What the Plan Doesn't Cover
Expenses Not Covered, Exclusions, and Limitations — UMP 2010
This plan covers only the services and conditions specifically identified in the UMP 2010 Certificate of Coverage. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. If you have questions, call Customer Service at 1-800-762-6004.
Here are some examples of common services and conditions that are not covered. Many others are also not covered—these are examples only, not a complete list. These examples are called exclusions, meaning these services are not covered, even if medically necessary.
1. Acupuncture, except as described under "Acupuncture".
2. Air ambulance, if ground ambulance would serve the same purpose.
3. Applied Behavioral Analysis.
4. Arthroscopic knee surgery for the diagnosis of osteoarthritis.
5. Cabulance or any other form of nonemergency transportation services.
6. Carotid Intima Thickness Testing.
7. Certified Registered Nurse First Assistants (CRNFAs): UMP does not pay for services provided by CRNFAs unless the CRNFA's supervising physician (MD or DO) bills for the services. UMP will pay only the physician or clinic; UMP does not accept bills from or pay directly to a CRNFA.
8. Circumcision, unless determined medically necessary for a medical condition.
9. Complications arising directly from bariatric (obesity) surgery at any time that the plan did not pay for, whether it would be covered today or not.
10. Complications arising directly from services that would not be covered by the plan during the current plan year. The plan will, however, cover complications arising directly from services that the plan paid for you in the past.
11. Cosmetic services or supplies, including drugs and pharmaceuticals. However, the plan does cover:
- Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury.
- Reconstructive surgery of a congenital anomaly, such as cleft lip or palate, to improve or restore function.
12. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered.
13. Custodial care (see definition).
14. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services listed under the "Dental Services" benefit.
15. Dietary or food supplements, including but not limited to:
- Herbal supplements, dietary supplements, medicinal foods, and homeopathic drugs.
- Infant or adult dietary formulas (except for treatment of congenital metabolic disorders such as phenylketonuria (PKU) detected by newborn screening when specialized formulas are medically necessary).
- Minerals.
- Prescription or over-the-counter vitamins (see exceptions).
16. Dietary programs.
17. Drugs or medicines not covered by Washington State Rx Services as described in "Your Prescription Drug Benefit".
18. Educational programs, except as described under "Diabetes Education" or "Tobacco Cessation Program".
19. Electron Beam Tomography (EBT), self-referred or prescribed by a provider.
20. Email consultations or e-visits.
21. Equipment not primarily intended to improve a medical condition or injury, including but not limited to:
- Air conditioners or air purifying systems
- Arch supports
- Communication aids
- Elevators
- Exercise equipment
- Massage devices
- Overbed tables
- Sanitary supplies
- Telephone alert systems
- Vision aids
- Whirlpools, portable whirlpool pumps, or sauna baths
22. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals.
23. Experimental or investigational services, supplies, or drugs, except for clinical trials consistent with Medicare coverage criteria.
24. Extracorporeal Shockwave Therapy (low-energy shock waves focused on a source of pain such as soft tissue).
25. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery.
26. Foot care: Cutting of toenails; treatment for diagnosed corns and calluses; or any other maintenance-related foot care.
27. Genetic counseling and testing, counseling for family planning, or any other genetic testing or counseling, except as described under "Genetic Services".
28. Home health care except as described under "Home Health Care".
29. Hospital inpatient charges such as:
30. Immunizations, except as described under the "Preventive Care" benefit.
31. Immunizations for the purpose of travel or employment, even if recommended by the Centers for Disease Control and Prevention.
32. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation.
33. Learning disabilities treatment after diagnosis, with two exceptions: as described under "Physical, Occupational, Speech, and Neurodevelopmental Therapy" or when part of treating a mental health disorder.
34. Magnetic Resonance Imaging—Upright MRIs (uMRI), also known as "positional," "weight-bearing" (partial or full), or "axial loading."
35. Maintenance therapy.
36. Manipulations of the spine or extremities, except as described under "Spinal and Extremity Manipulations".
37. Marriage, family, or other counseling or training services, except as provided to treat an individual member's neuropsychiatric, mental, or personality disorder.
38. Massage therapy services longer than one hour per session.
39. Massage therapy, unless services meet the criteria in "Massage Therapy".
40. Massage therapy services when the massage therapist is not a network provider.
41. Medicare-covered services or supplies delivered under a private contract with a provider who does not offer services through Medicare, when Medicare is the patient's primary coverage (see "What happens if a provider doesn't accept Medicare for services covered by Medicare?").
