Affordable Health Insurance
Benefits | Exclusions | Quote/ Apply Online
Knowing exactly what your plan does and doesn’t provide benefits for is important. To give you the best possible experience, we offer the following summary of what is not eligible for benefits (varies by state). Complete details will be included in your insurance contract.
Maintenance care and therapies:
- Routine hearing care, artificial hearing devices, cochlear implants, auditory prostheses, routine vision care, vision therapy, surgery to correct vision, routine foot care and foot orthotics
- Routine dentalcare,unlessyouchoosethedentalinsurance option
Cosmetic services and procedures:
- Services including chemical peels, plastic surgery and medications
- Any correction of malocclusion (irregular tooth contact), protrusion, hypoplasia (abnormality in dental enamel) or hyperplasia (abnormality) of the jaws
Reproductive-related procedures or concerns:
- Diagnosisandtreatmentofinfertility
- Maternity, pregnancy (except complications of pregnancy), routine newborn care, surrogate pregnancy, routine nursery care and abortion
- Sterilization and contraceptive procedures, drugs or devices
Quality of life concerns:
- Inpatienttreatmentofchronicpaindisorders
- Storage of umbilical cord stem cells or other blood components in the absence of sickness or injury
- Genetic testing, counseling and services
- Treatment, services and supplies related to sex transformation, gender dysphoric disorder and gender reassignment; treatment of sexual dysfunction or inadequacy; or restoration or enhancement of sexual performance or desire
- Treatment for smoking cessation and hair loss
- Cognitive enhancement
- Prophylactic treatment, services and surgery
Prescription drug benefits do not include and will not provide benefits for:
- Over-the-counterproducts
- Drugs not approved by the FDA
- Drugs obtained from sources outside the United States
- Take-home drugs dispensed at an institution
This plan also will not provide benefits for:
- Services incurred due to a pre-existing condition for the first 12 months the plan is in force
- Any amount in excess of any maximum benefit or for non- covered events and associated complications
- Durable medical equipment and personal medical equipment
- Treatment undergone outside the United States
- Treatment of behavioral health or substance abuse
- Treatment, services, supplies, diagnosis, drugs, medication, surgery or medical regimen related to controlling weight, obesity or morbid obesity
- Treatment for snoring or sleep disorders
- Experimental or investigational treatments; homeopathic treatments; alternative treatments, including acupuncture; spinal and other adjustments, manipulations, subluxation and services; massage therapy
- Telehealth and telemedicine (including but not limited to treatment rendered through the use of interactive audio, video or other electronic media)
- Illness or injury caused by war or while in the military; commission of a felony; or influence of an illegal substance
- Illness or injury caused or aggravated by suicide,attempted suicide or self-infliction
- Treatment or services due to injury from hazardous activities, such as extreme sports, whether or not for compensation
- Services ordered, directed or performed by a heathcare practitioner or medical provider who is an immediate family member
- Treatment used to improve memory or slow the normal process of aging
- Home healthcare, hospice care, skilled nursing facility care, inpatient rehabilitation services, custodial care and respite care
- Sickness or injury arising out of or as the result of any work for wage or profit that is eligible for benefits under Workers’ Compensation, employers’ liability or similar laws
- Treatment for behavioral modification or behavioral (conduct) problems; learning disabilities; developmental delays; attention deficit disorders; hyperactivity; educational testing, training or materials; memory improvement; cognitive enhancement or training; vocational or work-hardening programs and transitional living
- Growth hormone stimulation treatment to promote or delay growth
- Treatment for TMJ and/or CMJ and certain jaw/tooth disorders
Pre-existing conditions (definition varies by state) A pre-existing condition is a sickness or injury and related complications
- for which medical advice, consultation, diagnosis, care or treatment was sought, received or recommended from a provider or prescription drugs were prescribed during the 12-month period immediately prior to your effective date, regardless of whether the condition was diagnosed, misdiagnosed or not diagnosed; or
- that produced signs or symptoms during the 12-month period immediately prior to your effective date.
The signs or symptoms were significant enough to establish manifestation or onset by one of the following tests:
- The signs or symptoms reasonably should have allowed or would have allowed one knowledgeable in medicine to diagnose the condition; or
- The signs or symptoms reasonably should have caused or would have caused an ordinarily prudent person to seek diagnosis or treatment.
Pre-existing conditions limitation (varies by state)
We will not pay benefits for events that result from or are related to a pre-existing condition, or its complications, until the covered person has been continuously insured under this plan for 12 months. After this period, benefits will be available for events resulting from or related to a pre-existing condition, or its complications, provided that the covered event occurs while this plan is in force.
