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Hassle-Free Health Coverage: HMO Exclusions

Exclusions or limitaions 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 your HMO may exclude from coverage include: eye examinations and refractions for persons over age 17, eyeglasses or contact lenses, 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).

Your HMO is required to have a complaint system, often called a grievance procedure. It should provide forms for written complaints, including a contact address and telephone number. Additionally, your HMO must notify you 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.

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