Missouri Code of State Regulations › Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN › Division 10 - Health Care Plan › Chapter 3 - Public Entity Membership › Section 22 CSR 10-3.061 - Plan Limitations

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment removes the limitation on
				  infertility treatment.
(1)
				Benefits shall not be payable for, or in connection with, any medical benefits,
				services, or supplies which do not come within the definition of covered
				charges. In addition, the items specified in this rule are not covered unless
				expressly stated otherwise and then only to the extent expressly provided
				herein or in 22 CSR 10-3.057 or
				22 CSR
				10-3.090.
(A)
				Abortion-unless the life of the mother is endangered if the fetus is carried to
				term or due to death of the fetus.
(B) Acts of war including-injury or illness
				caused, or contributed to, by international armed conflict, hostile acts of
				foreign enemies, invasion, or war or acts of war, whether declared or
				undeclared.
(C) Alternative
				therapies-that are outside conventional medicine as determined by the claims
				administrator.
(D) Assistive
				listening device.
(E) Athletic
				enhancement services and sports performance training.
(F) Autopsy.
(G) Blood donor expenses.
(H) Blood pressure cuffs/monitors.
(I) Care received without charge.
(J) Charges exceeding the vendor contracted
				rate or benefit limit.
(K) Charges
				resulting from the failure to appropriately cancel a scheduled
				appointment.
(L) Childbirth
				classes.
(M) Comfort and
				convenience items.
(N) Cosmetic
				procedures.
(O) Custodial or
				domiciliary care-including services and supplies that assist members in the
				activities of daily living such as walking, getting in and out of bed, bathing,
				dressing, feeding, and using the toilet; preparation of special diets;
				supervision of medication that is usually self-administered; or other services
				that can be performed by persons who are not providers.
(P) Dental care, including oral
				surgery.
(Q) Devices or supplies
				bundled as part of a service are not separately covered.
(R) Dialysis received through a non-network
				provider.
(S) Educational or
				psychological testing unless part of a treatment program for covered
				services.
(T) Examinations
				requested by a third party.
(U)
				Exercise equipment.
(V)
				Experimental/investigational/unproven services, procedures, supplies, or drugs
				as determined by the claims administrator.
(W) Eye services and associated expenses for
				orthoptics, eye exercises, radial keratotomy, LASIK, and other refractive eye
				surgery.
(X) Genetic testing based
				on family history alone, except for breast cancer susceptibility gene (BRCA)
				testing.
(Y) Health and athletic
				club membership-including costs of enrollment.
(Z) Hearing aid replacement batteries.
(AA) Infusions received through a
				non-network provider.
(BB) Level of
				care greater than is needed for the treatment of the illness or
				injury.
(CC) Long-term
				care.
(DD) Maxillofacial
				surgery.
(EE) Medical care and
				supplies to the extent that they are payable under-
1. A plan or program operated by a national
				government or one (1) of its agencies; or
2. Any state's cash sickness or similar law,
				including any group insurance policy approved under such law.
(FF) Medical service performed by
				a family member- including a person who ordinarily resides in the subscriber's
				household or is related to the member, such as a spouse, parent, child,
				sibling, or brother/sister-in-law.
(GG) Military service-connected injury or
				illness- including expenses relating to Veterans Affairs or a military
				hospital.
(HH) Never events-never
				events on a list compiled by the National Quality Forum of inexcusable outcomes
				in a health care setting.
(II)
				Drugs that the pharmacy benefit manager (PBM) has excluded from the formulary
				and will not cover as a nonformulary drug unless it is approved in advance by
				the PBM.
(JJ) Non-medically
				necessary services.
(KK)
				Non-provider allergy services or associated expenses relating to an allergic
				condition, including installation of air filters, air purifiers, or air
				ventilation system cleaning.
(LL)
				Non-reusable disposable supplies.
(MM) Online weight management
				programs.
(NN) Other charges as
				follows:
1. Charges that would not otherwise
				be incurred if the subscriber was not covered by the plan;
2. Charges for which the subscriber or
				his/her dependents are not legally obligated to pay including but not limited
				to any portion of any charges that are discounted;
3. Charges made in the subscriber's name but
				which are actually due to the injury or illness of a different person not
				covered by the plan; and
4. No
				coverage for miscellaneous service charges including but not limited to charges
				for telephone consultations, administrative fees such as filling out paperwork
				or copy charges, or late payments.
(OO) Over-the-counter medications with or
				without a prescription including but not limited to analgesics, antipyretics,
				non-sedating antihistamines, unless otherwise covered as a preventive
				service.
(PP) Physical and
				recreational fitness.
(QQ)
				Private-duty nursing.
(RR) Routine
				foot care without the presence of systemic disease that affects lower
				extremities.
(SS) Services obtained
				at a government facility if care is provided without charge.
(TT) Sex therapy.
(UU) Surrogacy-pregnancy coverage is limited
				to plan member.
(VV) Telehealth
				site origination fees or costs for the provision of telehealth services are not
				covered.
(WW) Travel
				expenses.
(XX) Workers'
				Compensation services or supplies for an illness or injury eligible for, or
				covered by, any federal, state, or local government Workers' Compensation Act,
				occupational disease law, or other similar legislation.