An HMO may provide health services to its enrollees in addition
to the services required in §11.508 of this title (relating to
Basic Health Care Services and Mandatory Benefit Standards: Group,
Individual and Conversion Agreements). An HMO may limit these optional
health services as to time and cost. Evidences of coverage may contain
optional benefits, including:
(1) corrective appliances and artificial aids;
(2) cosmetic surgery;
(3) care for military service-connected disabilities
for which the enrollee is legally entitled to services and for which
facilities are reasonably available to the enrollee;
(4) care for conditions that state or local law requires
be treated in a public facility;
(5) dental services, except as otherwise required;
(6) vision care;
(7) custodial or domiciliary care;
(8) experimental and investigational medical, surgical,
or other experimental or investigational health care procedures, unless
approved as a basic health care service by the policymaking body of
the HMO, provided that:
(A) a denial of a request for experimental or investigational
services is an adverse determination; and
(B) an HMO must comply with Chapter 19, Subchapter
R, of this title (relating to Utilization Reviews for Health Care
Provided Under a Health Benefit Plan or Health Insurance Policy) if
the HMO denies requested services because the HMO determines that
the requested services are experimental and investigational;
(9) personal or comfort items and private rooms, unless
medically necessary during inpatient hospitalization;
(10) durable medical equipment for home use (such as
wheelchairs, surgical beds, ventilators, or dialysis machines);
(11) infertility medical services, including gamete
intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT),
and outpatient infertility drugs;
(12) reversal of voluntary sterilization;
(13) prescribed drugs and medicines incident to outpatient
care; and
(14) noninsurance benefits, provided that the HMO complies
with Chapter 21, Subchapter NN, of this title (relating to Noninsurance
Benefits and Features).
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