Citi Benefits Handbook
Covered Services and Supplies
This list of covered services and supplies applies to all In-Network Only Plan, Choice Plan and High Deductible Plan with HSA medical plans sponsored by Citi, except where noted.
Covered services and supplies must be medically necessary and related to the diagnosis or treatment of an accidental injury, a sickness or a pregnancy. Reimbursement for all covered services and supplies listed in this section is subject to the maximum allowed amount (MAA) or, for in-network services, the negotiated rates of the plan.
You and your physician decide which services and supplies are required, but the plan pays only for the following covered services and supplies that are medically necessary as determined by the Claims Administrators.
Covered services and supplies also include services and supplies that are part of a case management program. A case management program is a course of treatment developed by the Claims Administrator as an alternative to the services and supplies that would otherwise have been considered covered services and supplies. Unless the case management program specifies otherwise, the provisions of the plan related to benefit amounts, maximum amounts, copays and deductibles will apply to these services.
Acupuncture must be administered by a medical doctor or a licensed acupuncturist (if state license is available).
Aetna: Acupuncture is covered for the following:
- Pain management, treatment for nausea related to pregnancy, and postoperative and chemotherapy-induced nausea and vomiting;
- Chronic low back pain (maintenance treatment, where the patient's symptoms are neither regressing nor improving, is considered not medically necessary; if no clinical benefit is appreciated after four weeks, then the treatment plan should be re-evaluated);
- Migraine headache;
- Pain from osteoarthritis of the knee or hip (adjunctive therapy; if no clinical benefit is appreciated after four weeks, then the treatment plan should be reevaluated);
- Postoperative dental pain; and
- Temporomandibular disorders (TMD).
Anthem: Acupuncture is covered, with no visit limits or diagnosis requirements.
Acupuncture is covered if administered by a medical doctor, an osteopathic physician, a chiropractor or a licensed acupuncturist (if state license is available).
The following are the guidelines for covered adult immunizations:
- Tetanus, diphtheria (Td): Booster every 10 years;
- Influenza (flu): Annual for adults under age 50 and at risk; annual for adults age 50-plus;
- Pneumococcal vaccine (PPV): Once for adults under age 50 with risk factors; with booster after five years for adults at highest risk and those most likely to lose their immunity; once at age 65 with booster after five years if less than 65 at the time of primary vaccination;
- Varicella (chicken pox): Persons under age 50 with no history of varicella and who test negative for immunity. Persons over age 50 are assumed to be immune. Note: Women who are pregnant (or planning to become pregnant in the four weeks following vaccination) should NOT be vaccinated;
- Measles, mumps, rubella (MMR): For people born after 1956 — two doses measles with additional doses as MMR; people born before 1957 can be considered immune. Note: Women who are pregnant (or planning to become pregnant in the four weeks following vaccination) and people whose immune system is not working properly should NOT be vaccinated;
- Hepatitis A: Only for those at risk; for those at risk, two doses at least six months apart;
- Hepatitis B: Immunize if age 46 or under; if over age 45, only for those at high risk; if at risk, three doses (second dose one to two months after the first dose, and the third dose no earlier than two months after the first dose and four months after the second dose);
- Meningococcal: Meningitis (only for those at risk); if at risk, one dose (an additional dose may be recommended for those who remain at high risk);
- Tuberculin skin test: Annual testing for high-risk group (method: five tuberculin units of PPD);
- Gardasil vaccine for HPV: Males and females age 9 years to 26 years (age restrictions do not apply to Anthem BlueCross BlueShield); and
- Zostavax vaccine for shingles: Adults age 60 or older.
Ambulatory Surgical Center
A center's services must be given within 72 hours before or after a surgical procedure. The services must be given in connection with the procedure.
Anesthetics are drugs that produce loss of feeling or sensation either generally or locally, except when done for dental care not covered by the plan. When administered as part of a medical procedure, anesthesia must be administered by a board-certified anesthesiologist. Anesthesia is not covered when rendered in the doctor's office or when administered by the operating surgeon, unless it is administered by a dentist for dental care that is covered by the plan.
Autism Assistance Benefits
If you enroll in an Anthem or Aetna medical plan, family members who have been diagnosed with Autism Spectrum Disorder have access to autism assistance benefits, including applied behavior analysis (ABA) therapy.
Members diagnosed with Autism Spectrum Disorder (ASD) have coverage available for the diagnosis and treatment of ASD, when ordered by a physician, licensed psychologist or licensed clinical social worker as part of a treatment plan.
The following services and supplies may be given during an eligible newborn child's initial hospital confinement:
- Hospital services for nursery care;
- Other services and supplies given by the hospital;
- Services of a surgeon for circumcision in the hospital; and
- Physician services.
Note: If the newborn child is discharged at the same time as the mother, then the charges for the services rendered for the child are subject to coinsurance only. The mother's claims are subject to the deductible and coinsurance. If the newborn child remains in the hospital longer than the mother, the claims for the child apply to his or her own deductible and coinsurance limits if the member has not already met the family limits.
Note: If your covered dependent child gives birth, only the services for your dependent child are covered. Your newborn grandchild is not eligible for coverage.
