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Accessing Out-of-Plan Benefits
Medical Services are subject to the terms; conditions and limitations set forth in Section VI “In-
Plan Benefits” of this Certificate of Coverage. In order to be covered in-Plan, all referral and
authorization requirements must be followed. All other services, even if provided through
the participating network, will be considered out-of-Plan. All elective admissions and
outpatient surgical procedures require Pre-authorization. In other words, either your
physician, in the case of the HMO in-Plan benefit, or you, in the case of the POS out-of-Plan
benefit, must contact Atlantis in advance with regard to elective admissions and outpatient
surgery.
When using POS out-of-Plan benefits for elective admissions or outpatient surgical procedures,
if you do not contact Atlantis in advance, you will be subject to a penalty of 50% of the cost of
the service in addition to any deductible and or coinsurance.
Please note that Periodic Adult Physical Examinations and Well-Child Care, including
immunizations are only covered In-Plan.
See “SUMMARY OF BENEFITS” for limitations, coinsurance, deductibles, annual and lifetime
maximums on out-of-Plan (POS) benefits.
Restrictions, Exclusions and Limitations
You are entitled to all services listed in Section VI “Benefits” of this Certificate of Coverage. The
following are the restrictions, exclusions and limitations of those benefits.
A. Restrictions
1. The Plan will not pay for the services of a non-Participating Provider, unless: (1) the
treatment constitutes emergency care, (2) the Provider has been Pre-authorized by Atlantis
to provide In-Plan services, or (3) the Member is accessing Out-of-Plan Point of Service
benefits. See Section VII Accessing Out-of-Plan Benefits”.
2. The Plan will not pay for services which were not provided, arranged, or
authorized, in writing, by your Primary Care Provider and/or the Plan (except
for specific Out-of-Plan services which do not require Pre-authorization.)
3. Unnecessary Care - In general, the Plan will not cover any health care service
that the Plan, in its sole judgement, determines is not Medically Necessary.
If an External Appeal Agent certified by the State overturns the Plan’s denial,
however, the Plan shall cover the procedure, treatment, service, pharmaceutical
product, or durable medical equipment for which coverage has been denied, to
the extent that such procedure, treatment, service, pharmaceutical product,
or durable medical equipment is otherwise covered under the terms of this Subscriber
Certificate of Coverage. (For further information on external appeals, consult
your Member Handbook.) See also Section XXII “Medical Necessity and Appropriateness”.
B. Exclusions and Limitations
The following are not benefits under this Certificate of Coverage, regardless
of whether they are Medically Necessary. If these services are provided, the
Member is responsible for payment:
1. Pre-existing Conditions -In the absence of Creditable Coverage, Pre-existing
Conditions or Diseases will not be covered for 11 months from the initial Enrollment
Date. Note: The Preexisting Condition limitation does not apply to Members
of Large Groups.
2. Experimental/Investigational Treatments – In general, the Plan does not
cover experimental or investigational treatments. However, the Plan shall cover
an experimental or investigational treatment approved by an External Appeal
Agent certified by the State. If the External Appeal Agent approves coverage
of an experimental or investigational treatment that is part of a clinical trial,
the Plan will only cover the costs of services required to provide treatment
to you according to the design of the trial. The Plan shall not be responsible
for the costs of the investigational drugs or devices; the costs of non-health
care services, the costs of managing research, or costs that would not be covered
under this Subscriber Certificate of Coverage for non-experimental or non-investigational
treatments. (For further information on external appeals, consult your Member
Handbook.)
This exclusion does not apply to certain non-FDA approved prescribed drugs
recognized for the treatment of certain types of cancer by one of the following:
i. The American Medical Association Drug Evaluations;
ii. The American Hospital Formulary Service Drug Information;
iii. The United States Pharmacopoeia Drug Information; or recommended by review
article or editorial comment in a major peer reviewed professional journal.
3. Outpatient prescription drugs, unless a Rider has added coverage.
4. Long-term therapy for the treatment of mental, nervous or emotional disorders.
5. Inpatient Alcohol and Substance Abuse rehabilitation, unless coverage has
been added by a Rider to the Group Contract.
6. Illness, accident, treatment or medical conditions arising from: (1) war
or Acts of war (whether declared or undeclared); participation in a felony,
riot or insurrection; service in the Armed Forces or units auxiliary thereto;
(2) aviation, other than as a fare-paying passenger on a scheduled or charter
flight operated by a scheduled airline; and (3) suicide, attempted suicide or
intentionally self-inflicted injury. Behavioral Health care for attempted
suicide is a covered service.
