01.
Probationary or Waiting Period. Except as provided in Subsection
081.02 for a pre-existing
condition, a policy cannot contain provisions establishing a probationary or
waiting period during which no coverage is provided under the policy.
(3-31-22)
02.
Pre-existing
Conditions. A policy will not deny, exclude or limit benefits for
covered expenses incurred more than twelve (12) months following the effective
date of the coverage due to a pre-existing condition. (3-31-22)
a. A policy 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 to the extent such previous coverage 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. (3-31-22)
b. A carrier will not modify a policy with
respect to an individual or dependent through riders, endorsements, or
otherwise, to restrict or exclude coverage for specifically named pre-existing
conditions otherwise covered by the policy. (3-31-22)
03.
Exclusions. A policy cannot
limit or exclude coverage by type of illness, accident, treatment or medical
condition, except that a policy may include one or more of the following
limitations or exclusions: (3-31-22)
a.
Pre-existing conditions, except for congenital anomalies of a covered dependent
child; (3-31-22)
b. Mental or
nervous disorders, alcoholism and drug addiction; (3-31-22)
c. Pregnancy, except for complications of
pregnancy; (3-31-22)
d. Illness,
treatment or medical condition arising out of: (3-31-22)
i. War or act of war (whether declared or
undeclared); participation in a felony, riot or insurrections; service in the
armed forces or units auxiliary to it; (3-31-22)
ii. Suicide (sane or insane), attempted
suicide or intentionally self-inflicted injury; and (3-31-22)
iii. Professional aviation for wage or
profit; (3-31-22)
e.
Cosmetic surgery, except that "cosmetic surgery" cannot include reconstructive
surgery when the service is incidental to or follows surgery resulting from
trauma, infection or other diseases of the involved part; reconstructive
surgery because of congenital disease or anomaly of a covered dependent child;
or involuntary complications related to a cosmetic procedure;
(3-31-22)
f. Foot care in
connection with corns, calluses, flat feet, fallen arches, weak feet, chronic
foot strain or symptomatic complaints of the feet; (3-31-22)
g. Care in connection with the detection and
correction by manual or mechanical means of structural imbalance, distortion,
or subluxation in the human body for purposes of removing nerve interference
and the effects of it, where the interference is the result of or related to
distortion, misalignment or subluxation of, or in the vertebral column;
(3-31-22)
h. Benefits in excess of
Medicare eligible expense, if enrolled in Medicare or other governmental
program (except Medicaid), or benefits provided under a state or federal
worker's compensation law, employers liability or occupational disease law, or
motor vehicle no-fault law unless the motor vehicle no-fault plan provides for
coordination of benefits; services performed by a member of the covered
person's immediate family; and services for which no charge is normally made in
the absence of insurance; (3-31-22)
i. Dental care or treatment;
(3-31-22)
j. Eye glasses and the
examination for the prescription or fitting of them; (3-31-22)
k. Rest cures, custodial care,
transportation, and routine physical examinations; (3-31-22)
l. Territorial limitations;
(3-31-22)
m. 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)
n. Missed or cancelled appointments;
completion of claim forms or records copying; failure to vacate a room on or
before the facility's established discharge hour; educational and training
services except as provided by the policy; over the counter medical supplies,
consumable or disposable supplies, including but not limited to elastic
stockings, ace bandages, gauze, alcohol swabs or dressings; (3-31-22)
o. Treatment, services or supplies not
prescribed by or upon the direction of a licensed provider, acting within the
scope of his or her license; (3-31-22)
p. Services rendered prior to the effective
date of coverage or after termination of coverage, except as provided by an
extension of benefits provision; and (3-31-22)
q. The reversal of an elective sterilization
procedure, including but not limited to vasovasostomy or salpingoplasty.
(3-31-22)