Room and board and other services, supplies and anesthetics.
Diagnostic screenings not subject to precertification or notification include:
For cancer treatment.
Contraceptive services and devices including, but not limited to:
- Diaphragm and intrauterine device and related physician services;
- Voluntary sterilization including vasectomy, tubal ligation, sterilization implants and surgical sterilizations;
- Injectables such as Depo-Provera; and
- Surgical implants for contraception, such as Mirena or Norplant.
Nutritional counseling is covered by a licensed dietitian and/or licensed nutritionist for diabetes, bulimia, anorexia nervosa and morbid obesity.
Durable Medical Equipment
Durable medical equipment means equipment that meets all of the following:
- It is for repeated use and is not a consumable or disposable item;
- It is used primarily for a medical purpose; and
- It is appropriate for use in the home.
Some examples of durable medical equipment are:
- Appliances that replace a lost body part or organ or help an impaired organ or part;
- Orthotic devices such as arm, leg, neck and back braces;
- Hospital-type beds;
- Equipment needed to increase mobility, such as a wheelchair;
- Respirators or other equipment for the use of oxygen; and
- Monitoring devices (e.g., blood glucose monitor).
Each Claims Administrator decides whether to cover the purchase or rental of the equipment based on coverage guidelines. Changes made to your home, automobile or personal property are not covered. Rental coverage is limited to the purchase price of the durable medical equipment. Replacement, repair and maintenance are covered only if:
- They are needed due to a change in your physical condition; or
- It is likely to cost less to buy a replacement than to repair the existing equipment or rent similar equipment.
Care and treatment of the feet, if afflicted by severe systemic disease. Routine care such as removal of warts, corns or calluses; the cutting and trimming of toenails; and foot care for flat feet, fallen arches and chronic foot strain is covered only if needed due to severe systemic disease.
Aetna and Anthem BlueCross BlueShield plans cover the services of a podiatrist for the treatment of a disease or injury, including the treatment of corns, calluses, keratoses, bunions and ingrown toenails.
Gender Affirmation Services
For gender affirmation treatment benefits for members with gender dysphoria, the criteria that are used for determining the medical necessity of services for the diagnosis and treatment are based on the 7th edition of the clinical guidelines set forth by the World Professional Association for Transgender Health (WPATH) in their Standards of Care document. However, not all of the services included in WPATH are covered. Please see below for those services that are generally covered and those services that are not covered.
Many of the services noted below require pre-service authorization. Contact the Plan's Member Services for details.
It is strongly recommended that you call the applicable claims administrator before receiving any related services to ensure that the services you seek are covered under the Plan.
Generally, covered expenses include:
- Outpatient office visits
- Hormone therapy (and any subsequent associated risks) is covered under the pharmacy benefit (refer to the Prescription Drugs section for coverage information and any pre-service authorization instructions)
- Puberty suppression
- Voice modification and communication therapy
- Genital surgery and surgery to change secondary sex characteristics (including but not limited to thyroid chondroplasty, bilateral mastectomy, and augmentation mammoplasty) when the treatment plan conforms to the most recent edition of the World Professional Association for Transgender Health: Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Inpatient hospital services or treatment require pre-service authorization
- Reconstructive and complementary procedures (including but not limited to tracheal shave, male chest reconstruction, pectoral implants, gluteal augmentation, hair removal and hair transplants) according to the most recent edition of the World Professional Association for Transgender Health: Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. The Plan will review appropriateness of treatment. Inpatient hospital services or treatment require pre-service authorization.
- All preventive care is covered regardless of sex assigned at birth.
Note that all covered expenses are subject to plan pre-authorization limits and WPATH eligibility criteria.
- Services performed solely for beautification or to improve appearance;
- Charges for services or supplies that are not based on the guidelines set forth by the WPATH.
- Donor sperm and eggs
If a member has followed all of the criteria and clinical guidelines outlined in the WPATH Standards of Care, the plan will not cover costs related to reversal procedures or services. However, complications of procedures derived from reversal surgeries or treatments that are medically necessary will be covered.
Gene Therapy Services
Anthem BlueCross BlueShield: The Plan includes benefits for gene therapy services, when Anthem approves the benefits in advance through precertification. To be eligible for coverage, services must be medically necessary and performed by an approved provider at an approved treatment center. Even if a provider is an in-network provider for other services it may not be an approved provider for certain gene therapy services. Please call Anthem Member Services to find out which providers are approved providers. (When calling Member Services, ask for the transplant case manager for further details.)
Your Plan does not include benefits for services determined to be experimental/investigational or services provided by a non-approved provider or at a non-approved facility.
Hearing aids are covered, regardless of the reason for hearing loss.
Home Health Care (Combined with Private-Duty Nursing)
The following covered services must be given by a home health care agency:
- Temporary or part-time skilled nursing care by or supervised by a registered nurse (RN) or licensed practical nurse (LPN)
- Medical social services provided by, or supervised by, a qualified physician or social worker if your physician certifies with the plan that the medical social services are necessary for the treatment of your medical condition
Covered services are limited to 200 visits each calendar year (combined visits with private-duty nursing), and you must notify the plan in advance. Each period of home health aide care of up to eight hours given in the same day counts as one visit. Each visit by any other member of the home health team will count as one visit. Multiple services provided on the same day count as one visit and are billed by the same provider on the same bill. Visits may be increased with prior approval from your health plan.