7. Cosmetic Surgery performed primarily to improve the appearance of a portion
of the body that is not Medically Necessary, including, but not limited
to ear piercing, rhinoplasty, liposuction and related surgery.
This exclusion does not include reconstructive surgery when such
service is incidental to or follows surgery resulting from trauma, infection
or other diseases of the involved part, or reconstructive surgery because of
congenital disease or anomaly of a covered dependent child which has resulted
in a functional defect, nor breast surgery following a mastectomy to achieve
symmetry.
8. Routine foot care, in connection with corns, calluses, flat feet, fallen
arches, weak feet, chronic foot strain or symptomatic complaints of the feet.
9. Treatment provided in a government hospital; benefits provided under Medicare
or other government program (except Medicaid).
10. Benefits to the extent provided for any loss or portion thereof for which
Mandatory automobile no fault benefits are recovered or recoverable.
11. Benefits provided under any State or Federal Workers' Compensation, employers'
liability or occupational disease law.
12. Services rendered and separately billed by employees of hospitals, laboratories
or other institutions.
13. Services performed by a member of the covered person's immediate family.
14. Services for which no charge is normally made.
15. Dental Services (such as care, treatment, filling, removal of teeth and/or
treatment of diseases of teeth, gums or temporomandibular joint), including,
but not limited to apicoectomy (dental root resection), orthodontics, root canal
treatment, soft tissue impactions, temporomandibular joint dysfunction therapy,
alveolectomy and treatment of periodontal disease. Care or treatment of sound
natural teeth necessary due to accidental injury is a covered benefit for 12
months following the date of such injury and except for dental care or treatment
necessary due to congenital disease or anomaly.
16. Eye glasses, contact lenses, and examinations for the prescription or
fitting thereof, unless coverage has been added by a Rider to the Group Contract.
17. Rest cures, custodial care and transportation.
18. Coverage while outside the United States, its possessions or the countries
of Canada and Mexico, except for Emergency Services.
19. Autologous blood services.
20. Wigs or any other appliance or procedure related to hair loss, regardless
of the disease or injury causing the hair loss.
21. Living donor fees and transportation costs of a non-experimental organ
transplant.
22. Experimental Organ Transplants unless recommended by an external appeal
agent.
23. Contraceptive devices, even if prescribed for a medical condition other
than birth control. Birth pills, unless coverage has been added by a Rider
to the Group Contract.
24. Artificial means of achieving pregnancy to include invitro-fertilization,
Gamete Intra Fallopian Transfer, ZIFT, intracytoplasmic sperm injection, reversal
of voluntary induced sterilization, or other assisted reproductive technology
unless required by Law. This exclusion does not apply to surgical and
medical care for diagnosis and treatment of correctable medical conditions otherwise
covered by the Group Contract, solely because the medical condition results
in infertility.
25. Learning and Behavioral Disorders to include non-medical treatment
for Mental Retardation, except to the extent that such benefits are either Medically
Necessary or required to be provided by applicable Law.
26. Obesity Surgery, Weight Reduction Programs, and all other services or
procedures for treatment of non-morbid obesity, except to the extent
that such benefits are either Medically Necessary or required to be provided
by applicable Law.
27. Personal Items, including but not limited to telephone and television
rentals during an inpatient hospital stay.
28. Reports, Tests, or Procedures not directly related to treatment of the
Member, to include physical examinations for employment, school, camp or premarital.
29. Orthotic Devices, to include but not limited to, arch supports, corrective
shoes, elastic hose, braces, cervical collars, corsets, canes, crutches, hearing
aids, false teeth or special supplies or equipment.
30. Non-standard type prosthetic devices unless deemed medically necessary,
replacement of a prosthesis unless required due to growth, and artificial
organs, except where such artificial organs are deemed medically necessary.
Artificial organs are not covered if the treatment is experimental or investigational
in nature, unless recommended by an external appeal agent.
31. Sex, Martial or Religious Counseling, including Sex Therapy and treatment
of sexual dysfunction unless medically necessary.
32. Transsexual Surgery or Related Services where there is no organic basis.
33. Travel Immunizations
34. Acupuncture Therapy
35. Private Duty Nursing unless medically necessary.
36. "No-show” provider charges for broken appointments.