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MAP/MAP BASIC Exclusions
MAP BASIC covered benefits are limited to primary care visits at CommUnityCare, Lone Star Circle of Care, People’s Community Clinic, and El Buen Samaritano. MAP BASIC will only cover prescriptions written by providers associated with these organizations and prescriptions that are filled at one of the in-network pharmacies.
Services and related items excluded from coverage by the Medical Access Program (MAP) and MAP BASIC include but are not limited to the following list. MAP does not cover items on this list.
The following services are also excluded:
- If you fill out a form to ask if something will be covered by MAP, a pre-authorization, and the answer is no, then that service is not covered.
- Services not provided within the MAP system-the doctors and providers on the MAP list, unless you get pre-authorization.
- Services provided by your relative or a member of your household.
- Services that are not medically necessary to treat an injury or illness.
- Acute inpatient hospital services and supplies that a MAP review finds did not need a hospital level of care and could have been provided at a clinic or another place.
- Services resulting from any illegal act (including violation of probation) if you are put in jail or prison.
- Fees to some one else for completing or filling required forms or pre-authorization
- Any equipment, supplements, or supplies not ordered by a doctor or provider and/or not considered appropriate and necessary to treat a documented medical condition/disease process.
- Refills or prescriptions more than the number specified by the doctor or refill you get one year or more after the doctor’s original order.
- Charges for rental equipment if you move it from where it was delivered and do not immediately tell MAP the new location.
- Services and supplies to anyone who is in a public institution (like a jail, prison, or state hospital).
- In-patient hospital and related services for a patient in an institution for tuberculosis, mental disease, or a nursing section of a public institution for the intellectually disabled.
- At war: services resulting from any acts of war, declared or undeclared, or any type of military conflict, or from diseases or injuries gotten in any country at war or while on your way to or from any country at war, or from illness/injuries gotten while performing military services.
- Services provided for any work-related illness or injury if Workers’ Compensation Benefits (or any other similar regulation of the United States) are provided or should be provided by the laws of the state or territory of the employer where the illness or injury happened.
- Services supplies and medication you could get from a manufacturer’s Patient Benefit Program or Patient Assistance Program, or another way (like other program or insurance), if you did not have MAP.
- Services that can be paid by other insurance (health insurance, accident insurance, or other insurance) or by any private or other government benefits system, or any legally liable third party-some one who the law requires to pay your medical bills.
- Services and supplies provided through any government plan or law that could cover your care(e.g., Victims of Crime, Texas Rehabilitation Commission, Veteran’s Benefits, Medicare, Medicaid, TRICARE, CHAMPUS. etc.).
- Co-insurance fees and deductibles. MAP is not a secondary payer for any other insurance or governmental health care program. Individuals enrolled in other insurance are not eligible for MAP.
- Whole blood or packed red cells that are available at no cost to you
- Experimental services, supplies or medications- services and things that have not been approved by the Food and Drug Administration Services.
- Massage: Services from a massage therapist
- Mental Health: Care and treatment of mental and/or nervous disorder, psychiatric treatment or individual, family, or group counseling services, unless as a co-morbidity or secondary diagnosis during an inpatient stay or in the primary care setting.
- Substance abuse and detox: Treatment programs for substance abuse and/or detoxification.
- Chemonucleolysis intervertebral disc.
- Circumcision (routine) for clients one year of age or older.
- Cosmetic surgery except if needed to repair an accidental injury, if the initial treatment is received within 12 months of the accident, or to help a malformed body part work better, or when you get pre-authorization for another medical reason.
- Custodial or sanitaria care, rest cures, or for respite care.
- Ergonovine provocation test.
- Immunotherapy for malignant disease.
- Infertility supplies or medication.
- Joint sclerotherapy.
- Keratotomy or refractive surgeries: Radial and hexagonal keratotomy or refractive surgeries. Keratoprosthesis/refractive keratoplasty.
- Obesity procedures, obesity therapy and/or special diets (including medically supervised fasting and liquid nutrition) for weight reduction-even if for surgery or a specific medical condition.
- Organ transplant, medications and/or treatments associated with the transplant.
- Orthodontic treatment, and bridge procedures.
- Pain management programs (specialized) and/or treatment for chronic pain care, unless provided through MAP providers
- Rehabilitation inpatient and intensive outpatient rehabilitation.
- Sexuality treatments: Any treatments for transsexualism, gender dysphoria, sexual re-assignment or sex change, including, but not be limited to, drugs, surgery, medical or psychiatric care.
- Sterilization reversal.
- TMJ: Treatment or correction of temporomandibular joint (TMJ) dysfunction.
- Adaptive equipment for daily living such as eating utensils, reachers, handheld shower extensions, etc.
- Air cleaners/purifiers.
- Augmentive communication devices, e.g., TTY device, artificial voice box, and this kind of machinery.
- Bed cradles.
- Bladder stimulators (pacemakers).
- Cervical pillows.
- Electric wheelchairs or scooters (outpatient).
- Enuresis monitors.
- Feeding supplements (e.g., Ensure, Osmolyte) and supplies for long-term use.
- Home and vehicle modifications, including ramps, tub rails/bars.
- Humidifiers, except when used with respiratory equipment (for example., oxygen concentrators, CPAP/BIPAP, nebulizers, or for clients with a tracheostomy).
- Implantable medication pumps and related supplies, with the exception of insulin pumps and related supplies.
- Luxury or entertainment items (like TV, video, beauty aids, etc.).
- Non-medical equipment: Equipment or services not primarily and usually used for a medical purpose (for example., an air conditioner might be used to lower room temperature to reduce fluid loss in a cardiac patient, or a whirlpool bath might be used in the treatment of osteoarthritis. however because the primary and usual of these things in non-medical, they cannot be considered medical equipment).
- Vocational, educational, and recreational equipment.
- Cosmetic medical or surgical procedures-except reconstructive surgery necessary to repair a functional disorder as a result of disease, injury or congenital anomaly. The exclusions include: surgical or reformation of any sagging skin on any part of the body, including but not limited to the eyelids, face, neck, abdomen, arms, legs, or buttocks;
Any services performed in connection with the enlargement, reduction, implantation or change in the appearance in a part of the body including but not limited to the breasts, face, lips, jaw, chin, ears or genitals.
Also excluded: hair transplantations, chemical facial peels, or abrasions of the skin, electrolysis depilation, treatment of birthmarks or superficial veins or any other surgical or non-surgical procedures which are for cosmetic purposes.
There may be other things that are not on this list that are not covered.