Hospice services for a participant who is terminally ill include:
- Room and board coverage limited to expenses for the regular daily charge made by the hospital for a semiprivate room (or private room when medically appropriate or if it is the only room type available);
- Other services and supplies prescribed by a physician to keep the patient comfortable while in hospice care;
- Part-time nursing care by or supervised by an RN or LPN;
- Home health care services as shown under home health care; the limit on the number of visits shown under home health care does not apply to hospice patients;
- Counseling for the patient and covered dependents;
- Pain management and symptom control; and
- Bereavement counseling.
Bereavement counseling must be provided by a licensed counselor. Services for the patient must be given in an inpatient hospice facility or in the patient's home. The physician must certify that the patient is terminally ill with six months or less to live.
Anthem BlueCross BlueShield: You are eligible for hospice care if your doctor and hospice medical director certify that you are terminally ill and likely have less than twelve (12) months to live. You may access hospice care while participating in a clinical trial or continuing disease modifying therapy, as ordered by your treating provider. Disease modifying therapy treats the underlying terminal illness.
The services and supplies listed below are covered services when given by a hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include:
- Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care.
- Short-term Inpatient hospital care when needed in periods of crisis or as respite care.
- Skilled nursing services, home health aide services, and homemaker services given by or under the supervision of a registered nurse.
- Services and counseling services from a licensed social worker.
- Nutritional support such as intravenous feeding and feeding tubes.
- Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist.
- Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition, including oxygen and related respiratory therapy supplies.
- Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the member's death. Bereavement services are available to surviving members of the immediate family for one year after the member's death. Immediate family means your spouse/partner, children, stepchildren, parents, brothers and sisters.
Aetna and Anthem BlueCross BlueShield: Hospital services include:
- Room and board: Covered expenses are limited to the regular daily charge made by the hospital for a semiprivate room (or private room when medically appropriate);
- Other services and supplies, including:
- Intensive or special care facilities when medically appropriate;
- Visits by your physician while you are confined;
- General nursing care;
- Surgical, medical and obstetrical services;
- Use of operating rooms and related facilities;
- Medical and surgical dressings, supplies, casts and splints;
- Drugs and medications;
- Intravenous injections and solutions;
- Nuclear medicine; and
- Preoperative care and post-operative care:
Emergency room services are covered only if determined to be medically appropriate and there is not a less intensive or more appropriate place of service, diagnostic or treatment alternative that could be used. If your health plan, at its discretion, determines that a less intensive or more appropriate treatment could have been given, then no benefits are payable.
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable). Authorizations are required for longer stays.
Infertility Treatment and Cryopreservation
Precertification is recommended for treatment of infertility. However, no penalties apply if the treatment is received without precertification.
In order to be eligible for fertility benefits you must be a covered employee, spouse/partner or eligible dependent ("covered person") under a Citi medical plan
- Basic infertility expenses:
- Covered expenses include charges made by a physician to diagnose and to surgically treat the underlying medical cause of infertility. These expenses do not count toward the medical lifetime fertility maximum.
- Comprehensive infertility services benefits:
- Advanced reproductive technology (ART) benefits: ART is defined as:
- In vitro fertilization (IVF) cycles, including freeze-all cycle (fertilization and culture of embryo)
- Reciprocal IVF cycles
- Intrauterine embryo lavage
- Embryo transfer
- Elective single embryo transfer
- Artificial insemination
- Gamete intrafallopian tube transfer (GIFT)
- Zygote intrafallopian tube transfer (ZIFT)
- Low tubal ovum transfer
- Assisted hatching
- Pre-implantation genetic diagnosis (PGD) and screening (PGS), when it is medically necessary (subject to medical criteria)
- Evaluation by a reproductive endocrinologist or infertility specialist, drug therapy, and intracytoplasmic sperm injection (ICSI)
- Cryopreserved embryo transfers
- Oocyte (Egg) thaw cycles
- ART services for procedures that are covered expenses including charges associated with storage and procurement of partner's sperm for ART and Testis Biopsy, when the partner is also covered under the Plan
- Sperm sourcing includes specialized sperm retrieval techniques (including vasal sperm aspiration, microsurgical epididymal sperm aspiration (MESA), percutaneous epididymal sperm aspiration (PESA), electroejaculation, testicular sperm aspiration (TESA), microsurgical testicular sperm extraction (TESE), seminal vesicle sperm aspiration and sperm recovery from bladder or urine for retrograde ejaculation are considered medically necessary to overcome anejaculation or azoospermia
- Medically Necessary: Cryopreservation of sperm, oocytes or embryos is considered medically necessary for members undergoing infertility due to chemotherapy, pelvic radiotherapy or other gonadotoxic therapies, with no storage time limitation when approved and covered under the plan. Gonadotoxic treatments include chemotherapy, radiation, conditions, and surgical resection (for treatment of disease or gender affirmation treatment.
- For IVF: All cryopreservation services are provided for members undergoing IVF.
