Benefits Handbook

MMC Benefits Handbook

Health services and supplies that do not meet the definition of a Covered Service
Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered under the Plan when:
Required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption
Related to judicial or administrative proceedings or orders
Conducted for purposes of medical research
Required to obtain or maintain a license of any type
Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends
Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan
In the event that a non-network provider waives the annual deductible for a particular health service, no benefits are provided for the health service for which the annual deductible are waived
Charges in excess of eligible expense or in excess of any specified limitation
Custodial care
Domiciliary care (e.g., group living arrangements)
Private duty nursing while inpatient
Respite care
Rest cures
Treatment of benign gynecomastia (abnormal breast enlargement in males)
Medical and surgical treatment of excessive sweating (hyperhidrosis)
Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea
Appliances for snoring
Any charges for missed appointments, room or facility reservations, completion of claim forms or record processing
Any charges higher than the reasonable and customary charge
Any charge for services, supplies or equipment advertised by the provider as free
Any charges by a provider sanctioned under a federal program for reason of fraud, abuse or medical competency
Any charges prohibited by federal anti-kickback or self-referral statues
Any additional charges submitted after payment has been made and your account balance is zero
Any charges by a resident in a teaching hospital where a faculty physician did not supervise services
Outpatient rehabilitation services, spinal treatment or supplies including, but not limited to spinal manipulations by a chiropractor or other doctor, for the treatment of a condition which ceases to be therapeutic
Spinal treatment, including chiropractic and osteopathic manipulative treatment, to treat an illness, such as asthma or allergies
Speech therapy to treat stuttering, stammering, or other articulation disorders
Autopsies and other coroner services and transportation services for a corpse
Self-administered home diagnostic tests, including but not limited to HIV and Pregnancy tests
Work hardening (individualized treatment programs designed to return a person to work or to prepare a person for specific work)
Treatment provided in connection with or to comply with commitments, police detentions and other similar arrangements, unless authorized by the Plan's preauthorization review service
Expenses for health services and supplies that are received as a result of war or any act of war, whether declared or undeclared, while part of any armed service force of any country. This exclusion does not apply to Covered Persons who are civilians injured or otherwise affected by war, any act of war or terrorism in a non-war zone
Foreign language and sign language interpretation services offered by or required to be provided by a Network or non-Network provider
Health services related to a non-Covered Health Service: When a service is not a Covered Health Service, all services related to that non-Covered Health Service are also excluded. This exclusion does not apply to services the Plan would otherwise determine to be Covered Health Services if they are to treat complications that arise from the non-Covered Health Service
For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is superimposed on an existing disease and that affects or modifies the prognosis of the original disease or condition. Examples of a "complication" are bleeding or infections, following a Cosmetic Procedure, that require hospitalization