Missouri Code of State Regulations › Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN › Division 10 - Health Care Plan › Chapter 2 - State Membership › Section 22 CSR 10-2.061 - 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 10-2.055 or
				22 CSR
				10-2.090.
(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.