- Elective: Cryopreservation of oocytes when being done electively and not for medical reasons is covered, but the storage limitation will be for the 1st year and the cost of this service will apply to the infertility lifetime maximum.
- Infertility services, except as described under Covered Services.
- The plan does not cover charges for the storage of cryopreserved embryos or oocytes after the first year, or storage of sperm unless medically necessary.
- Covered services do not include the costs associated with surrogate mothers and the costs of donating donor eggs or services rendered to a non-covered member. Payment for charges associated with the care of an eligible covered person under this plan who is participating in a donor IVF program.
- Third-Party Donors: The purchase of donor sperm and any charges for the storage of sperm; the purchase and storage of donor eggs and any charges associated with care of the donor required for donor egg retrievals or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier.
- Reversal of sterilization surgery.
Medical expenses for infertility treatment are covered up to a covered person's lifetime maximum of $24,000. Only expenses for elective cryopreservation, advanced services (e.g., IVF, GIFT, ZIFT) and comprehensive services (e.g., artificial insemination) accumulate toward the lifetime maximum.
Expenses for diagnosis and treatment of the underlying medical condition do not count toward the lifetime maximum.
Prescription drug expenses associated with infertility treatment and elective cryopreservation are covered up to a lifetime maximum of $7,500 per covered person under the Plan, as outlined in the Prescription Drugs section.
Each HMO offers different infertility coverage and limits, if they offer any such coverage at all. Check with your HMO for details of infertility coverage.
Intensive Outpatient Program
Structured, multidisciplinary behavioral health treatment that provides a combination of individual, group and family therapy in a program that operates no less than 3 hours per day, 3 days per week. Out-of-Network Facility-based Programs must occur at Facilities that are both licensed and accredited.
X-rays or tests for diagnosis or treatment.
Licensed Counselor Services
Services of a licensed counselor for mental health and substance abuse treatment.
- Surgical supplies (such as bandages and dressings); supplies given during surgery or a diagnostic procedure are included in the overall cost for that surgery or diagnostic procedure; and
- Blood or blood derivatives:
Aetna and Anthem BlueCross BlueShield
- Autologous blood donation: The donation of your own blood for use during a scheduled covered surgical procedure;
- Directed blood donation: The donation of blood by a person chosen by the patient to donate blood for the patient's use during a scheduled covered surgical procedure;
- Autologous or directed blood donation prior to a scheduled surgery when it generally requires blood transfusions and the provider/organization that obtains and processes the blood makes a charge that the patient is legally obligated to pay; and
- Aetna: Blood, blood products, processing, storage and administration. Blood and blood products such as platelets or plasma are reimbursable. Blood product processing fees (typing, serology and cross-matching and blood storage) are also reimbursable. However, transportation charges are included in the reimbursement for the product itself and are not separately reimbursable. Note: Routine harvesting and storage from stem cells from newborn cord blood is not covered. However, Aetna covers stem cells for hematopoietic cell transplant when deemed medically necessary according to the following criteria: Aetna considers compatibility testing of prospective donors who are close family members (first-degree relatives [i.e., parents, siblings and children] or second-degree relatives [i.e., grandparents, grandchildren, uncles, aunts, nephews, nieces, half-siblings]) and harvesting and short-term storage of peripheral stem cells or bone marrow from the identified donor medically necessary when an allogeneic bone marrow or peripheral stem cell transplant is authorized by Aetna.
- Aetna considers umbilical cord blood stem cells an acceptable alternative to conventional bone marrow or peripheral stem cells for allogeneic transplant.
- Aetna considers medically necessary the short-term storage of umbilical cord blood for a member with a malignancy undergoing treatment when there is a match. Note: The harvesting, freezing and/or storing of umbilical cord blood of non-diseased persons for possible future use is not considered treatment of disease or injury. Such use is not related to the person's current medical care.
- Anthem BlueCross BlueShield: Blood, blood products, processing, storage and administration. Blood and blood products such as platelets or plasma are reimbursable. Blood product processing fees (typing, serology, cross-matching and blood storage) are also reimbursable. However, transportation charges are included in the reimbursement for the product itself and are not separately reimbursable. Blood and blood product administration services are reimbursable only on an outpatient basis when billed hourly or at a flat rate with total eligible charges capped at the average approved semiprivate room rate.
The use of umbilical cord blood progenitor cell transplantation is considered medically necessary for selected individuals when all of the following criteria are met:
- One or two donor cord unit(s) are used for a single recipient;
- The total nucleated cell (TNC) count is equal to or greater than 2.3 x 107 per kg; and
- The umbilical cord blood stem cell unit(s) is used for an allogeneic stem cell transplant for an approved indication and the appropriate stem cell transplant criteria are met.
Collection and storage of cord blood is considered medically necessary only when an allogeneic transplant is imminent for an identified recipient and the above criteria are met. Storage will only be authorized at centers approved by one of the following accreditation bodies:
Investigational and Not Medically Necessary: The use of umbilical cord blood progenitor cell transplantation is considered investigational and not medically necessary when it does not meet the criteria listed above.
