervention" or "consultation" by telephone for which a charge is made to the patient. "Get acquainted" visits without physical assessment or diagnostic or therapeutic intervention provided and treatment sessions by computer Internet service;
  • Missed appointments;
  • Non-emergency medical transportation;
  • Allergy shots and allergy serums, except as provided in section 4.1.4;
  • All Services and supplies related to the treatment of obesity or morbid obesity, except as provided in section 4.2.7;
  • Services for dietary therapy including medically supervised formula weight-loss programs, unsupervised self-managed programs and over-the-counter weight loss formulas, except as provided in section 4.2.7;
  • Transportation or travel time, food, lodging accommodations and communication expenses except as provided in section 4.10 and with our prior approval;
  • Charges for health clubs or health spas, aerobic and strength conditioning, work-hardening programs, and all related material and products for these programs;
  • Massage therapy;
  • Biofeedback, except as provided in section 4.8.16;
  • Thermography;
  • Homeopathic procedures;
  • Comprehensive digestive stool analysis, cytotoxic food allergy test, dark-field examination for toxicity or parasites, EAV and electronic tests for diagnosis and allergy, fecal transient and retention time, Henshaw test, intestinal permeability, Loomis 24-hour urine nutrient/enzyme analysis, melatonin biorhythm challenge, salivary caffeine clearance, sulfate/creatinine ratio, urinary sodium benzoate, urine/saliva pH, tryptophan load test, and zinc tolerance test;
  • Spinal manipulation and acupuncture;
  • Light therapy for seasonal affective disorder, including equipment;
  • Any vitamins, dietary supplements, and other non-prescription supplements, except as required by federal or Oregon state law;
  • Services for genetic testing are excluded, except as provided in Section 4.8.5. Genetic testing is not covered for screening, to diagnose carrier states, or for informational purposes in the absence of disease;
  • Services to modify the use of tobacco and nicotine, except as provided in section 4.8.13 or when provided as Extra Values or Discounts (see our website at www.ProvidenceHealthPlan.com), where available;
  • Services for Cosmetic Services including supplies and drugs, except as approved by us and described in section4;
  • Services, including routine physical examination, immunizations and vaccinations for insurance, employment, licensing purposes, or solely for the purpose of participating in camps, sports activities, recreation programs, college entrance or for the purpose of traveling or obtaining a passport for foreign travel;
  • Non-sterile examination gloves;
  • Sales taxes, handling fees and similar surcharges, as explained in the definition of UCR; and
  • Air ambulance transportation for non-emergency situations unless approved by us in advance.

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Exclusions that apply to Mental Health and Chemical Dependency

  • Conditions for mental and nervous conditions not specified as excluded in section 13 Definitions, for Mental Health and Chemical Dependency;
  • Services provided under a court order or as a condition of parole or probation or instead of incarceration which are not Medically Necessary;
  • Personal growth services such as assertiveness training or consciousness raising;
  • Services related to developmental disabilities, developmental delays or learning disabilities including, but not limited to, education services, except as provided in sections 4.8.2 and 4.8.3. A learning disability is a condition where there is meaningful difference between a child's current academic function and the level expected for a child that age. Educational Services include, but are not limited to, language and speech training, reading, and psychological and visual integration training as defined by the American Academy of Pediatrics Policy Statement – "Learning Disabilities, Dyslexia and Vision: A Subject Review;"
  • School counseling and support services, home-based behavioral management, household management training, peer support services, recreation, tutor and mentor services; independent living services, therapeutic foster care, wraparound Services; emergency aid to household items and expenses; services to improve economic stability, and interpretation services;
  • Evaluation or treatment for educations, professional training, employment investigations, and fitness for duty evaluations;
  • Community care facilities that provide 24 hour non-medical residential care;
  • Speech therapy, physical therapy and occupational therapy services provided in connection with treatment of psychosocial speech delay, learning disorders, including mental retardation and motor skill disorders, and educational speech delay including delayed language development (except as provided in sections 4.4.3, 4.8.2 and 4.8.3);
  • Counseling related to family, marriage, sex and career including, but not limited to, counseling for adoption, custody, family planning or pregnancy, in the absence of a DSM-IV-TR diagnosis;
  • Neurological Services and tests including, but not limited to EEGs; PET, CT, MRA and MRI imaging Services; and beam scans (except as provided in section 4.8.1);
  • Vocational, pastoral or spiritual counseling;
  • Dance, poetry, music or art therapy, except as part of an approved treatment program; and
  • Treatments that do not meet the national standards for Mental Health and Chemical Dependency professional practice.

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Exclusions that apply to Provider Services

  • Services of homeopaths; faith healers; or lay, Direct Entry and Certified Professional midwives; and
  • Services of any unlicensed providers.

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Exclusions that apply to Reproductive Services

  • All services related to sexual disorders or dysfunctions regardless of gender or cause;
  • All services for the treatment of infertility, including all services related to surrogate parenting. For the purpose of this exclusion, infertility is defined as the inability to become pregnant after a year of unprotected intercourse or the inability to carry a pregnancy to term as evidenced by three consecutive spontaneous abortions;
  • Termination of pregnancy, unless there is a severe threat to the mother, or if the life of the fetus cannot be sustained;
  • Reversal of voluntary sterilization;
  • Condoms and other over-the-counter birth control products; and
  • Services provided in a premenstrual syndrome clinic or holistic medicine clinic.

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Exclusions that apply to Vision Services

  • Surgical procedures which alter the refractive character of the eye, including, but not limited to laser eye surgery, radial keratotomy, myopic keratomelelusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia, hyperopia or astigmatism;
  • Services for routine eye care and vision care, vision exams/screenings, refractive disorders, eyeglass frames and lenses, contact lenses, except as provided in sections 4.2.1, 4.2.5, 4.5.3, 4.7.2 and 4.12 of this Contract, and if applicable, as covered under the Adult Vision Supplemental Benefit; and
  • Orthoptics and vision training.

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Exclusions that apply to Hearing Services

  • Hearing aids, hearing therapies and/or devices, including all services related to the examination and fitting of the hearing aids, except as provided in section 4.7.5; and
  • Hearing screenings and exams, except as provided in section 4.2.1.

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Exclusions that apply to Dental Services

  • Oral surgery (non-dental or dental) or other dental services (all procedures involving the teeth, wisdom teeth, areas surrounding the teeth and dental implants), except as stated in sections 4.8.10;
  • Services for orthognathic surgery, except as approved by us and described in section 4.8.10;
  • Services to treat temporomandibular joint syndrome (TMJ); and
  • Dentures and orthodontia; except as provided in sections 4.8.10.

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Exclusions that apply to Foot Care Services

  • Routine foot care, such as removal of corns and calluses, except for Members with diabetes; and
  • Services for insoles, arch supports, heel wedges, lifts and orthopedic shoes, except as described in section 4.7.2.

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Exclusions that apply to Prescription Drugs, Medicines and Devices

  • Outpatient prescription drugs, medicines and devices except as provided in sections 4.3.3, 4.8.14 and 4.11, and
  • Any drug, medicine, or device that does not have the United States Food and Drug Administration formal market approval through a New Drug Application, Pre-market Approval, or 510K.

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