Oregon Medical Insurance > HealthNet of Oregon > Exclusions

IFP Exclusions and Limitations

All the following benefits, accommodations, care, services, equipment, medications or supplies are expressly excluded or limited from coverage:

• Any care deemed not medically necessary.
• Services or supplies exceeding benefits maximums.
• Treatment of illness or injury for which a third party is responsible.
• Experimental or investigational procedures.
• Non-authorized emergency services as required by Plan contract.
• Expenses other than for emergency medical care for any condition or complication caused by any procedure, treatment, service, drug, device, product or supply excluded from coverage.
• Private room; private duty nurses.
• Temporomandibular joint (TMJ) related services and orthognathic (jaw) surgery.
• Orthodontic services and dental implants.
• Custodial, respite care.
• Vision services or supplies (except as outlined in your policy).
• Corrective appliances and artificial aids, braces, disposable or nonprescription or over-the-counter supplies.
• Cosmetic services.
• Reduction or augmentation mammoplasty, except as provided in your policy.
• Medical or psychological reports or physical examinations required primarily for your protection and convenience or for third parties.
• Immunizations and inoculations, except as provided in your policy.
• Public facility care; military service disabilities.
• Infertility services and supplies.
• Reversal of voluntary, infertility (sterilization).
• Diagnosis, treatment and rehabilitation services for obesity and eating disorders.
• All organ and tissue transplants or autologous stem cell rescue not explicitly listed as covered.
• Personal comfort items.
• Learning disorders, psychosocial problems, speech delay, conceptual handicap and developmental delay or dyslexia, except as provided in your policy.
• Speech generating devices.
• Rehabilitation, speech and hearing therapy, except as provided in your policy; chiropractic manipulations.
• Medications, surgical treatment or hospitalization for treatment of impotency, penile implants, services, devices or aids related to treatment of any types of sexual dysfunction, congenital or acquired; sperm storage or banking.
• Genetic engineering.
• Non-medical self-help training.
• Bone bank and eye bank charges.
• Counseling or training in connection with family, sexual, marital or occupational issues.
• Orthoptics, pleoptics (visual therapy and/or training), visual analysis.
• Services and supplies for which the Member is not required to pay or that the Member would receive at no cost in the absence of health coverage; services and supplies for which the Member is not billed by a provider or for which we are billed at zero dollar charge.
• Any illness, condition, or injury occurring in or arising out of the course of employment.
• Court-ordered care, unless determined to be medically necessary and prior authorized.
• Outpatient prescription or other drugs and medications. Prescriptions relating to an inpatient/outpatient confinement filled at a hospital pharmacy prior to discharge or use at home (take-home medications) except for prescriptions for a 24-hour supply or less, following an emergency room visit.
• Diagnosis, treatment and rehabilitation services for injuries sustained while practicing for or competing in a professional or semiprofessional athletic contest.
• Pain management programs.
• Biofeedback.
• Hair analysis.
• Extraction and storage of autologous or family member or friend, blood and derivatives.
• Routine foot care unless prescribed for the treatment of diabetes.
• Growth hormone therapy.
• Preventive and routine examination, services, testing and supplies, except as provided in your policy.
• Circumcisions.
• Alternative care: Services include chiropractic, naturopathic, acupuncture and massage therapy.
• Services of a nutritionist, except for diabetes management and inborn errors of metabolism.
• All services provided in wilderness residential treatment programs.
• Services and supplies rendered by an immediate family member (spouse, Registered Domestic Partner, parent, child, grandparent or sibling related by blood, marriage or adoption) or prescribed or ordered by an immediate family member of the Member; Member self-treatment, including but not limited to self-prescribed medications and medical self-ordered services and laboratory tests.
• Services provided outside of the United States which are not emergency medical care.

Exclusion periods

• Services related to an organ transplant, including evaluation, will be covered after a 24-month exclusion period has been satisfied.
• Services for the following specified conditions will be covered after a 12-month exclusion period has been satisfied.
  • Allergies and their symptoms, including asthma.
  • Elective procedures that we determine can be reasonably postponed until the end of the exclusion period.
  • Mental disorders.
• Exclusion periods do not apply to a subscriber who is under the age of 19.
• Services for a pre-existing condition will be covered after a 6-month exclusion period has been satisfied. Pregnancy is subject to the pre-existing conditions. The pre-existing condition exclusion period does not apply to a subscriber who is under the age of 19.
• Upon our receipt of a certificate of Creditable Coverage, the exclusion periods will be reduced by the length of Creditable Coverage under other Health Benefit Plans provided the following conditions are met:
  • Creditable Coverage must either remain in effect on the effective date of coverage or have been terminated no more than 63 days prior to the effective date, and
  • Except for services for a pre-existing condition, the excluded service must have been covered under the other Health Benefit Plan.
  • The exclusion periods do not apply to a newborn or newly adopted child.