Prophylactic collection and storage of umbilical cord blood is considered investigational and not medically necessary when proposed for an unspecified future use for an autologous stem cell transplant in the original donor or for an unspecified future use as an allogeneic stem cell transplant in a related or unrelated donor.
Medical Transportation Services
Covered expenses for ground ambulance include charges for transportation:
- To the first hospital where treatment is given in a medical emergency;
- From one hospital to another hospital in a medical emergency when the first hospital does not have the required services or facilities to treat your condition;
- From hospital to home or to another facility when medically necessary according to health plan clinical guidelines;
- From home to hospital for covered inpatient or outpatient treatment when medically necessary according to health plan clinical guidelines; and
- When during a covered inpatient stay at a hospital, skilled nursing facility or acute rehabilitation hospital, an ambulance is required to safely and adequately transport you to or from inpatient or outpatient medically necessary treatment.
- Air ambulance requiring a transport to a hospital or from one hospital to the nearest hospital because:
- A covered member is injured/stricken by illness more than 200 miles from their home, and
- Need for care is determined by the current ordering provider to be longer than seven days, and
- Need for care meets the utilization review criteria completed by the Aetna or Anthem clinical team, and
- A commercial flight is deemed as not medically appropriate.
- In-network ambulances should be utilized in all circumstances, network permitting.
- Air ambulance is not covered for transport that is:
- For short-term illness or injury (less than seven days of ongoing inpatient medical care needed),
- For illness or injury not requiring ongoing covered inpatient medical care/rehabilitation stay,
- For custodial services or any care that does not meet medical requirements for coverage,
- For location less than 200 miles from home region, or
- The current facility determines the covered member is not stable to travel.
In extremely rare occasions, exceptions may be made based on the Medical Director discretion.
Morbid Obesity Expenses (Non-HMO/PPO Plans)
Covered medical expenses include charges made on an inpatient or outpatient basis by a hospital or a physician for the surgical treatment of morbid obesity of a covered person. Limitations apply. For more information, contact your plan directly.
Dietician/nutritionist coverage is also available for morbid obesity. See "Dietitian/Nutritionist".
Services of a licensed or certified nurse-midwife. Maternity-related benefits are payable on the same basis as services given by a physician.
Services of a licensed or certified nurse practitioner acting within the scope of that license or certification. Benefits are payable on the same basis as covered services given by a physician.
Oral Surgery/Dental Services
The plan pays first (the primary plan) for oral surgery if needed as a necessary, but incidental, part of a larger service in treatment of an underlying medical condition.
The following oral surgeries are considered medical in nature and covered under the medical plan as necessary:
- Treat a fracture, dislocation or wound;
- Cut out:
- Teeth partly or completely impacted in the bone of the jaw;
- Teeth that will not erupt through the gum;
- Other teeth that cannot be removed without cutting into bone;
- The roots of a tooth without removing the entire tooth; and
- Cysts, tumors or other diseased tissues.
- Cut into gums and tissues of the mouth. This is covered only when not done in connection with the removal, replacement or repair of teeth;
- Alter the jaw, jaw joints or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement;
- If oral surgery/dental services are needed in connection with an accident or injury:
- If crowns, dentures, bridges or in-mouth appliances are installed due to injury, covered expenses only include charges for:
- The first denture or fixed bridgework to replace lost teeth;
- The first crown needed to repair each damaged tooth; and
- An in-mouth appliance used in the first course of orthodontic treatment after the injury.
- Any such teeth must have been free from decay or in good repair, and are firmly attached to the jaw bone at the time of the injury.
- Anthem BlueCross BlueShield accepts the following oral surgeries as medical in nature and covered under the medical plan as necessary:
Corrective surgery is covered if medically necessary for purposes of chewing and speaking.
The following services and supplies are covered only if needed because of accidental injury to sound and natural teeth that happened to you or your dependent while covered under this plan.:
- Oral surgery;
- Full or partial dentures;
- Fixed bridgework;
- Prompt repair to sound and natural teeth; and
Keep in mind that qualified transplant procedures will be covered at the out-of-network level when performed at a facility that is not deemed a Center of Excellence (COE) or Blue Distinction Center (BDC) through BlueCross BlueShield. Contact your plan for more information about locating a COE (or BDC).
Your Claims Administrator must be notified before the scheduled date (or as soon as reasonably possible) of any of the following:
- The evaluation;
- The donor search;
- The organ procurement/tissue harvest; and
- The transplant procedure.
- Anthem BlueCross BlueShield and Aetna do not require precertification within a certain number of days.
Donor Charges for Organ/Tissue Transplants
- In the case of an organ or tissue transplant, donor charges are considered covered expenses only if the recipient is a covered person under the plan. If the recipient is not a covered person, no benefits are payable for donor charges.
- The search for bone marrow/stem cells from a donor who is not biologically related to the patient is not considered a covered service unless the search is made in connection with a transplant procedure arranged by a designated transplant facility.
If a qualified procedure, listed in this section, is medically necessary and performed at a designated transplant facility, the "medical care and treatment" and "transportation and lodging" provisions described in this section apply.
- Heart transplants;
- Lung transplants;
- Heart/lung transplants;
- Liver transplants;
- Kidney transplants;
- Pancreas transplants;
- Kidney/pancreas transplants;
- Bone marrow/stem cell transplants; and
- Other transplant procedures when your Claims Administrator determines that they are medically necessary to perform the procedure as a designated transplant.
