Oregon Medical Insurance > ODS Health Plans of Oregon > Plan Exclusions & Limitations

Service Area - Illustrated in ODS Provider Directory

Dependent Eligibility

Dependents are a lawful spouse or partner pursuant to theOregon Family Fairness Act and unmarried children younger than age 26.

Out of Area Dependent Children Coverage

If your enrolled dependent child)ren) resides outside the service area, we will extend benefits for treatment of an illness or injury, and women's routine healthcare (or preventive healthcare if available in the plan) and maternity services, as if care were rendered by a participating physician or provider.  Out-of-area dependents must have access benefits within a 30 mile radius of their residence in order for the PPO Benefit to apply.

Limitations:

• All medical and surgical admissions must be authorized by ODS
• Mental illness treatment up to 20 outpatient visits, or 10 days each, for inpatient or residential services per plan year
• Alcohol treatment up to 20 outpatient visits, or 10 days each, for inpatient or residential services per plan year
• ODS will not pay benefits for covered expenses to the extent that you have any other coverage for those expenses
• Hearing aid coverage limited to members under age 26 with a maximum benefit of up to $4,100 every 48 months
• Rehabilitation benefits are limited to 15 inpatient days and 15 outpatient sessions per plan year
• Hospice benefits are limited to 12 days of inpatient care; 170 hours/three months respite care
• Vision benefits are limited to one visit per plan year for members under age 18, and one visit every two years up to $200 for members age 18 and over

Exclusion Periods

• Myringotomy with tubes
• Removal of tonsils or adenoids
• Allergies
• Sterilization
• Elective procedures (procedures that can be reasonably postponed for the exclusion period)
• Pre-existing conditions, even if they worsen or recur, unless the insured is under the age of 19
  
  24-month exclusion period applies to:
• Transplants (benefits are limited to an aggregate lifetime maximum benefit of $750,000)

Note: Your plan’s exclusion period will be shortened one day for each day you had “creditable coverage” under another health plan, provided you do not have a 63-day lapse (or longer) in coverage immediately prior to your effective date in our plan.

ODS Health Plans exclusions include the following:

• Services provided by a member of the patient's immediate family.
• Services or supplies that are not medically necessary.
• Services and supplies for reversal of sterilization or infertility.
• Surgery for obesity, including complications arising out of such treatment
• Surgery to alter the refractive character of the eye.
• Dental examinations and treatment, except as specifically listed.
• Massage or massage therapy.
• Services or supplies for the treatment of sexual dysfunction or inadequacy, or those related to sex change procedures.
• Treatment of personality disorders.
• Experimental or investigational treatment.
• Services or supplies available in whole, or in part under any city, county, state, or federal law, except for medicaid coverage.
• Charges above those considered the maximum plan allowance.
• Services or supplies for which an employer is required by law to provide benefits even if you choose not to accept those benefits (those exempt from state and federal workers' compensation law will have 24-hour coverage).
• Instruction programs, including, but not limited to, those to learn to self-administer drugs or nutrition, except as specifically provided for under the outpatient diabetic instruction benefit of this plan.
• Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control, or education.
• Cosmetic services and supplies.
• Services and supplies associated with orthognathic surgery.
• Drugs for treatment of mental illness.
• Chemical dependency treatment, except for alcohol treatment.

This list is representative of the limitations and exclusions to this policy. It is not a complete list.  For a complete list, see the individual policy