VOB Advanced Benefits, Exclusions and Policies

Index

• Tricky Benefits

• 10 Most Common Exclusions

• Additional Waiting Periods

• Pre-Notification Requirements

  • Short-Term Policies

  • Cigna Policies

• Mental Health Benefits

  • STM Benefits

  • State Mandates

  • Applicable to All Plans

  • Serious Mental Illness List

  • Frequently Asked Questions

• Prescription Benefits

• Dental & Vision Benefits

• COVID Benefits

• Telehealth Benefits

• VOB Form Chart

Tricky Benefits

• Screening Mammogram: Search “mamm” on both the COI and state rider.

• Screening Colonoscopy: Search “colo” on both the COI and state rider.

• Routine Childcare & Immunizations: Search “routine childcare” in the COI; always search “immunizations” separately in both COI and state rider.

• COVID Tests, Vaccines, & Office Visits: Refer to the COVID state mandates spreadsheet.

• Pap Smears: Search “pap” and “cervical” in both COI and state rider.

10 Most Common Exclusions

• Bone & Joint Exclusion: Joint replacement or treatment of joints, spine, bones, or connective tissue (unless related to a covered injury).

• Foot Exclusion: Care/treatment of feet, orthopedic shoe devices, corns, calluses, bunions, toenails.

• Skin Exclusion: Treatment for acne, moles, skin tags, sebaceous gland disease, cysts, hypertrophic/atrophic skin conditions, nevus.

• Pregnancy Exclusion: Routine prenatal, pregnancy, childbirth, and postnatal care (exceptions for complications).

• Chiropractic Exclusion: Spinal manipulation or adjustment.

• Conception Exclusion: Any drug/procedure promoting or preventing conception (e.g., infertility treatment, sterilization, reversal).

• Sleep Exclusion: Treatment of sleep disorders.

• Allergy Exclusion: Allergy diagnosis/treatment, except emergency allergic reactions.

• Obesity Exclusion: Weight modification or obesity-related surgery.

• Routine Physical Exams: Not covered, except as state-mandated.

 

Additional Waiting Periods

Services with additional 3–6 month waiting periods include:

• Adenoidectomy

• Tonsillectomy

• Sinus or Nasal Septum Surgery

• Myringotomy (eardrum)

• Preventive Examination

• Tympanotomy (ear tubes)

• Herniorrhaphy (hernia)

• Cholecystectomy (gallbladder)

• Joint/Neck/Spine treatment

• Hysterectomy

• Cancer treatment (usually 30 days)

• Appendectomy

Pre-Notification Requirements

Short-Term Policies

Pre-notification required for:

• PET scans

• D&C, hysteroscopy, uterine bleeding dx

• Chemo/Radiation

• All inpatient admissions

• All outpatient surgeries (including laparoscopic)

• Biopsies (bone marrow, liver, kidney, lung)

• ER visits resulting in observation

 

Cigna Policies

Pre-note required for:

• All inpatient admissions

• All outpatient surgeries/procedures

• D&C, hysteroscopy, uterine bleeding dx

• Diagnostic/therapeutic radiology

• Home health

• PT/OT/ST

• DMME

• Prosthetics/orthotics

• Outpatient IV infusion & radiation therapy

Mental Health Benefits

STM Benefits

• Subject to deductible/coinsurance unless stated otherwise.

• Outpatient: 10 visit limit, $50 max.

• Inpatient: 31-day limit, $100 max.

 

State Mandates

Mandates may override STM limits. Examples:

• Serious vs. non-serious

• Chemical vs. alcohol

• Dollar/day limits

• Detoxification benefits

• Coverage variations

Applicable to All Plans

• Family-Group Therapy: Covered if tied to one diagnosed member.

• Group Therapy: Not covered on STM.

• Psychotherapy: Subject to M/A/C limits only for ADD, ADHD, anorexia, bulimia, Alzheimer’s.

• Lab/Pharmacology: Treated as medical unless psychotherapy.

• Psych Testing: As any other illness.

• RX: Processed with mental/nervous benefits if covered.

• ER Visit: Usually not M/A/C unless psychotherapy performed.

• Partial Hospitalization: Check state rider.

• Uncoded therapy (e.g. marital counseling): Not covered.

Serious Mental Illness List

Includes: anorexia, bulimia, bipolar, delusional disorder, major depressive disorder, OCD, panic disorder, schizo-affective disorder, schizophrenia.

Frequently Asked Questions

• Self or fully funded? Group = Self, STM = Fully.

• Licensing/accreditation? State license sufficient.

• Freestanding facilities? Yes.

• Residential treatment facilities? Doctor on staff + 24hr nursing.

• IOP/PHP benefits? Same as outpatient.

• Court-ordered eligible? Yes.

Prescription Benefits

• We do not handle RX for STM policies except Anchor.

• HiiQuote: Discount card only. Refer to SingleCare.

• Pivot: Coverage varies. Check AI. Refer to Cigna or Cerpass Rx.

• Anchor:

  • Value: Cerpass discount card only

  • Select: 2/month ($5 generic / $20 brand)

  • Maximum: 2/month ($10 generic / $30 brand)

• Premier: Discount card only.

• Healthy America: No RX coverage.

Dental & Vision Benefits

• We do not handle STM dental/vision benefits.

• Pivot: Renaissance Dental & Vision: 855-253-4664

• HiiQuote: Refer to HealthInsurance.com

COVID Benefits

• If a COVID rider is in the portal, follow that.

• Otherwise use the COVID State Mandate Guidance spreadsheet: Y:Drive → Public_Info → Product_Information → 1-All Carriers → COVID-19.

• Locate carrier tab and read red mandates at top.

Telehealth Benefits

• HiiQuote: Excluded unless mandated. Teladoc vendor available.

• Pivot: Varies by plan/state. NaviGo vendor available.

VOB Form Chart