For Aetna, transplant services are covered as long as the transplant is not experimental or investigational and has been approved in advance. Transplants must be performed in hospitals specifically approved and designated by Aetna to perform the procedure. The Institutes of Excellence (IOE) network is Aetna's network of providers for transplants and transplant-related services, including evaluations and follow-up care. Each facility has been selected to perform only certain types of transplants, based on its quality of care and successful clinical outcomes.
For Aetna plans (Choice Plan and High Deductible Plan with HSA), a transplant will be covered as an in-network service only if performed in a facility that has been designated as an IOE facility for the type of transplant in question. Any facility that is not specified as an Institute of Excellence network facility is considered a non-participating facility for transplant-related services, even if the facility is considered a participating facility for other types of services. With the In-Network Only Plan, any approved IOE or a participating Aetna facility.
The National Medical Excellence (NME) Program® will coordinate all solid organ, bone marrow and CAR-T and T-cell therapy services, and other specialized care you need.
Many pre and post-transplant medical services, even routine ones, are related to and may affect the success of your transplant. While your transplant care is being coordinated by the NME Program, all medical services must be managed through NME so that you receive the highest level of benefits at the appropriate facility. This is true even if the covered service is not directly related to your transplant.
Members must receive precertification for transplant procedures. When a member or physician calls Aetna to precertify a transplant evaluation, a case nurse will direct him or her to an IOE facility.
For Anthem BlueCross BlueShield (Choice Plan and High Deductible Health Plan with HSA), coverage is based on the facility used for the transplant. If a Blue Distinction Center (BDC or BDC+) is used, the service will be covered at 80% with access to the travel and lodging benefit. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies, including the Center for International Blood and Marrow Transplant Research (CIBMTR), the Scientific Registry of Transplant Recipients (SRTR), and the Foundation for the Accreditation of Cellular Therapy (FACT), and are subject to periodic re-evaluation as criteria continue to evolve. Call Anthem at 1 (855) 593-8123 for additional coverage information as well as assistance in locating a BDC or BDC+ facility. With the In-Network Only Plan, any network provider will be covered.
Precertification is required for these services. Services performed at BDC or BDC+ facilities are covered at 80% with access to the travel and lodging benefit; all other facilities are covered at 60% with no access to the travel and lodging benefit under the Choice Plan and High Deductible Health Plan with HSA. With the In-Network Only Plan, transplants are covered at 100% after deductible with a $400 copay per confinement for services in an approved network facility.
Medical Care and Treatment
Covered expenses for services provided in connection with the transplant procedure include:
- Pre-transplant evaluation for one of the procedures listed above;
- Organ acquisition and procurement;
- Hospital and physician fees;
- Transplant procedures;
- Follow-up care for a period of up to one year after the transplant;
- Search for bone marrow/stem cells from a donor who is not biologically related to the patient. If a separate charge is made for bone marrow/stem cell search, a maximum benefit of $25,000 is payable for all charges made in connection with the search. Note: Coverage of donor costs is generally limited to medically necessary procedures, inpatient confinement (e.g., semiprivate room and board in an acute hospital setting) and a postoperative global period.
When available, the plan will assist the patient and family with travel and lodging arrangements when a qualified procedure, listed in this section, is medically necessary and performed at a designated Center of Excellence facility. See "Travel and Lodging".
If the covered person chooses not to receive his or her care in connection with a qualified procedure pursuant to this organ/tissue transplant section, the services and supplies received by the covered person in connection with that qualified procedure will be paid under the plan if and to the extent covered by the plan without regard to this organ/tissue transplant section.
Keep in mind that qualified orthopedic procedures will be covered at the out-of-network level when performed at a facility that is not deemed a Center of Excellence (COE) or a Blue Distinction Center (BDC or BDC+) through BlueCross BlueShield. Contact Member Services at your health carrier for more information about locating a COE (or BDC).
If a qualified procedure, listed in this section, is medically necessary and performed at a designated Center of Excellence facility, the "medical care and treatment" and "transportation and lodging" provisions described in this section apply.
- Total knee replacement;
- Total hip replacement; and
- Spine surgery (discectomy, spinal fusion, spinal decompression).
When available, the plan will assist the patient and family with travel and lodging arrangements when a qualified procedure, listed in this section, is medically necessary and performed at a designated Center of Excellence facility. See "Travel and Lodging".
For Anthem BlueCross BlueShield, coverage is based on the facility used for the transplant. If a Blue Distinction Center (BDC or BDC+) is used, the procedure will be covered at 80%. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies and are subject to periodic re-evaluation as criteria continue to evolve. Call Anthem at 1 (855) 593-8123 for additional coverage information as well as assistance in locating a BDC or BDC+ facility.
Precertification is required for these services. Services performed at BDC or BDC+ facilities are covered at 80% benefit; all other facilities are covered at 60%. If care at a BDC or BDC+ facility requires you to travel 75 miles or more from your home, you'll have access to a travel and lodging benefit, with a maximum of $10,000 per surgery or treatment. There is no travel and lodging benefit for services rendered outside of a Blue Distinction Center.
