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
ambulette service.  
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.  
Chiropractic Care 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.  
Dental Exclusions 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
        involved area.  
    Orthodontics (unless the group contract contains an orthodontic rider).
    Services not normally performed in accordance with accepted standards of dental
        practice.  
    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
        welfare fund.  
    Implants.  
    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
        covered.  
    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
Department.   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
benefit.  
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.  
Medical Summaries 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
non-acute care. This exclusion applies to a hospital stay or a portion of a hospital stay in
connection with physical check-ups, convalescent or custodial care, rest cures, or sanitarium-type
care. Care is considered custodial when it is primarily for the purpose of meeting personal needs
and could be provided by persons without professional skills or training. For example, custodial
care includes help in walking, getting in and out of bed, bathing, dressing, eating, and orally
taking medicine.  
No-Fault Automobile Insurance Payment will not be made for any service for which mandatory automobile no-fault benefits are
recovered or are recoverable.  
Nutritionists and Related Services   You are not covered for the services of nutritionists or special dietary products, except as
specifically provided in your Certificate of Insurance. You are not covered for weight counseling.  
Pre-existing Conditions Any illness, injury, or condition that starts after your first day of coverage is covered. However,
coverage of a pre-existing illness, injury or condition is limited. A pre-existing condition is any
disease, symptom or condition that was present on the first day of coverage, and for which
medical advice or treatment was recommended or received during the six (6) month period prior
to the enrollment date. If you have a pre-existing condition, that condition is not covered during
the first eleven (11) months this contract is in effect. For example, if you have asthma prior to
your enrollment date under this plan, you will be covered for treatment of asthma beginning on
the first day of the twelfth month after the enrollment date.  
This limitation applies to all services related to a pre-existing condition, disease, or symptom.
There are several exceptions to this rule.  
1.    Coverage Under a Prior Health Plan If you were previously covered under a health insurance plan and the lapse in coverage
between the termination of the prior plan and your enrollment date under this Plan does
not exceed sixtythree (63) days, GHI will credit the time you were covered under the prior
plan toward the eleven (11) month pre-existing condition limitation that applies to this
Plan. For purposes of this paragraph, a health insurance plan includes any of the
following:
o   a group health plan,
o   health insurance coverage,
o   Part A or B of Title XVIII of the Social Security Act,
o   Title XIX of the Social Security Act (other than coverage consisting solely of
        benefits under Section 1928)1
o   Chapter 55 of Title 10 of the United States Code,
o   a medical care program of the Indian Health Service or of a tribal organization,
o   a state health benefits risk pool,,
o   a health plan offered under Chapter 89 of Title 5 of the United States Code,
o   a public health plan (as defined in regulations),
o   a health benefit plan under Section 5(E) of the Peace Corp Act (22 U.S.C. 2504
(e)).         GHI may choose to credit separately the time you were covered under your prior
        plan for several classes of benefits. These categories of benefits are set forth
        
below:
o   Prescription Drugs.
o   Vision Care.
o   Dental Care.
o   Mental Health.
o   Substance Abuse.
o   If the benefit periods under your prior plan are different for any of the above
benefits than the overall amount of time you were covered by your prior plan,
GHI may choose to credit separately the amount of time you were covered for
the specific benefit(s).  
2.    Birth Defects Treatments of birth defects (congenital anomalies) of a covered child are not subject to
the pre-existing condition limitation.  
3.    Pregnancy Pregnancy existing on the enrollment date will not be considered to be a preexisting
condition except under direct payment health insurance plans. Under direct payment
health insurance plans, pregnancy is considered to be a pre-existing condition. GHI will
apply a ten (10) month pre-existing condition limitation for pregnancy existing on the
enrollment date, subject to any credit for coverage under a prior health plan.  
4.    Newborns and Adopted Children A newborn or a child who is adopted or placed for adoption before they are eighteen (18)
years old, will not be subject to a pre-existing condition limitation. This will apply if the
child is enrolled under creditable coverage within thirty (30) days after birth or adoption or
placement for adoption. This provision will not apply if the child has a break in coverage
exceeding sixty-three (63) days.  
Podiatric Care (Routine) Except as otherwise provided in your group's plan, you are not covered for routine podiatric care.
