ODS. Healthcare from your head to your toes.

Medical plan limitations and exclusions

Dependent eligibility

Dependents include a lawful spouse or registered domestic partner pursuant to the Oregon Family Fairness Act and children up to age 26.

Out-of-area children coverage

If your enrolled child(ren) resides outside the service area, we will extend benefits for treatment of an illness or injury, women’s routine healthcare (or preventive healthcare if available in the plan) and maternity services as if the care were rendered by a participating physician or provider. Out-of-area dependents may receive the in-network benefit level by using the travel network. If a travel network provider is not available, the services will be paid at the in-network benefit level if provided within a 30-mile radius of the child’s residence or at the closest appropriate facility. Fees charged by out-of-area providers will be reimbursed as the maximum plan allowance for those services.

Limitations

Six-month exclusion period applies to the following:

Myringotomy with tubes
Removal of tonsils or adenoids
Allergies
Sterilization
Elective procedures (procedures that can be reasonably postponed for the exclusion period)
Pre-existing conditions, even if they worsen or recur, unless the insured is under the age of 19

24-month exclusion period applies to the following:

Transplants (benefits are limited to an aggregate lifetime maximum benefit of $750,000)

Note: Your plan's exclusion period will be shortened one day for each day you had "creditable coverage" under another health plan, provided you do not have a 63-day lapse (or longer) in coverage immediately prior to your enrollment date in our plan.

In addition, the following limitations apply:

All medical and surgical admissions must be authorized by ODS
Mental illness treatment up to 20 outpatient visits, or 10 days each, for inpatient or residential services per plan year
Alcohol treatment up to 20 outpatient visits, or 10 days each, for inpatient or residential services per plan year
ODS will not pay benefits for covered expenses if you have any other coverage for those expenses
Hearing aid coverage limited to members under age 26 with a maximum benefit of up to $4,100 every 48 months
Rehabilitation benefits are limited to 15 inpatient days and 15 outpatient sessions per plan year
Hospice benefits are limited to 12 days of inpatient care; 170 hours/three months respite care
Vision benefits are limited to one visit per plan year for members under age 18, and one visit every two years up to $200 for members age 18 and over

The following services and treatments are excluded from coverage by ODS medical plans:

Services provided by a member of the patient’s immediate family
Services or supplies that are not medically necessary
Services and supplies for reversal of sterilization or infertility
Services and supplies for obesity, including complications arising out of such treatment, except for those rated A or B by the U.S. Preventive Services Task Force.
Surgery to alter the refractive character of the eye
Dental examinations and treatment, except as specifically listed
Massage or massage therapy
Services or supplies for the treatment of sexual dysfunction or inadequacy, or treatments related to sex-change procedures
Treatment of personality disorders
Experimental or investigational treatment
Services or supplies available in whole or in part under any city, county, state or federal law, except Medicaid
Charges above those considered the maximum plan allowance
Services or supplies for which an employer is required by law to provide benefits even if you choose not to accept those benefits (those exempt from state and federal workers’ compensation law will have 24 hour coverage)
Instruction programs, including, but not limited to, those to learn to self-administer drugs or nutrition, except as specifically provided for under the outpatient diabetic instruction benefit of ODS plans
Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control or education
Cosmetic services and supplies
Services and supplies associated with orthognathic surgery
Drugs for treatment of mental illness
Chemical dependency treatment, except for alcohol treatment

This is a benefit summary only. For a complete description of benefits, limitations, and exclusions, refer to your Member Handbook. Benefits are subject to changes to comply with subsequent state and federal guidance.