Long Term Care (DSHP Plus)
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1 Benefits Bed Liners Coverage for members age 4 and up Behavioral Health Outpatient Mental Health and Substance Abuse Services Behavioral Health Inpatient Mental Health and Substance Abuse Services Blood and Plasma Products Bone Mass Measurement (bone density) Care Management Chemotherapy Colorectal and Prostate Screening Exams CT Scans Dental Services ( Under age 21) Call or toll free Dental Services (Adult) Diabetic Education Diabetic Equipment Diabetic Supplies Dialysis Diapers (for members age 4 and up) Drugs Prescribed by a Doctor Durable Medical Equipment Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services (for under age 21) Emergency Medical Transportation (Air and ambulance) Emergency Room Care Eye Exam, Medical (for conditions such as eye infections, glaucoma and diabetes) Under age 18: for 30 visits per year. After 30 visits per year, services are covered by the Department of Services for Children, Youth and Families (DSCYF) Age 18 and older: Under age 18: covered by DSCYF Age 18 and older: The Delaware Medical Assistance Program covers certain dental care for children up to age 21, including the Delaware Healthy Children Program Removal of bony impacted wisdom is covered Not covered except removal of bony impacted wisdom teeth Glucose monitors/strips for All Members Eye Exam, Routine under age 21 See additional benefits for adult coverage
2 Eye Glasses and Contact Lenses under age 21 See additional benefits for adult coverage Family Planning Services Genetic Testing Glaucoma Screening Gynecology Visits Hearing Aids and Batteries under age 21 Hearing Exams HIV/AIDS Testing Home Health Care and Infusion Therapy Hospice Care Hospitalization Immunizations Lab Tests and X-rays Mammograms Medical Supplies MRI, MRA, PET Scan Nursing Home up to 30 days per year Additional days are considered long term care; an application must be submitted to and approved by the Delaware Medical Assistance Program for long term care. Obstetrical/Maternity Care Orthopedic Shoes. Outpatient Surgery, Same Day Surgery, Ambulatory Surgery Pain Management Services Parenting / Child Birth Education Personal Care / Aide Services (in home) Podiatry Care (routine diabetic care or peripheral vascular disease) Prescription Drugs Primary Care Provider Visits Private Duty Nursing Prosthetics and Orthotics Your physician must get a prior authorization if over $300. Radiation Rehabilitation (inpatient hospital) Skilled Nursing Facility Care up to 30 days per year Sleep Apnea Studies Smoking Cessation Counseling
3 Specialty Physician Services Surgical Center Therapy - Outpatient Occupational, Physical, Speech Additional Benefits Benefit Weight scales Pill boxes Adult Vision Requirements Members must have heart failure Limit one per household Members must take prescription medication Limit 5 per member per year Covers one eye exam every 12 months and up to $150 for eye glasses or contacts every 24 months LTSS Enhanced Benefits These benefits must be part of a plan of care in order to be covered. Benefit Adult Day Care Cognitive Services Community-Based Residential Alternatives That Include Assisted Living Facilities Day Habilitation Home-Delivered Meals In-Home Respite Care In-Patient Respite Care Minor Home Modifications What it is A place that provides supervised care and activities during the day Services that: Assess your ability to care for yourself Assess your ability to interact with others Help you create a plan to help you do these things Help improve the member s behavior or thinking disorders A place where you live that provides help with personal care needs and taking your medicine. You must pay for your room and board A place, other than your private home, where you receive help to: Reinforce skills you learned in another setting Gain additional skills that give you more independence and control of your life This service is often for people who have problems acting or thinking clearly because of an injury. A common example is a traumatic brain injury. Up to 1 meal per day. Someone to come and stay with you in your home for a short time, so your caregiver can get some rest. There are annual benefit limits. A short stay in a nursing home or assisted care living facility, so your caregiver can get some rest. There are annual benefit limits. Changes to your home to help you get around easier and safer when medically necessary. For example, a wheelchair ramp. There are lifetime limits.
4 Nursing Facility Care Personal Care Attendant/Care Services These residential facilities provide all personal and 24 hour nursing care for those with long term care needs. Help with Activities of Daily Living (ADL), such as: Getting out of bed Bathing Getting dressed Using the bathroom May also include help with Instrumental Activities of Daily Living (IADLs), such as: Light housekeeping chores Shopping Fixing a meal Personal Emergency Response System (PERS) Specialized Durable Medical Equipment and Supplies Support for Consumer Direction Transition Services (Money Follows the Person Only) Transition Services Workshops This kind of help is available if it s part of your plan of care. A call button so you can get help in an emergency. Use it when your caregiver is not around. This service is not available if you live in an assisted care living facility or a nursing home because these facilities already have a way to help you when you need it. Items or devices that help you do things easier or safer in your home. For example, grabbers to reach things. Not covered under the Medicaid State Plan. Information and assistance to so you can direct your Personal Care/Attendant services yourself and get help managing the money to do this. Help with the initial costs of a move from a nursing home back to a home in the community. Examples: Security deposit Telephone connection fee Groceries to get you started Furniture Bedding Workshops that help prepare you and your family and other caregivers for community living. Not : Services that are not medically necessary Services provided outside the United States Non-emergency services from an out-of-network provider that are not prior approved
5 Abortion, unless in the case of rape or incest or in life-threatening situations Sterilization of a mentally incompetent or institutionalized person Vaccines for travel outside the United States Experimental procedures Cosmetic services, items and prescriptions Hearing aids for members 21 and older Infertility treatment and medicines Sex change services Christian Science nurses and sanitariums Prescriptions written by non-network providers (except when an emergency supply is needed) Routine foot care for members that do not have diabetes
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