42. Missed appointments.
43. Non-approved provider types — Services delivered by types of providers not listed as approved, or by providers delivering services outside the scope of their licenses, are not covered.
44. Non-network provider charges that are above the allowed amount, even when the provider is paid at the out-of-area rate, except when the enrollee has been admitted to the hospital as a result of an emergency room visit and the annual medical out-of-pocket limit has been met.
45. Organ donor coverage for anyone who is not a plan member, or costs of locating a donor (such as tissue typing of family members), except as described under "Transplants".
46. Orthognathic surgery (see definition).
47. Orthoptic therapy except to treat strabismus, a muscle disorder of the eye. See "Vision Care (Related to Diseases and Disorders of the Eye)".
48. Orthotics.
49. Panniculectomy or removal of excess skin due to weight loss, even if weight loss was the result of surgery paid for by the plan.
50. Physical exam—Any additional portion of a physical exam beyond what the plan covers under the preventive care benefit, even if required for employment, travel, immigration, licensing, school, insurance, or other purposes, and related reports.
51. Physician Assistants (PAs): UMP does not pay for services provided by PAs unless the PA's supervising physician (MD or DO) bills for the services. UMP will pay only the physician or clinic; UMP does not accept bills from or pay directly to a PA.
52. Prescription drug charges over the allowed amount, regardless of where purchased.
53. Prescription drugs that require preauthorization unless the request is:
- Supported by medical justification from a clinician other than the patient or member of the patient's family.
- Approved by the plan.
54. Provider administrative fees—Any charges for completing forms, copying records, or finance charges, except for records requested by the plan to perform retrospective (postpayment) review.
55. Recreation therapy.
56. Registered counselors.
57. Replacement of lost, stolen, or damaged durable medical equipment.
58. Replacement of medications that are any of the following:
- Confiscated or seized by Customs or other authorities
- Contaminated
- Damaged
- Lost or stolen
- Ruined
59. Reproductive failure or fertility testing or treatment, including drugs, pharmaceuticals, artificial insemination, and any other type of testing, treatment, or visits for reproductive failure.
60. Residential treatment programs that are not solely for chemical dependency treatment or a mental health condition requiring inpatient treatment. Examples include, but are not limited to, schools, wilderness programs, and behavioral programs.
61. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures).
62. Separate charges for records or reports.
63. Service animals: Any expenses related to a service animal.
64. Services or supplies:
- That are not medically necessary for the diagnosis and treatment of injury or illness or restoration of physiological functions, and are not covered as preventive care. This applies even if services are prescribed, recommended, or approved by your provider.
- For which no charge is made, or for which a charge would not have been made if you had no health care coverage.
- Provided by a family member or any household member.
- Provided by a resident physician or intern acting in that capacity.
- That are solely for comfort.
- For which you are not obligated to pay.
65. Services performed during a noncovered service.
66. Services performed only to ensure the success of a noncovered service, including but not limited to a hiatal hernia repair done to ensure the success of a noncovered Laparoscopic Adjustable Gastric Banding surgery.
67. Services, supplies, or drugs related to occupational injury or illness (see definition).
68. Services, supplies, or items that require preauthorization unless the request is:
- Supported by medical justification from a clinician other than the patient or member of the patient's family.
- Approved by the plan.
69. Sexual reassignment drugs, surgery, services, or supplies.
70. Skilled nursing facility services or confinement:
- When primary use of the facility is as a place of residence.
- When treatment is primarily custodial.
71. Telephone consultations, except as described under "Telehealth Services".
72. Temporomandibular joint (TMJ) disorder treatment, except as described under "Temporomandibular Joint (TMJ) Treatment".
73. TENS (Transcutaneous Electrical Nerve Stimulation) Units.
74. Tobacco cessation services, supplies, or medications, except as described under "Tobacco Cessation Program".
75. Treatment of chemical dependency or mental health conditions by an inpatient facility when the facility or unit is not primarily for chemical dependency or mental health treatment.
76. Weight control, weight loss, and obesity treatment:
- Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity treatment. Exercise programs (formal or informal), exercise equipment, or travel expenses associated with non-surgical or surgical services are not covered. Such treatment is not covered even if prescribed by a provider.
- Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and any related medical services, drugs, or supplies, except if approved through case management as described under "Obesity Surgery". Removal of excess skin is not covered.
77. Wilderness training programs.
78. Workers' compensation—This plan does not cover services or supplies for work-related injury or illness.
If you have questions about whether a certain service or supply is covered, call Customer Service at 1-800-762-6004.
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