Benefits Handbook

MMC Benefits Handbook

Autopsies and other coroner services and transportation services for a corpse.
Charges for:
Completion of Claim forms.
Missed appointments.
Record processing.
Room or facility reservations.
Charges prohibited by federal anti-kickback or self-referral statutes.
Direct-to-consumer retail genetic tests.
Expenses for health services and supplies:
For which the Participant has no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Surest Plan.
That are received after the date the Participants coverage ends, including health services for medical conditions which began before the date the Participants coverage ends.
That are received as a result of war or any act of war, whether declared or undeclared, or caused during services in the armed forces of any country. This exclusion does not apply to Participants who are civilians injured or otherwise affected by war, any act of war, or terrorism in a non-war zone.
That exceed Eligible Expenses, or the Recognized Amount when applicable, or any specified limitation in this SPD.
Foreign language and sign language services.
Health care services that Surest determines are not Medically Necessary.
Long-term (more than 30 days) storage of blood, umbilical cord, or other material (e.g., cryopreservation of tissue, blood, and blood products).
Over-the-counter self-administered home diagnostic tests (except direct-to-consumer/home-based tests), including but not limited to HIV, ovulation, and pregnancy tests.
Physical, psychiatric, or psychological exams, testing, and all forms of vaccinations and immunizations, or treatments when:
Conducted for purposes of medical research. This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials.
Related to judicial or administrative proceedings or orders, unless determined to be Medically Necessary.
Required solely for purposes of adoption, career or employment, education, insurance, marriage, sports or camp, travel, or as a result of incarceration.
Required to obtain or maintain a license of any type.
Health care 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 that would otherwise be determined to be a Covered Health Service if the service treats 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.
Treatment provided in connection with or to comply with commitments, police detentions and other similar arrangements, unless authorized by the Plan's prior authorization review.
Inpatient or intermediate or Outpatient care services that were not pre-authorized, if they were required to be pre-authorized under the Plan.
Non-medical 24-hour withdrawal management which is an organized residential service, including those defined in the American Society of Addiction Medicine (ASAM) criteria providing 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal, using peer and social support rather than medical and nursing care.
Tuition or services that are school-based for children and adolescents required to be provided by, or paid for by, the school under the Individuals with Disabilities Education Act.
Psychosurgery (brain surgery to treat psychiatric symptoms).
Transitional Living services.