Mo. Code Regs. tit. 22 § 10-2.061

Current through Register Vol. 49, No. 21, November 1, 2024.

Section 22 CSR 10-2.061 - Plan Limitations

PURPOSE: This amendment removes the limitation on infertility treatment.

(1) Benefits shall not be payable for, or in connection with, any medical benefits, services, or supplies which do not come within the definition of covered charges. In addition, the items specified in this rule are not covered unless expressly stated otherwise and then only to the extent expressly provided herein or in 22 CSR 10-2.055 or 22 CSR 10-2.090.

(AA) Infusions received through a non-network provider.

(BB) Level of care greater than is needed for the treatment of the illness or injury.

(CC) Long-term care.

(DD) Maxillofacial surgery.

(EE) Medical care and supplies to the extent that they are payable under-

1. A plan or program operated by a national government or one (1) of its agencies; or

2. Any state's cash sickness or similar law, including any group insurance policy approved under such law.

(FF) Medical service performed by a family member- including a person who ordinarily resides in the subscriber's household or is related to the member, such as a spouse, parent, child, sibling, or brother/sister-in-law.

(GG) Military service-connected injury or illness- including expenses relating to Veterans Affairs or a military hospital.

(HH) Never events-never events on a list compiled by the National Quality Forum of inexcusable outcomes in a health care setting.

(II) Drugs that the pharmacy benefit manager (PBM) has excluded from the formulary and will not cover as a nonformulary drug unless it is approved in advance by the PBM.

(JJ) Non-medically necessary services.

(KK) Non-provider allergy services or associated expenses relating to an allergic condition, including installation of air filters, air purifiers, or air ventilation system cleaning.

(LL) Non-reusable disposable supplies.

(MM) Online weight management programs.

(NN) Other charges as follows:

1. Charges that would not otherwise be incurred if the subscriber was not covered by the plan;

2. Charges for which the subscriber or his/her dependents are not legally obligated to pay including but not limited to any portion of any charges that are discounted;

3. Charges made in the subscriber's name but which are actually due to the injury or illness of a different person not covered by the plan; and

4. No coverage for miscellaneous service charges including but not limited to charges for telephone consultations, administrative fees such as filling out paperwork or copy charges, or late payments.

(OO) Over-the-counter medications with or without a prescription including but not limited to analgesics, antipyretics, non-sedating antihistamines, unless otherwise covered as a preventive service.

(PP) Physical and recreational fitness.

(QQ) Private-duty nursing.

(RR) Routine foot care without the presence of systemic disease that affects lower extremities.

(SS) Services obtained at a government facility if care is provided without charge.

(TT) Sex therapy.

(UU) Surrogacy-pregnancy coverage is limited to plan member.

(VV) Telehealth site origination fees or costs for the provision of telehealth services are not covered.

(WW) Travel expenses.

(XX) Workers' Compensation services or supplies for an illness or injury eligible for, or covered by, any federal, state, or local government Workers' Compensation Act, occupational disease law, or other similar legislation.

22 CSR 10-2.061

Adopted by Missouri Register April 1, 2019/Volume 44, Number 7, effective 5/31/2019

Amended by Missouri Register April 1, 2020/Volume 45, Number 7, effective 5/31/2020

Amended by Missouri Register December 1, 2023/volume 48, Number 23, effective 1/1/2024, exp. 6/28/2024 (Emergency).

Amended by Missouri Register April 1, 2024/volume 49, Number 07, effective 5/31/2024.