Training by a licensed optometrist or an orthoptic technician. The plan covers a hidden ocular muscle condition where the eyes have a tendency to under-converge or over-converge. Manifest conditions of exotropia (turning out) or esotropia (turning in) are covered. Coverage is limited to 32 visits per calendar year.
Outpatient Occupational Therapy
Outpatient Physical Therapy
Partial Hospitalization Program
Structured, multidisciplinary behavioral health treatment that offers nursing care and active individual, group and family treatment in a program that operates no less than six hours per day, five days per week. Out-of-Network Facility-based Programs must occur at Facilities that are both licensed and accredited.
Prescribed drugs and medicines for inpatient services.
Covered expenses include:
- Routine physical exam (including a well-woman exam), subject to frequency limits;
- Routine immunizations;
- Smoking cessation; and
- Screening and counseling for obesity for adults and children.
A $250 calendar-year maximum applies to out-of-network services per covered family member. (Choice Plan only). Each participant has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible, and expenses that exceed the $250 credit are covered at 60% of MAA.
For more specific information regarding what is considered to be Preventive Care, see "Preventive Care".
Private-Duty Nursing Care (combined with Home Health Care)
Private-duty nursing care is given on an outpatient basis by an RN, LPN or licensed vocational nurse (LVN). This service must be approved by your Claims Administrator.
- Aetna Choice Plan and Anthem BlueCross BlueShield Choice Plan: A combined in-network and out-of-network maximum benefit of 200 visits per calendar year (combined with home health care visits) applies. One visit is equal to one eight-hour shift. Inpatient private-duty nursing is not covered. Precertification is required. Additional visits may be covered if approved in advance by your plan.
Services of a psychologist for psychological testing and psychotherapy.
Defined as short-term occupational therapy, physical therapy, speech therapy and spinal manipulation:
- Services of a licensed occupational or physical therapist, provided the following conditions are met:
- The therapy must be ordered and monitored by a licensed physician (when required by state law); and
- The therapy must be given according to a written treatment plan approved by a licensed physician. The therapist must submit progress reports at the intervals stated in the treatment plan;
- Services of a licensed speech therapist. These services must be given to restore speech lost or impaired due to one of the following:
- Surgery, radiation therapy or other treatment that affects the vocal chords;
- Cerebral thrombosis (cerebral vascular accident);
- Brain damage due to accidental injury or organic brain lesion (aphasia);
- Accidental injury that happens while the person is covered under the plan;
- Chronic conditions (such as cerebral palsy or multiple sclerosis); or
- Developmental delay (including Down syndrome).
- Services of a hospital or rehabilitation facility for room, board, care and treatment during a confinement. Coverage for room and board is limited to expenses for the regular daily charge made by the hospital for a semiprivate room (or private room when medically appropriate or if it is the only room type available).
- Inpatient rehabilitative therapy is a covered service only if intensive and multidisciplinary rehabilitation care is necessary to improve the patient's ability to function independently.
- Services of a hospital, comprehensive outpatient rehabilitative facility (CORF), or licensed therapist as described above.
- Coverage includes short-term cardiac rehabilitation following angioplasty, cardiovascular surgery, congestive heart failure or myocardial infarction.
- Coverage includes short-term pulmonary rehabilitation for the treatment of reversible pulmonary disease.
- All visit limits apply for both in-network and out-of-network services, wherever the services are being provided, for example, at home, at a therapist's office or in a free-standing therapy facility.
- Choice Plan and High Deductible Plan with HSA: Spinal manipulation therapy is limited to 20 visits per calendar year. Physical and occupational therapies combined are limited to 60 visits per calendar year. Speech therapy is limited to 90 visits per calendar year except when there is a diagnosis of mental health, behavioral health or substance abuse, including Autism Spectrum Disorder.
Covered expenses include:
A $250 calendar year maximum applies to out-of-network services per covered family member (Choice Plan only).Each participant has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible, and expenses that exceed the $250 credit are covered at 60% of MAA
Residential Treatment Center/Facility
A provider licensed and operated as required by law, which includes:
- Room, board and skilled nursing care (either an RN or LVN/LPN) available on-site at least eight hours daily with 24-hour availability;
- A staff with one or more doctors available at all times;
- Residential treatment that takes place in a structured facility-based setting;
- The resources and programming to adequately diagnose, care and treat a psychiatric and/or substance use disorder;
- Facilities that are designated residential, subacute or intermediate care and may occur in care systems that provide multiple levels of care; and
- Is fully accredited by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the National Integrated Accreditation for Healthcare Organizations (NIAHO) or the Council on Accreditation (COA).
The term Residential Treatment Center/Facility does not include a provider, or that part of a provider, used mainly for:
Skilled Nursing Facility Services
- Room and board: Covered expenses for room and board are limited to the facility's regular daily charge for a semiprivate room.
- Other services and supplies.
Covered services are limited to the first 120 days of confinement each calendar year.
Services of a physician given for the detection or correction (manipulation) by manual or mechanical means of structural imbalance or distortion of the spine. Routine maintenance and adjustments are not a covered service under this plan.
