Medical plans limitations and exclusions
DEPENDENT ELIGIBILITY
Dependents are a lawful spouse or registered domestic partner and eligible children up to age 26.
COVERAGE FOR CHILDREN RESIDING OUTSIDE THE SERVICE AREA
If your enrolled child(ren) resides outside the service area, we will extend benefits as if care were rendered by a participating provider. Out-of-area children may receive the in-network benefit level by using the Travel Network. If a Travel Network provider is not available, the services will be paid at the in-network benefit level if provided within a 30-mile radius of the child's residence or at the closest appropriate facility. Fees charged by out-of-area providers will be reimbursed at the maximum plan allowance for those services.
LIMITATIONS
- All medical and surgical admissions must be authorized by Moda Health.
- Rehabilitation benefits are limited to eight inpatient days and 15 outpatient sessions per calendar year.
- Hospice benefits are limited to 12 days of inpatient care; 170 hours/three months respite care.
- Skilled nursing facility benefits are limited to 40 inpatient days per calendar year.
- Home health benefits are limited to 130 visits per calendar year.
- Moda Health will coordinate benefits for covered expenses to the extent that you have any other available coverage for those expenses.
EXCLUSION PERIODS
- Pre-existing conditions, even if they worsen or recur, unless the covered person is under the age of 19
12-month exclusion period applies to:
- Transplants (benefits are limited to an aggregate lifetime maximum benefit of $350,000)
Note: Your plan's exclusion period will be shortened one day for each day you had "creditable coverage" under another health plan, provided you do not have a 63-day lapse (or longer) in coverage immediately prior to your effective date in our plan.
EXCLUSION
- Services provided by a member of the patient's immediate family
- Services or supplies that are not medically necessary
- Services and supplies for reversal of sterilization or infertility
- Services and supplies for obesity, including complications arising out of such treatment, except for those rated A or B by the U.S. Preventive Services Task Force
- Surgery to alter the refractive character of the eye
- Dental examinations and treatment, except as specifically listed
- Services or supplies for the treatment of sexual dysfunction or inadequacy, or those related to sex change procedures
- Treatment of personality disorders
- Experimental or investigational treatment
- Services or supplies available in whole, or in part, under any city, county, state or federal law, except Medicaid
- Charges above those considered the maximum plan allowance
- Services or supplies for which an employer is required by law to provide benefits even if you choose not to accept those benefits (those exempt from state and federal workers' compensation law will have 24-hour coverage)
- Instructional programs, including, but not limited to, those to learn to self-administer drugs or nutrition, except as specifically provided for under the outpatient diabetic instruction benefit of this plan
- Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control or education
- Cosmetic services and supplies
- Services and supplies associated with orthognathic surgery except for treating congenital anomalies
- Chemical dependency treatment
- Hearing aid coverage
For costs and further details of the coverage, including exclusions, any reductions or limitations and the terms under which the policy may be continued in force, see your producer or write to Moda Health.
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Hello.
We have exciting news to share. ODS is changing its name to Moda Health.
Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.
Together, we can be more, be better.
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