MILA : WHAT IS NOT COVERED

	Benefits Summary


	What Is Covered


	What is Not Covered

Medical Expensese Not Covered Under the Plan

Charges Not Covered in the Behavioral Health Program

Charges Not Covered in the Prescription Drug Program

Dental Charges and Services Not Covered Under the Plan

Vision Charges and Services Not Covered Under the Plan

Coordination of Benefits

Third Party Reimbursement and Subrogation

Waiver of Benefits


	Participation Under the Plan


	Claims and Appeals


	Your Rights Under ERISA


	Administrative Information


	Glossary

WHAT IS NOT COVERED

Medical Expenses Not Covered Under the Plan

While the MILA National Health Plan covers reasonable medical expenses, it does not cover every medical service. Listed below are treatments, procedures and services that are not covered by the MILA National Health Plan as medical care:

Abortion (elective), unless the physician certifies that the pregnancy would endanger the life of the mother. However, charges arising from medical complications from an abortion are covered;
Allergy testing by blood, unless direct skin testing cannot be performed or is inconclusive;
Care not deemed medically necessary (defined here) except for preventive medical treatment if provided by a network provider or for a tubal ligation or a vasectomy;
Certain military-related services performed in a U.S. government hospital as a result of an illness or injury directly related to military service;
Charges in excess of reasonable and customary charges (defined here);
Charges made by a covered provider who is a family member or who normally lives in your home;
Cosmetic surgery or treatments unless such treatments are:

To remedy a condition that is a result of an accidental injury or that is a congenital abnormality that causes a functional defect in a dependent child; or
To reconstruct a breast on which a mastectomy has been performed or the other breast to produce symmetry of appearance;

Custodial care which is not intended primarily to treat a specific illness or injury, or any care for the purpose of education or training;
Dental treatment, except for the removal of impacted teeth and treatments for accidental injury to natural teeth as described here;
Expenses incurred outside the United States unless the participant who is traveling is a resident of the United States who is traveling for pleasure;
Expenses incurred after coverage ends, even if incurred for a condition existing before coverage ended;
Experimental medicines or substances not approved by the Food and Drug Administration (FDA) or limited by federal law to investigational use;
Experimental treatments or procedures not approved by the American Medical Association (AMA) or an appropriate medical specialty society;
Extraordinary nutrition such as hyperalimentation or Total Parenteral Nutrition (TPN) except for the specific treatment described here;
Food supplements, except where required to sustain life in the course of tube feeding;
Eye treatment, including routine examinations and corrective surgery where glasses or contact lenses will provide correction. The Plan will cover a first purchase of eyeglasses or contact lenses after cataract surgery if those supplies are not covered under a vision plan for which the participant is eligible. In addition, surgical treatments for correction of refractive errors, including radial keratotomy, are excluded;
Routine use of a hospital emergency room other than for a valid emergency;
Treatment or surgery and the associated care and supplies if such treatment or surgery is not essential for the necessary care and treatment of an illness or injury;
Charges made by an assistant surgeon in excess of 20% of the surgeon’s allowable expense;
Charges made by an additional surgeon when medically necessary in excess of the surgeon’s allowable expense plus 20%;
Charges for services that would not have been made in the absence of the Plan or for which the patient is not legally obligated to pay;
For drugs and medicines not furnished by and administered during confinement as an inpatient in a hospital or provided through the Plan’s prescription drug program, unless the Plan’s Medical and Prescription Drug Claims Administrators determine that an alternative source for such drugs and medicines provides a safer and more cost effective purchase method;
Home Health Care

Home health care visits during a calendar year, in excess of 120 visits per calendar year;
Care or treatment which is not stated in the home health care plan;
The services of a person who is a member of your family or your dependent’s family or who normally lives in your home or your dependent’s home; or
A period of care during which a person is not under the continuing care of a physician; and to determine the benefits payable, each visit by an employee of a home health care agency will be considered one home health care visit and each 4 hours of home health aid services will be considered one home heath care visit;

Hospice Care

In excess of a lifetime maximum of 180 days;
During which the patient is not under the care of a physician;
That is not a part of an approved hospice care Plan;
That is either curative, life prolonging or primarily to aid in daily living; or
Bereavement counseling for family members in excess of three sessions per family is not covered;

Fertility tests or procedures to correct infertility performed by Out-of-Network/In-Area providers and the actual or attempted impregnation or other fertilization expenses, including but not limited to artificial insemination, in vitro fertilization, embryo transplant, gamete intra-fallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and related procedures or services, are not covered services whether performed In-Network or Out-of-Network;
Gender-change treatment or surgery;
Hearing aids;
Injuries or illness due to acts of war, declared or undeclared;
Job-related injury or illness covered by Workers’ Compensation or any other similar legislation;
To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. The Claim Administrator will take into account any adjustment option chosen under such part by the Participant;
Ordinary home medical supplies and first-aid items;
Penile prosthetics and implants and any related services are not covered regardless of the medical reasons for which such treatment has been prescribed;
Physical fitness equipment or supplies, athletic training, or general health upkeep or for any treatment or other services related thereto including applied kinesiology, aquatic therapy, dance therapy, movement therapy, Extracorporeal Shock Wave Lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, massage therapy or rolfing;
Preventive care obtained from an Out-of-Network provider except when covered in the Premier Plan Out-of-Area or in the Medicare Wrap-around Plan;
Reversal of sterilization;
Self-inﬂicted injuries incurred prior to April 28, 2014;
Services that would have been paid first by Medicare for any covered person who failed to enroll in that program;
Services paid for by the U.S. government or a public program other than Medicare or Medicaid;
Sexual function improvement or restoration;
For or in connection with speech therapy, if such therapy is:

Used to improve speech skills that have not fully developed;
Can be considered custodial or educational; or
Is intended to maintain speech communication (speech therapy which is not restorative in nature will not be covered);

Television, telephone and other nonessential, non-medical items;
Testing and storing blood for future use, unless for an operation scheduled within six months;
Treatment for weight loss, including gastric by-pass and related surgical procedures unless required by an underlying, severe medical condition as determined by the Claim Administrator;
Treatment or services which have been provided by a licensed provider but which are not within the scope of his/her license;
Expenses for reports, evaluations, examinations or hospitalizations which are not required to diagnose or treat an illness or injury. For example, employment physical examinations or insurance examinations are not covered;
Service and related supplies required to repair or replace an otherwise covered implant are not covered;
Expenses necessary to perform amniocentesis, ultrasound, or any other procedures requested solely for sex determination of a fetus, unless medically necessary to determine the existence of a sex-linked genetic disorder;
Expenses for artificial aids to health including but not limited to Arch Supports, Corrective Orthopedic Shoes, Dentures, Elastic Stockings, Garter Belts, Corsets, and Wigs;
Expenses for the use of ambulance service when such service is not medically necessary or when a lower cost mode of transport would suffice. Air ambulance service will be covered only when the requirement for transport is necessitated by a valid emergency and only this form of transport will accomplish medically necessary delivery of the patient to an adequate treatment setting; and
Other non-medical services.

Note

If you have additional questions about a service, health care product or expense that may not be covered, call the Plan’s Claims Administrator, Cigna, at the toll-free Member Services number shown on the MILA Resources chart in the Administrative Information section.