Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.081 - LIMITATIONS AND EXCLUSIONS

Current through August 31, 2023
01.
Allowances
. A health benefit plan will not limit or exclude coverage by
			 type of illness, accident, treatment, or medical condition, except as follows:
			 (3-31-22)
a. Any service not medically
			 necessary or appropriate unless specifically included within the coverage
			 provisions. (3-31-22)
b. Custodial,
			 convalescent or intermediate level care or rest cures. (3-31-22)
c. Services that are experimental or
			 investigational. (3-31-22)
d.
			 Services eligible for coverage by Workers' Compensation, Medicare or CHAMPUS.
			 (3-31-22)
e. Services for which no
			 charges are made or for which no charges would be made in the absence of
			 insurance or for which the insured has no legal obligation to pay.
			 (3-31-22)
f. Services for weight
			 control, nutrition, and smoking cessation, including self-help and training
			 programs as well as prescription drugs, used in conjunction with such programs
			 and services. (3-31-22)
g. Cosmetic
			 surgery and services, except for treatment or surgery for congenital anomaly
			 and mastectomy reconstruction as described in the Women's Health and Cancer
			 Rights Act. (3-31-22)
h. Artificial
			 insemination, infertility treatment, and the treatment of sexual dysfunction
			 not related to organic disease. (3-31-22)
i. Services for reversal of elective,
			 surgically or pharmaceutically induced infertility. (3-31-22)
j. Vision therapy, tests, glasses, contact
			 lenses and other vision aids. Radial keratotomy, myopic keratomileusis and any
			 surgery involving corneal tissue to alter or correct myopia, hyperopia or
			 stigmatic error. Vision tests and glasses will be covered for children under
			 the age of twelve (12), except in catastrophic health benefit plans.
			 (3-31-22)
k. For treatment of weak,
			 strained, or flat feet, including orthopedic shoes or other supportive devices,
			 or for cutting, removal, or treatment of corns, calluses, or nails other than
			 corrective surgery, or for metabolic or peripheral vascular disease.
			 (3-31-22)
l. One thousand dollars
			 ($1,000) per year limit, subject to the policy deductible, coinsurance, or
			 copayment, on manipulative therapy and related treatment, including heat
			 treatments and ultrasound, of the musculoskeletal structure for other than
			 fractures and dislocations of the extremities. (3-31-22)
m. Dental care or treatment, except for
			 injury sustained while insured under this policy, or as a result of nondental
			 disease covered by the policy. (3-31-22)
n. Hearing or speech tests without illness
			 being suspect. (3-31-22)
o. 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)
p. Private room accommodation charges in
			 excess of the institution's most common semi-private room charge except when
			 prescribed as medically necessary. (3-31-22)
q. Services performed by a member of the
			 insured's family or of the insured's spouse's family. Family includes parents
			 or grandparents of the insured or spouse and any descendants of such parents or
			 grandparents. (3-31-22)
r. Care
			 incurred before the effective date of the person's coverage.
			 (3-31-22)
s. Immunizations and
			 medical exams and tests of any kind not related to treatment of covered injury
			 or disease, except as specifically stated in the policy. (3-31-22)
t. Injury or sickness caused by war or armed
			 international conflict. (3-31-22)
u. Sex change operations and treatment in
			 connection with transsexualism. (3-31-22)
v. Marriage and family and child counseling
			 except as specifically allowed in the policy. (3-31-22)
w. Acupuncture. (3-31-22)
x. Private duty nursing except as
			 specifically allowed in the policy. (3-31-22)
y. Services received from a medical or dental
			 department maintained by or on behalf of an employer, a mutual benefit
			 association, labor union, trust, or similar person or group.
			 (3-31-22)
z. Services incurred
			 after the date of termination of a covered person's coverage except as allowed
			 by any extension of benefits provision of the policy. (3-31-22)
aa. Expenses for personal hygiene and
			 convenience items such as air conditioners, humidifiers, and physical fitness
			 equipment. (3-31-22)
bb. Charges
			 for failure to keep a scheduled visit, charges for completion of any form, and
			 charges for medical information. (3-31-22)
cc. Charges for screening examinations except
			 as otherwise provided in the policy. (3-31-22)
dd. Charges for wigs or cranial prostheses,
			 hair analysis, hair loss and baldness. (3-31-22)
ee. Pre-existing conditions, except as
			 provided specifically in the policy. (3-31-22)
i. A health benefit plan will not deny,
			 exclude or limit benefits for a covered individual for covered expenses
			 incurred more than twelve (12) months following the effective date of the
			 individual's coverage due to a pre-existing condition. (3-31-22)
ii. A health benefit plan waives any time
			 period applicable to a pre-existing condition exclusion or limitation period
			 with respect to particular services for the period of time an individual was
			 previously covered by qualifying previous coverage that provided benefits with
			 respect to such services, provided that the qualifying previous coverage was
			 continuous to a date not more than sixty-three (63) days prior to the effective
			 date of the new coverage. This provision does not preclude application of any
			 waiting period applicable to all new enrollees under the health benefit plan.
			 (3-31-22)
iii. A health benefit
			 plan may exclude coverage for late enrollees for the greater of twelve (12)
			 months or for a twelve (12) months pre-existing condition exclusion; provided
			 that if both a period of exclusion from coverage and a pre-existing condition
			 exclusion are applicable to a late enrollee, the combined period will not
			 exceed twelve (12) months from the date the individual enrolls for coverage
			 under the health benefit plan. (3-31-22)