CHIP Scope of Benefits (Continued)

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Exclusions

• Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system
• Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment of sickness or injury
• Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community
• Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court
• Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.
• Mechanical organ replacement devices including, but not limited to artificial heart
• Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan
• Prostate and mammography screening
• Elective surgery to correct vision
• Gastric procedures for weight loss
• Cosmetic surgery/services solely for cosmetic purposes
• Out-of-network services not authorized by the Health Plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section
• Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan
• Acupuncture services, naturopathy and hypnotherapy
• Immunizations solely for foreign travel
• Routine foot care such as hygienic care
• Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails)
• Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor
• Corrective orthopedic shoes
• Convenience items
• Orthotics primarily used for athletic or recreational purposes
• Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice.
• Housekeeping
• Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities
• Services or supplies received from a nurse, which do not require the skill and training of a nurse
• Vision training and vision therapy
• Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP
• Donor non-medical expenses
• Charges incurred as a donor of an organ when the recipient is not covered under this health plan