Routine podiatric care refers to the services set forth below rendered in connection with the
routine care of the feet.  
1.    Orthopedic shoes and other supportive devices.
2.    Services or supplies for the treatment of the following, unless open surgery is
necessary: o   Weak feet  
o   Strained feet
o   Flat feet
o   Any instability or imbalance of the feet
o   Metatarsalgia (pain in the sole of the foot in the region of the arch)
o   Bunions
3.    Services or supplies for the treatment of any of the following services, except when the treatment is prescribed for metabolic disease. o   Corns  
o   Calluses  
o   Toenails
Prohibited Referrals You are not covered for clinical laboratory services, X-ray or imaging services, pharmacy
services, or any other services provided pursuant to a referral prohibited by Section 238-a(l) of
the New York State Public Health Law.  
Services Covered by Government Except for Medicaid, payment will not be made for services furnished, even in part, under the Law
of the United States or any state or municipality. Care for non-service related injuries or illnesses
rendered in a Veteran Affairs hospital is covered.  
Services Not Listed as Covered Payment will not be made for services which are not listed in the Benefits Chart as being covered
under your plan.  
Services Rendered by Member of Immediate Family Payment will not be made for services rendered by the member, the member's spouse, by a
child, brother, sister, or parent of the member or of the member's spouse.  
Services Rendered in Governmental Hospitals   You are not covered for care, unless otherwise specifically provided, in any hospital or other
institution which is owned, operated, or maintained by the Veterans Administration (except as
noted below), the Federal government, a state government, or any local government, unless the
hospital has an agreement with GHI to provide services to GHI members. However, you are
covered in such a hospital if, because of serious injury or sudden illness, you are taken to one of
these hospitals for emergency care. You must be taken to this hospital because it is close to the
place where you were injured or became ill. In this type of emergency situation, GHI will continue
to make payment only for as long as emergency care, in GHI's sole judgment, is necessary and it
is not possible for you to be transferred to another hospital.
GHI will make payments for outpatient visits for the treatment of chemical dependency even if the
facility is owned, operated, or maintained by a state government or focal government. However,
the facility must be certified by the New York State Division of Alcoholism and Alcohol Abuse or
the New York State Division of Substance Abuse Services or, if outside of New York state,
accredited to provide an alcohol or substance abuse treatment program by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO). GHI will make payments to such a
certified or accredited facility only if the facility would have charged you if you did not have
insurance. Payment will not be made for any service that is normally furnished without charge.
Care for non-service related injuries or illnesses rendered in a Veterans Administration Hospital is
always covered.  
Services Through Your Employer, Union, or Welfare Fund You are not covered for services rendered in a hospital, department, or clinic run by your
employer, labor union, or welfare fund for which there is no charge.  
Stand-by Services You are not covered for stand-by services. Stand-by services are services that a provider
performs relating to being available to provide services on a contingent basis. Mere standing-by is
not covered. Stand-by services may be deemed to be rendered by any provider.
For example, the administration of anesthesia is not a stand-by service. It is a covered service.
The services listed below when rendered by an anesthesiologist are not covered. They are
deemed stand-by services.
    Preparing a contingency anesthesia plan
    Merely being in the operating area
    Merely being in the hospital
    Being available for diagnosis or treatment on a contingent basis if needed
As another example, stand-by services may also be provided by a surgeon. Surgery or assisting
at surgery are not stand-by services. They are covered services. The services listed below are
not covered when performed by a surgeon, they are deemed stand-by services:
    Preparing a contingency surgery plan
    Merely reviewing a patient's chart
    Merely being in the operating area
    Merely being in the Hospital
    Being available for diagnosis, treatment, or surgery on a contingent basis if needed
War Payment will not be made for services for care of illness or injury due to war, declared or
undeclared.  
Workers' Compensation Payment will not be made for care for any injury, condition, or disease if payment is available to
you under a Workers' Compensation Law or similar legislation. GHI will not make any payments
even if you do not claim benefits you are entitled to receive under the Workers' Compensation
Law. Aso, payment will not be made even if you bring a lawsuit against the person who caused
the injury or condition. Payment will not be made even if you receive money from that lawsuit and
you have repaid the hospital or other provider.