General Benefit Exclusions and Limitations
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The general coverage limitations are as follows:
- Any services not authorized through the member's selected participating physician group (PPG) in accordance with procedures established by the PPG, Health Net and Medicare are not covered (except for emergency or out-of-area urgently needed renal dialysis services; refer to the Emergency Services topic)
- Acupuncture
- Cosmetic services and supplies - The following services and supplies, irrespective of the purpose for which they are performed, are not covered: hair transplant, hair analysis, hairpieces, wigs and cranial/hair prosthesis, chemical face peels, abrasive procedures of the skin, liposuction of any body part, or epilation by electrolysis or other means
The following services are not covered except when required for the prompt repair of accidental injury or for the improvement of the functioning of a malformed body member:
- Surgery to excise, enlarge, reduce, or change the appearance of any part of the body
- Surgery to reform or reshape skin or bone
- Surgery to excise or reduce skin, corrective or fatty tissue that is loose, wrinkled, sagging, or excessive on any part of the body
This limitation does not apply to breast surgery and all stages of reconstruction for the breast on which a medically necessary mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast is covered.
- Chiropractic care - Coverage for chiropractic services is limited to treatment by means of manual manipulation of the spine to correct subluxation, unless specifically listed in the member's Evidence of Coverage (EOC)
- Custodial or domiciliary care - Regardless of the type of facility, custodial and domiciliary care is not covered
- Dental services - Care or treatment of teeth and gingival tissues, extraction of teeth; treatment of dental abscess or granuloma, other than tumors, dental examinations, spot grinding, crowns, bridge work, onlays, inlays, dental implants, braces, and any orthodontic appliances are not covered unless specifically provided in the member's EOC
- Duplicate Health Net coverage - If the member is covered by more than one Health Net group plan, coverage is determined by applying provisions in the Coordination of Benefits topic
- Expenses before coverage begins - Services received before the member's effective date are not covered
- Expenses after termination of coverage - Services received after coverage is terminated are not covered
- Experimental or investigative procedures - All procedures generally recognized by the organized medical community and its societies and per Medicare guidelines as experimental or investigative, including services that are solely and explicitly related to these procedures (but not including medical complications relating to or arising out of such procedures), are not covered. Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under an approved clinical trial. Experimental procedures and items are those items and procedures determined by Health Net and Original Medicare to not be generally accepted by the medical community. Participation in a clinical trial that meets Medicare requirements are covered for members with a diagnosis of cancer. Such members may enroll in a clinical trial program, which is administered by the Centers for Medicare and Medicaid Services (CMS) and is separate and distinct from their Health Net plan
- Hospice benefits - Any item or service which is included in the plan of care developed by a hospice and for which payment may be made under Medicare as necessary for the palliation and management of a terminal illness and related conditions is considered a hospice benefit. Hospice services and any other services relating to the member's terminal condition are not covered by Health Net under its Medicare Advantage (MA) plans to Medicare-entitled members. Such members may enroll in a Medicare hospice program, which is administered by the CMS and is separate and distinct from a Health Net MA plan. The member's attending physician or primary care physician (PCP) refers the member to a Medicare participating hospice if the member wishes to elect such coverage. If the member remains enrolled in a Health Net MA plan, the member continues to seek and receive all services and coverage unrelated to the member's terminal condition through the Health Net MA plan, the member's PPG or PCP
- Military service-connected disability - Diseases and disabilities rated by the U.S. Department of Veterans Affairs (VA) as being "service-connected disabilities" entitling members to benefits from the department, if the member obtains care through the VA
- Miscellaneous hospital expenses - Personal or convenience items, such as a telephone or television in the room at a hospital or skilled nursing facility (SNF), are not covered
- Non-covered items:
- Disposable supplies for home use, including diapers, incontinence pads, plastic gloves, comfort items (for example, pillows, adjustable beds)
