Exlusions from Georgia Health Insurance Coverage

What's Not Covered

• Durable Medical Equipment - The following items related to Durable Medical Equipment are specifically excluded:
• • Air conditioners, humidifiers, dehumidifiers, or purifiers;
  • Arch supports and orthopedic or corrective shoes;
  • Heating pads, hot water bottles, home enema equipment, or rubber gloves;
  • Sterile water;
  • Deluxe equipment, such as motordriven chairs or beds, when standard equipment is adequate;
  • Rental or purchase of equipment if you are in a facility which provides such equipment;
  • Electric stair chairs or elevator chairs;
  • Physical fitness, exercise, or ultraviolet/tanning equipment;
  • Residential structural modification to facilitate the use of equipment;
  • Blood pressure monitors;
  • Other items of equipment which BCBSGA feels do not meet the listed criteria.
• Employer Medical Care - Care given by a medical department or clinic run by your Employer.
• Experimental or Investigational - Treatments, procedures, equipment, drugs, devices, or supplies (hereafter called "services") which are, in BCBSGA's judgment, Experimental or Investigational for the diagnosis for which the Participant is being treated. An Experimental or Investigational service is not made eligible for coverage by the fact that other treatment is considered by a Participant's Physician to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life.
• Failure to Keep a Scheduled Visit - Charges for failure to keep a scheduled visit or for completion of claim forms; for Physician or Hospital's stand-by services; for holiday or overtime rates.
• Foot Care - Care of corns, bunions (except capsular or related surgery), calluses, toenail (except surgical removal or care rendered as treatment of the diabetic foot or ingrown toenails), flat feet, fallen arches, weak feet, chronic foot strain, or asymptomatic complaints related to the feet.
• Free Services - Services and supplies for which you have no legal obligation to pay, or for which no charge has been made or would be made if you had no health insurance coverage.
• Government Programs - Treatment where payment is made by any local, state, or federal government (except Medicaid), or for which payment would be made if the Participant had applied for such benefits. Services that can be provided through a government program for which you as a member of the community are eligible for participation. Such programs include, but are not limited to, school speech and reading programs.
• Hair - Hair transplants, hairpieces or wigs (except when necessitated by disease), wig maintenance, or prescriptions or medications related to hair growth.
• Hearing Services - Hearing aids, hearing devices and related or routine examinations and services.
• Homes - Services provided by a rest home, a home for the aged, a nursing home or any similar facility.
• Hypnotherapy.
• Ineligible Hospital - Any services rendered or supplies provided while you are confined in an Ineligible Hospital.
• Ineligible Provider - Any services rendered or supplies provided while you are a patient or receive services at or from an Ineligible Provider.
• Infertility/Reproduction - Services related to or performed in conjunction with artificial insemination, in-vitro fertilization, reverse sterilization or a combination thereof. Surrogate parenting. Infertility monitoring, correction of treatment, including infertility drugs and reproductive medications, storage of egg sperm blood product for future use.
• Injury or Illness - Care, supplies, or equipment not Medically Necessary, as determined by BCBSGA, for the treatment of an Injury or illness.
• In-Network Non-emergency Care - In-Network non-emergency care, supplies, or equipment that are not authorized by your Primary Care Physician or by other BCBSHP certification procedures, except that Participants have the right to Direct Access to specified In-Network providers without a Primary Care Physician Referral. Such providers include a gynecologist for obstetrical or gynecological-related conditions, a dermatologist; and an optometrist/ophthalmologist for medical conditions only.
• Inpatient Mental Health - Inpatient Hospital care for mental health conditions when the stay is:
• • determined to be court-ordered, custodial, or solely for the purpose of environmental control;
  • rendered in a home, halfway house, school, or domiciliary institution;
  • associated with the diagnosis(es) of acute stress reaction, childhood or adolescent adjustment reaction, and/or related marital, social, cultural or work situations.
• Inpatient Rehabilitation - Inpatient rehabilitation in the Hospital or Hospital-based rehabilitation facility, when the Participant is medically stable and does not require skilled nursing care or the constant availability of a Physician or:
• • the treatment is for maintenance therapy; or
  • the Participant has no restorative potential; or
  • the treatment is for congenital learning or neurological disability/disorder; or
  • the treatment is for communication training, educational training or vocational training.
• Medical Reports - Specific medical reports, including those not directly related to treatment of the Participant, e.g., employment or insurance physicals, and reports prepared in connection with litigation.
• Methadone - Methadone is excluded for coverage when used (1) for any maintenance program and/or for the treatment of drug addiction or dependency (unless the Plan has mental health outpatient benefits) and (2) for the management of chronic, non-malignant pain and/or any off-label usage which does not meet established off-label coverage guidelines. Such maintenance programs must meet Medical Necessity requirements.
• Miscellaneous Care - Custodial Care, domiciliary care, rest cures, or travel expenses even if ended for health reasons by a Physician. Inpatient room and board charges in connection with a Hospital or Skilled Nursing Facility stay primarily for environmental change, Physical Therapy or treatment of chronic pain, except as specifically stated as Covered Services. Ambulance transportation from the Hospital to the home. Transportation back to a facility nearest home (emergency transportation is only covered to the nearest facility that can care for or treat the patient's condition/Injury).
• Non-Covered Services - Any item, service, supply or care not specifically listed as a Covered Service in this SPD Booklet, even when a prior Referral has been issued by a Primary Care Physician.
• Non-Physician Care - Care prescribed and supervised by someone other than a Physician unless performed by other licensed health care Providers as listed in this SPD Booklet.
• Obesity - Any services or supplies for the treatment of obesity, including but not limited to, weight reduction, medical care or Prescription Drugs, or dietary control (except as related to covered nutritional counseling). Nutritional supplements; services, supplies and/or nutritional sustenance products (food) related to enteral feeding except when it is the sole means of nutrition. Food supplements. Services for Inpatient treatment of bulimia, anorexia or other eating disorders which consist primarily of behavior modification, diet and weight monitoring and education. Any services or supplies that involve weight reduction as the main method of treatment, including medical, psychiatric care or counseling. Weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature. Excluded procedures include but are not limited to bariatric services, bariatric surgery (e. g., gastric bypass or vertically banded gastroplasty, liposuction, gastric balloons, jejunal bypasses, and wiring of the jaw).
• Orthoptics - Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision) or visual training.