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
Universal Citation: 22 MO Code of State Regs 10-3.061
Current through Register Vol. 49, No. 18, September 16, 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.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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