GHI Principal Limitations and Exclusions
The following items are not covered under GHI's benefit plans.
Admissions to a Hospital Before You Become Covered Under This Plan
If you are admitted to a hospital as a registered bed patient before the date you become covered
under this plan, GHI will not pay for any part of your hospital stay regardless of whether the
services were rendered either before or after you become covered under this plan.
Air Ambulance and Ambulette Service
Except as otherwise provided in your Benefits Chart, you are not covered for air ambulance or
Care Furnished Without Charge
Payment will not be made for any care if the care is furnished or would normally be furnished to
you without charge. You are not covered for services rendered for which no legally enforceable
charge is incurred.
Unless your coverage specifically includes chiropractic care, you are not covered for care in
connection with the detection and correction by manual or mechanical means of structural
imbalance, distortion or subluxation in the human body for the purpose of removing nerve
interference and the effects thereof, where such interference is the result of or related to
distortion, misalignment, or subluxation of or in the vertebral column.
Convalescent or Custodial Care
You are not covered for services related to bed rest, rest cures, convalescent care, or custodial
care. You are not covered for sanitarium care. Custodial care refers to care primarily to help with
the activities of daily living. For example, help in walking or getting in or out of bed, dressing,
eating, or taking medication are all considered custodial care. The guidelines used by Medicare
will be used to determine whether care is custodial in nature.
Cosmetic Surgery and Treatment
Unless specifically provided otherwise in your Benefits Chart, payment will not be made for
services in connection with elective cosmetic surgery or treatment which is primarily intended to
improve your appearance. However, payment will be made for services in connection with
reconstructive surgery when such service is incidental to or follows surgery resulting from trauma,
infection, or other diseases of the part of the body involved. Payment will also be made for
reconstructive surgery performed due to congenital disease or anomaly of a covered child which
has resulted in a functional defect.
Here is a partial list of services that are not covered by the GHI Dental Plan.
· Temporary appliances.
· Cosmetic surgery or cosmetic treatment. Cosmetic surgery is covered only when it
involves reconstructive surgery resulting from trauma, infection, or other diseases of the
· Orthodontics (unless the group contract contains an orthodontic rider).
· Services not normally performed in accordance with accepted standards of dental
· Services not listed in a subscriber's group contract.
· Services that are covered under any law of any State or the United States, such as
services covered by Medicare, Workers Compensation, or No-Fault.
· Services rendered in a hospital, department, or clinic run by an employer, labor union, or
· Crowns or pontics for attachments or clasp purposes, unless the tooth is so broken down
that it cannot be restored properly by fillings. A cantilever pontic, when used for
attachment reasons for a partial in the same jaw, is also not covered.
· Replacement of crowns, bridges or dentures within five (5) years of prior insertion (three
(3) years under M-Plan).
· Items and services required by dentists to comply with OSHA regulations.
· Anesthesia administered outside of a hospital by the provider performing the surgery.
· Services or appliances used solely as an adjunct to periodontal care or
temporomandibular joint dysfunction.
· Duplication (jump), rebase or chairside reline to a denture is limited to one per denture
per five-year period under Spectrum, Spectrum Plus or Preferred; one per denture per
three-year period under Type M-2.
· Overlay full upper and lower dentures are paid for at the fee for full upper and lower
dentures. There is no payment for treatment of an abutment tooth or attachment tooth
under the Spectrum, Spectrum Plus or Preferred programs.
· Precious metal material used in crowns is reimbursed at the base metal rate.
· Ceramic inlay/onlay (ADA Code 2640) is not covered. However, the maximum restoration
fee for this procedure is allowed.
· Crowns used in splints for periodontal conditions.
· When a fixed bridge and partial denture are inserted in the same jaw, only the partial
denture is covered. Payments will not be made for replacements or substitutions for a
period of five (5) years under Spectrum, Spectrum Plus or Preferred, and a period of
three years under Type M-2.
· Acrylic crowns must be laboratory-processed and permanent. They will only be paid as
single crowns. They will not be paid as bridge abutments or splints. Acrylic crowns are
only covered on the six anterior upper and lower teeth under Spectrum, Spectrum Plus or
Preferred. Acrylic crowns are only covered on the eight anterior upper and lower teeth
under Type M-2. Replacement of a crown will not be paid for a period of five years under
Spectrum, Spectrum Plus or Preferred, or a period of three years under Type M-2.
· Double or multiple abutments are not covered. Fixed or removable splints are not
covered except when a missing tooth is being replaced. Only that portion of the splint
replacing the missing tooth is covered. Splints using enamelate or similar material are not
· Rebase or repair of a newly inserted denture is not covered for a period of six months
under the Spectrum, Spectrum Plus or Preferred dental plans.
· Repair of tooth and/or clasp addition to an existing denture within six (6) months of the
insertion of a new denture.
This is a partial summary of GHI Dental Benefits and Exclusions. If there is any question about
coverage of these services, or a service not listed above, please call the GHI Provider Services
Drugs and Medical Equipment
except when provided as a separate rider.
Educational or Vocational Services
You are not covered for services which are either educational or vocational in nature.
Elective Reversal of Sterilization
You are not covered for the elective reversal of sterilization.
Excess Inpatient Hospital Charges
You are not covered for hospital charges which are not covered under your inpatient hospital
Experimental Treatment and Treatment Not Conforming to Accepted Medical Standards
Payment will not be made for treatment considered to be experimental according to GHI's criteria
for experimental treatment. All services must conform to accepted standards of medical or
hospital practice in order to be eligible for reimbursement. Services received which are beyond
the scope of the license of the person rendering the service are not covered.
Eyeglass and Hearing Aids
Payment will not be made for eyeglasses, contact lenses (except post-cataract lens if covered by
rider) or hearing aids or examinations for the prescription or fitting of those items. These benefits
may be provided by a separate rider.
You are not covered for Medical Summaries and/or medical invoice preparations.
Medicare and Other Government Programs
Payment under your plan may be reduced by the amount you are eligible to receive for the same
service under Medicare or any other Federal, state, or local government program.
Non-Acute Hospital Care
You are not covered for a hospital stay or a portion of a hospital stay during which you receive