Services Available or Provided from Other Sources Services for any condition, illness, or disease which should be covered by the United States government or any of its agencies, Medicare, any state or municipal government or any of its agencies except emergency care when there is a legal responsibility to provide it. • Services or supplies for military-related conditions, such as war, or any military action, which takes place after your coverage becomes effective. • Services received in a facility mainly meant to care for students, faculty, or employees of a college or other institution of learning. • Covered healthcare services provided to you when there is no charge to you or there would have been no charge to you absent this health plan. • Services if another entity or agency is responsible under state or federal laws, which are provided for the health of schoolchildren or children with disabilities. See Title 16, Chapters 21, 24, 25, and 26 of the R.I. General Laws. See also applicable regulations about the health of schoolchildren and the special education of children with disabilities or similar rules set forth by federal law or state law of applicable jurisdiction. • Services and supplies which are required under the laws of a state, other than Rhode Island, and are not provided under this health plan. All Other Exclusions • Services not approved by the FDA or other governing body. • Services we have not reviewed or we have not determined are eligible for coverage. • Services obtained through fraud or intentional misrepresentation. • Administrative service charges for: o missed appointments; o completion of claim forms; o additional fees, sometimes referred to as access fees, associated with concierge, boutique, or retainer practices; and o any other administrative charges. • Blood services for drawing, processing, or storage of your own blood, including any penalty fees related to blood services. • Continuation of a covered healthcare service or benefit as a result of a clerical error. • Custodial care, rest care, day care, or non-skilled care services. • Convalescent homes, nursing homes including non-skilled care, assisted living facilities, or other residential facilities. • Educational classes, unless listed as covered, and training services. • Exams or services that are required for or related to employment, education, marriage, adoption, insurance purposes, court order, or similar third parties when not medically necessary or when the benefit limit for the exam or service has been met. • Routine foot care, including the treatment of corns, bunions except capsular or bone surgery, calluses, the trimming of nails, the treatment of simple ingrown nails and other preventive hygienic procedures, except when performed to treat diabetic related nerve and circulation disorders of the feet. • Treatment of flat feet unless the treatment is a covered surgical service. • Telephone consultations, telephone services, or medication monitoring by phone, except for clinically appropriate telemedicine services as described in Section 3. • Healthcare services for work-related illnesses or injuries for which benefits are available under Workers’ Compensation , whether or not you are entitled to such benefits, unless: o you are self-employed, a sole stockholder of a corporation, or a member of a partnership; and o your illnesses or injuries were incurred in the course of your self-employment, sole stockholder, or partnership activities; and o you are not enrolled as an employee under a group health plan sponsored by another employer. • Services and supplies used for your personal appearance and/or comfort, whether or not prescribed by a physician and regardless of your condition. These services and supplies include, but are not limited to: o batteries, unless indicated as covered;
Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers Quality healthcare begins with a partnership between you and your primary care provider (PCP). When you need care, call your PCP, who will help coordinate your care. Your healthcare coverage under this plan is provided or arranged through our network of PCPs, specialists, and other providers. You’re encouraged to: • become involved in your healthcare by asking providers about all treatment plans available and their costs; • take advantage of the preventive health services offered under this plan to help you stay healthy and find problems before they become serious. Each member is required to provide the name of his or her PCP. However, if the name of a PCP is not provided with the application, your enrollment will not be delayed and your coverage will not be cancelled. How to Find a PCP or Other Providers Finding a PCP in our network is easy. To select a provider, or to check that a provider is in our network, please use the “Find a Doctor” tool on our website or call Customer Service. Please note: We are not obligated to provide you with a provider. We are not liable for anything your provider does or does not do. We are not a healthcare provider and do not practice medicine, dentistry, furnish health care, or make medical judgments.
