Tip: This definition applies only to those benefits in which it is used in your certificate of coverage. Other benefits have additional limits related to medical necessity or preauthorization of services (see the "Limits on plan coverage" section of your certificate of coverage for more information on preauthorization).
A limited benefit is a benefit that is limited to a certain number of visits or a maximum dollar amount. The limit applies to these benefits even if the provider prescribes additional visits and even if the visits are medically necessary. The plan does not make exceptions to benefit limits.
For benefits limited to a certain number of visits, any visits that are applied to your deductible* also count against your annual visit or dollar limit. In addition, visits that are paid by another health plan that is primary apply to the plan limit. For example, if your primary plan applies your first six massage therapy sessions to your deductible,* you may receive coverage for 10 more sessions in that calendar year, for a total of 16 visits (the visit maximum for massage therapy). These limits apply per member.
Services are counted against a limited benefit according to the type of service, not the provider type. When a provider practicing within the scope of their license provides services coded under a limited benefit (e.g., spinal manipulation or physical therapy), those services will be counted against the benefit regardless of the provider type. In addition, if more than one type of limited benefit service is provided during a single visit, the services will count against all the limited benefits. For example, if both manipulation and physical therapy codes are billed for a visit, that visit will count against both the spinal and extremity manipulation and physical therapy benefits.
*For UMP Achieve 1, UMP Achieve 2, UMP Classic and UMP Plus, this is the medical deductible.