- Exercise or hygienic equipment, including shower chairs and benches, bath tub lifts exercise bicycles, free weights
- Over-the-counter support appliances and supplies, such as stockings and arch supports, or ace bandages
- Hearing aids - unless specifically provided in the Schedule of Benefits, EOC or approved by Health Net or the member's PPG
- Contact or corrective lenses (except an implanted lens that replaces the organic eye lens, and one pair of eyeglasses or contact lenses following cataract surgery) and eyeglasses are not covered, unless specifically provided elsewhere in the member's EOC or under Medicare guidelines
- Non-eligible institutions - Any services or supplies furnished by a non-eligible institution, which is other than a legally operated hospital or Medicare-approved SNF, or which is primarily a place for the aged, a nursing home or any similar institution, regardless of how designated, are not covered
- Non-prescription birth control - Non-prescription contraceptive supplies and devices are not covered
- Orthopedic shoes - Orthopedic shoes are not covered, except when such a shoe is an integral part of a leg brace. The orthopedic shoe exclusion does not apply to therapeutic extra-depth shoes with inserts or custom-molded shoes for an individual with diabetes
- Prescription medications - Outpatient prescription medications are not covered (unless specifically stated otherwise in the subscriber's EOC)
- Private-duty nursing - Private-duty nurses are not covered for a registered bed patient in a hospital or long-term care facility. Full-time, private-duty nursing care in the home is not covered
- Private rooms - Private rooms in a hospital or SNF is not covered unless it is deemed to be medically necessary
- Refractive eye surgery - Any eye surgery for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia) and astigmatism, is not covered (except as outlined in the Medicare Coverage Issues Manual sections 35-54)
- Surgery and related services (often referred to as orthognathic surgery or maximally and mandibular osteotomy) - These are not covered for the following reasons:
- For the improvement of an individual's facial structure in the absence of significant malocclusion correction
- Modified condylotomy for the treatment of temporomandibular joint (TMJ) disorders or myofascial pain dysfunction because they are considered investigational in nature
- For correction of articulation disorders and other impairments in the production of speech
- For correction of distortions within the sibiliant sound class or for other distortions of speech quality (for example, hypernasal or hyponasal speech)
- Braces and any other orthodontic services
- Therapeutic shoes - Therapeutic shoes are covered for members with diabetes. In order to be covered, the member's physician managing the member's diabetic condition certifies that the therapeutic shoes are needed because the member has diabetes and is being treated under a comprehensive plan of care
- Treatment and services for disorder for TMJ disorder - Treatment and services for TMJ disorder are covered when determined to be medically necessary, except:
- Crowns
- Inlays
- Onlays
- Dental implants
- Bridgework (to treat dental conditions related to TMJ disorder)
- Braces and active splints for orthodontic purposes (movement of teeth)
- Unlisted services - Any services or supplies not specifically listed in the member's EOC as covered are not covered, unless coverage is required by law
- Workers' compensation - If the member requires services for which coverage is in whole or in part either payable or required to be paid under any workers' compensation or occupational disease law, Health Net provides coverage to which the member is entitled and then pursues recovery
General Coverage Limitations (Physicians only)
The general coverage limitations are as follows:
- Any services not authorized through Health Net and Medicare are not covered (except for emergency or out-of-area urgently needed renal dialysis services; refer to the Emergency Services topic)
- Cosmetic services and supplies - The following services and supplies, irrespective of the purpose for which they are performed, are not covered: hair transplant, hair analysis, hairpieces, wigs and cranial/hair prostheses, chemical face peels, abrasive procedures of the skin, liposuction of any body part, or epilation by electrolysis or other means
The following services are not covered except when required for the prompt repair of accidental injury or for the improvement of the functioning of a malformed body member:
- Surgery to excise, enlarge, reduce, or change the appearance of any part of the body
- Surgery to reform or reshape skin or bone
- Surgery to excise or reduce skin, corrective or fatty tissue that is loose, wrinkled, sagging, or excessive on any part of the body
This limitation does not apply when surgery is performed to affect breast reconstruction after a mastectomy or if coverage for cosmetic surgery is specifically provided elsewhere in the member's Evidence of Coverage (EOC) or per Medicare guidelines.
