State of Illinois - HealthLink

Section IV – Exclusions and Limitations
No benefits shall be payable under any part of this plan (unless specifically superseded under
any other section of this plan) with respect to:
1. Services and supplies which are not medically necessary; nor for charges for which the
covered person is not legally liable, or any expenses which exceed the usual and customary
(U&C) charges for the geographic area in which the expenses were incurred.
2. Any charges that are considered over usual and customary (U&C) for out-of-network
providers. Further explanation of what usual and customary (U&C) is will be found in
Definitions.
3. Any charges that are considered over usual and customary (U&C) for out-of-network
providers when Medicare reimbursement schedule (MAC) is utilized for services,
beginning January 1, 2014. See Definitions for additional explanation.
4. Any expenses for any condition or disability, which is due to injury or illness arising out of
or in the course of any occupation or employment for wage or profit and which would
entitle the covered person to any benefit under a Workers’ Compensation act, law or
similar legislation, including those situations whereby the covered person lawfully chose
not to be covered or waived or failed to assert his/her rights under a Workers’
Compensation law, act or similar legislation.
5. Any expenses for any conditions or services that are reimbursed by a third party.
6. Any service, procedure or supply not specifically identified as being covered under the plan.
7. Care of any injury or illness incurred while on active or reserve military duty. Care of any injury
or illness resulting from war, declared or undeclared, any act of war or any act of terrorism.
8. Convalescent care, custodial care, sanatoria care, care in residential and non-residential
treatment centers and nursing homes.
9. Any expenses for cosmetic surgery. Cosmetic surgery is beautification or aesthetic surgery
to improve an individual's appearance by surgical alteration of a physical characteristic.
Cosmetic surgery for psychiatric or psychological reasons, or to change family
characteristics or conditions due to aging is not covered. Benefits for cosmetic surgery and
related expenses are allowed only when such surgery is required as the result of accidental
injury, or congenital deformities evident in infancy and/or may become evident as the
individual grows and develops, or for reconstructive mammoplasty after partial or total
mastectomy when medically indicated.
10. Non-medical counseling or ancillary services, including but not limited to custodial
services, education, training, vocational rehabilitation, behavioral training, neurofeedback,
hypnosis, sleep therapy, employment counseling, return to work services, work hardening
programs, driving safety and services, training, educational therapy or non-medical
ancillary services for learning disabilities, developmental delays or mental retardation
except when deemed medically necessary under autism coverage.
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