Services for surgical procedures.
- Reconstructive surgery to improve the function of a body part when the malfunction is the direct result of one of the following:
- Birth defect;
- Surgery to treat a sickness or accidental injury; or
- Accidental injury that happens while the person is covered under the plan;
- Reconstructive breast surgery following a mastectomy including areolar reconstruction and the insertion of a breast implant. The plan covers expenses associated with reconstructive surgery following a mastectomy, expenses for reconstructive surgery on the other breast to achieve symmetry, the cost of prostheses and the cost for treatment of physical complications at any stage of the mastectomy, including lymphedemas. Plan deductibles, coinsurance and copays will apply; and
- Reconstructive surgery to remove scar tissue on the neck, face or head if the scar tissue is due to sickness or accidental injury that happens while the person is covered under the plan.
Covered expenses for assistant-surgeon services are limited to 20% of the amount of covered expenses for the primary surgeon's charge for the surgery for non-HMO/PPO plans. An assistant-surgeon generally must be a licensed physician. Physician's-assistant services are not covered if billed on his or her own behalf. (Aetna and Anthem BlueCross BlueShield cover assistant surgeon services for certain surgeries. Aetna covers registered nurses acting as assistant surgeons for certain surgeries. Contact Anthem BlueCross BlueShield for information about which providers qualify as assistant surgeons.)
Multiple Surgical Procedure Guidelines
If you are using an out-of-network provider for a surgical procedure, the following multiple surgical procedure guidelines will apply.
If more than one procedure will be performed during one operation — through the same incision or operative field — the plan will pay according to the following guidelines:
- First procedure: The plan will allow 100% of the negotiated rate or MAA.
- Second procedure: The plan will allow 50% of the negotiated rate or MAA.
- Third and additional procedures: The plan will allow 50% of the negotiated rate or MAA for each additional procedure.
- Bilateral and separate operative areas: The plan will allow 100% of the negotiated rate or MAA for the primary procedure, 50% of the negotiated rate or MAA for the secondary procedure, and 50% of the negotiated rate or MAA for tertiary/additional procedures.
If billed separately, incidental surgeries will not be covered. An incidental surgery is a procedure performed at the same time as a primary procedure and requires few additional physician resources and/or is clinically an integral part of the performance of the primary procedure.
Termination of Pregnancy
- Voluntary (i.e., abortion);
- Involuntary (i.e., miscarriage); and
- Travel and Lodging Expenses related to voluntary termination of pregnancy (i.e., abortion). The plan will assist the patient and family with travel and lodging arrangements. Services must be received at an in-network facility. See "Travel and Lodging" below.
Note: In light of the U.S. Supreme Court's recent ruling in Dobbs v. Jackson Women's Health, any related claim submitted for payment shall be subject to additional review to determine if payment is legally permitted under applicable state law. If upon subsequent review, a paid claim is determined to be impermissible under applicable law, the Plan shall be reimbursed upon demand.
Temporomandibular Joint Syndrome (TMJ)
Surgical treatment of TMJ does not include treatment performed by prosthesis placed directly on the teeth or physical therapy for TMJ.
Transsexual Surgery, Sex Change or Transformation
The plan does cover procedures, treatments and related services designed to alter a participant's physical characteristics from his or her biologically determined sex to those of another sex.
Travel and Lodging
- For covered medical services, the Plan will pay travel and lodging (T&L) expenses if such services cannot be obtained from a qualified provider within a 75-mile radius of the covered individual's residence, subject to certain conditions.
- For eligible T&L expenses, there is a $10,000 lifetime reimbursement limit per covered individual, per covered service. "Per covered service" relates to each event; for instance, the $10,000 lifetime limit will apply for a single hip replacement as opposed to a lifetime limit for all hip replacements.
- Covered travel includes transportation for the patient and one companion by car at the current federal rate of reimbursement, plane (economy/coach only), train, taxi, bus, or car rental (excluding mileage). There can be no element of recreation or vacation in the travel away from home to receive medical care.
- Lodging away from home includes coverage for the patient and one companion up to the IRS limit of $50 per day, per person ($100 per day for patient and companion). Lodging must be primarily for and essential to receiving the covered medical service and may not be considered "lavish or extravagant" per IRS rules. Meals, groceries, and personal care items are not covered.
- For covered services that require precertification/prior authorization (e.g., bariatric surgery), any related T&L expenses do not require precertification/prior authorization.
- To be eligible for coverage, T&L expenses must be for medical services that are covered under the Plan, legal in the state in which they are performed, and received from a qualified provider, including a doctor or other licensed health care professionals.
- To have eligible T&L expenses apply to your deductible, and receive reimbursement if applicable, you must complete and submit a claim form and required documentation/receipts within two years of the date of service.
- Please be aware that our travel benefits cover travel and lodging for any medical procedure that meets applicable conditions and subject to applicable limits, effectively as of January 1, 2022. If you are eligible for reimbursement for covered expenses incurred on or after January 1, 2022, please remember to submit a claim any time within two years after the expense was incurred.
Reversals are not covered.
Office visit charges for routine well-child care exams and immunizations based on guidelines from the American Medical Association.