Merritt Personal Lines Manual: HMO Exclusions And Limitations

Exclusions or limitations are used to either limit a benefit provided or specifically exclude a type of coverage, benefit, medical procedure, etc. HMOs may not exclude and limit benefits as readily as commercial insurance companies. This is usually because the rationale of an HMO is to provide comprehensive health care coverage

Benefits that an HMO may exclude from coverage include: eye examinations and refractions for persons over age 17, eyeglasses or contact lenses resulting from an eye examination, dental services, prescription drugs (other than those administered in a hospital), long-term physical therapy (over 90 days) and out-of-area benefits (other than emergency services).

The HMO is required to have a complaint system, often called a grievance procedure, to resolve any written complaints that the insured may have. They provide forms for written complaints, including the address and telephone number of where complaints should be directed. Additionally, the HMO must notify the insured of any time limits applying to a complaint.

Complaints must be resolved within 180 days of being filed with the HMO (with a few exceptions). They may be resolved through binding arbitration if so specified by the HMO.