- Chiropractic care - Coverage for chiropractic services is limited to treatment by means of manual manipulation of the spine to correct subluxation, unless specifically listed in the member's EOC
- Custodial or domiciliary care - Regardless of the type of facility, custodial and domiciliary care is not covered
- Dental services - Care or treatment of teeth and gingival tissues, extraction of teeth, treatment of dental abscess or granuloma other than tumors, dental examinations and spot grinding, crowns, bridge work, onlays, inlays, dental implants, braces, and any other orthodontic appliances are not covered unless specifically provided in the member's EOC
- Duplicate Health Net coverage - If the member is covered by more than one Health Net group plan, coverage is determined by applying provisions in the Coordination of Benefits topic
- Expenses before coverage begins - Services received before the member's effective date are not covered
- Expenses after termination of coverage - Services received after coverage is terminated are not covered
- Experimental or investigative procedures - All procedures generally recognized by the organized medical community and its societies and per Medicare guidelines as experimental or investigative, including services that are solely and explicitly related to these procedures (but not including medical complications relating to or arising out of such procedures), are not covered. Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under an approved clinical trial. Experimental procedures and items are those items and procedures determined by Health Net and Original Medicare to not be generally accepted by the medical community. Participation in a clinical trial that meets Medicare requirements is covered for members with a diagnosis of cancer. Such members may enroll in a clinical trial program, which is administered by the Centers for Medicare and Medicaid Services (CMS) and is separate and distinct from their Health Net plans
- Hospice benefits - Any care that is offered to control or manage terminal illness or related conditions, usually designed to be provided primarily in the member's home, is considered a hospice benefit or service. Hospice services and any other services relating to the member's terminal condition, which necessitates hospice services are not provided by Health Net under this Health Net Medicare Advantage (MA) plan to Medicare entitled members. Such members may enroll in a Medicare hospice program, which is administered by CMS and is separate and distinct from this Health Net MA plan. Health Net refers the member to a Medicare participating hospice if the member wishes to elect such coverage. If the member remains enrolled in a Health Net MA plan, the member continues to receive all coverage unrelated to hospice care or the care of the member's terminal condition through the MA plan
- Military service-connected disability - Diseases and disabilities rated by the U.S. Department of Veterans Affairs (VA) as being "service-connected disabilities" entitling members to benefits from the department, if the member obtains care through the VA
- Miscellaneous hospital expenses - Personal or convenience items, such as a telephone or television in the room at a hospital or skilled nursing facility (SNF) are not covered
- Non-covered items:
- Disposable supplies for home use, including diapers, incontinence pads, plastic gloves, comfort items (for example, pillows or adjustable beds)
- Exercise or hygienic equipment, including shower chairs and benches, bath tub lifts, exercise bicycles, free weights
- Over-the-counter support appliances and supplies, such as stockings and arch supports, ace bandages
- Hearing aids - unless specifically provided in the Schedule of Benefits, EOC or approved by Health Net or the member's participating physician group (PPG)
- Contact or corrective lenses (except an implanted lens that replaces the organic eye lens, and one pair of eyeglasses or contact lenses following cataract surgery) and eyeglasses are not covered, unless specifically provided elsewhere in the member's EOC or under Medicare guidelines
- Non-eligible institutions - Any services or supplies furnished by a non-eligible institution, which is other than a legally operated hospital or Medicare-approved SNF, or which is primarily a place for the aged, a nursing home or any similar institution, regardless of how designated, are not covered
- Non-prescription birth control - Non-prescription contraceptive supplies and devices are not covered
- Orthopedic shoes - Orthopedic shoes are not covered, except when such a shoe is an integral part of a leg brace. The orthopedic shoe exclusion does not apply to therapeutic extra-depth shoes with inserts or custom-molded shoes for an individual with diabetes
- Prescription medications - Outpatient prescription medications are not covered (unless specifically stated otherwise in the subscriber's EOC)
- Private-duty nursing - Private-duty nurses are not covered for a registered bed patient in a hospital or long-term care facility. Full-time, private-duty nursing care in the home are not covered
- Private rooms - Private rooms in a hospital or long term care facility is not covered unless it is deemed to be medically necessary
- Refractive eye surgery - Any eye surgery for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia) and astigmatism is not covered (except as outlined in the Medicare Coverage Issues Manual sections 35-54)
- Surgery and related services (often referred to as orthognathic surgery or maximally and mandibular osteotomy) - These are not covered for the following reasons:
- For the improvement of an individual's facial structure in the absence of significant malocclusion correction
- To reshape or enhance the size of the chin to restore facial harmony and chin projection (for example, mentoplasty, genioplasty, chin augmentation, mandibular osteotomies, ostectomies, chin implant)
- Modified condylotomy for the treatment of temporomandibular joint (TMJ) disorders or myofascial pain dysfunction because they are considered investigational in nature
- For correction of articulation disorders and other impairments in the production of speech
- For correction of distortions within the sibiliant sound class or for other distortions of speech quality (for example, hypernasal or hyponasal speech)
- Braces and any other orthodontic services
- Therapeutic shoes - Therapeutic shoes are covered for members with severe diabetes. In order to be covered, the member's physician managing the member's diabetic condition certifies that the therapeutic shoes are needed because the member has diabetes and is being treated under a comprehensive plan of care
- Treatment and services for TMJ disorder - Treatment and services for TMJ disorder are covered when determined to be medically necessary, except:
- Crowns
- Inlays
- Onlays
- Dental implants
- Bridgework (to treat dental conditions related to TMJ disorder)
- Braces and active splints for orthodontic purposes (movement of teeth)
- Unlisted services - Any services or supplies not specifically listed in the member's EOC as covered are not covered, unless coverage is required by law
- Workers' compensation - If the member requires services for which coverage is in whole or in part either payable or required to be paid under any workers' compensation or occupational disease law, Health Net provides coverage to which the member is entitled and then pursues recovery