Covered Services M*Plus MMA Enrollees
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1 Covered Services M*Plus MMA Enrollees You may receive covered services that are performed, prescribed, or directed by a participating provider. Remember, you must receive your health care services by a participating network provider. It is your responsibility to check if a provider is participating. You can look in your Health Care Provider Directory. Since the network changes, you may also call Customer Service to make sure the provider you choose is a UnitedHealthcare Community Plan participating provider. Services are limited to Medicaid-covered services as specified in the contract with the State of Florida Agency for Health Care Administration. The following is a summary of the Plan s health services and limitations on covered services. Please call Customer Service to verify covered services. Services that are considered experimental and cosmetic are not covered. For a counseling or referral service that the health plan does not cover because of moral or religious objections, the health plan need not furnish information on how and where to obtain the service. AHCA-B-O-NAN-5/14-12/ CST5178 5/14
2 Covered Services M*Plus MMA Enrollees Ambulatory Surgical Center Services Assistive Care Services Behavioral Health Services Birth Center & Licensed Midwife Services Chiropractic Services Child Checkup Services Medically necessary surgical care that does not have to be done in the hospital. Assistive Care Services are an array of services provided to enrollees 18 years old or older on a daily basis by or through a network Assisted Living Facility. The following types may be included in the Assistive Care Service plan: Health support: Assistance with activities of daily living (ADLs); Assistance with instrumental activities of daily living (IADLs); and Assistance with self-administration of medication. Services may include: Inpatient hospital services for behavioral health conditions; Outpatient hospital services for behavioral health conditions; Psychiatric physician services; Community behavioral health services for mental health and substance abuse conditions; Mental Health Case Management; Specialized therapeutic foster care; Therapeutic group care services; Residential care; and Statewide Inpatient Psychiatric Program (SIPP) services for individuals under age twenty-one (21). Services for low-risk pregnancies, deliveries, and the postpartum period. Services to restore mobility and range of motion to the spine. Routine checkups according to the preventive guidelines section of this handbook. These services include: health and development history, unclothed physical assessment or examination, nutritional assessment, routine immunization update, laboratory tests (including lead screening), vision screening, hearing screening, dental screening, health education, and developmental assessment for enrollees ages 20 and younger. You do not need a referral for these services. 2 M*Plus MMA Enrollee Addendum
3 Dental Services Medicaid Covered Diabetes Supplies and Education Emergency Services Family Planning Services Freestanding Dialysis Facility Services Hearing Services Full dental services for all enrollees age 20 and below. Medically necessary oral and maxillofacial surgery for all eligible Medicaid recipients regardless of age, emergency dental services to enrollees age 21 and older, and denture and denture-related services. Medically necessary, emergency dental procedures to alleviate pain or infection to enrollees age 21 and older. Emergency dental care for enrollees 21 years of age and older is limited to a problem-focused oral evaluation, necessary radiographs in order to make a diagnosis, extractions, and incision and drainage of an abscess. Full and removable partial dentures and denture-related services are also covered services for enrollees 21 years of age and older. Coverage for medically appropriate and necessary equipment, supplies, and services used to treat diabetes, including outpatient self-management training and educational services, if your treating provider says these services are needed. Includes emergency medical care 24 hours a day, 7 days a week. You do not need approval from UnitedHealthcare or your Primary Care Provider (PCP) to go to the emergency room. To help you plan a family size or help you space the time between having children. Family Planning Services includes information, referral education, counseling, diagnostic procedures and contraceptive drugs and supplies. Services are voluntary and you are permitted full freedom of choice of methods for Family Planning. You can go to any provider that participates with Medicaid for these services without a referral from your Primary Care Provider (PCP). Includes routine laboratory tests, dialysis-related supplies, ancillary and other items. Services include all services and procedures rendered by a participating provider when needed for preventive, diagnostic or therapeutic care, or to treat a particular injury, illness or disease. Hearing Services includes examinations and evaluations necessary for the furnishing of one standard hearing aid every three years. Florida 3
4 Covered Services M*Plus MMA Enrollees (cont.) Healthy Start Services Home Health Care Services and Durable Medical Equipment Hospice Hospital Ancillary Services Immunizations Independent Lab and Portable X-Ray Services Inpatient Hospital Services Programs to improve pregnancy outcomes and infant health, including: coordination with the Healthy Start program, immunization programs, WIC program, and the Children s Medical Services program for children with special health care needs. Includes intermittent or part-time nursing services (R.N. or L.P.N.), personal care services by a home health aide, and medical items (limited to approved types of supplies and equipment, suitable for use in the home). All services and equipment must be ordered by a participating provider. Your Primary Care Provider (PCP) must notify UnitedHealthcare for services or equipment that require home health care. Home health care does not include homemaker services, Meals on Wheels, companion, sitter or social services. Services that are forms of palliative medical care designed to meet the physical, social, psychological, emotional, and spiritual needs of terminally ill recipients and their families. When your provider authorizes these to be provided by the hospital: radiology, pathology, neurology, neonatology, and anesthesiology. According to the recommended immunization schedule as approved for the United States. Includes laboratory and X-ray services when ordered by a participating provider. Includes all items and services needed to give appropriate care during a stay at a participating hospital, including room and board, nursing care, medical supplies, and all diagnostic and therapeutic services. UnitedHealthcare covers a maximum of 45 inpatient days for the period from July 1 through June 30 (includes only non-emergency care at hospitals where prior notification was obtained by your Primary Care Provider (PCP) from UnitedHealthcare). 4 M*Plus MMA Enrollee Addendum
5 Interpreter Services Maternity Services Outpatient Services If you are in need of interpreter services or are vision and/or hearing impaired, please call the Customer Service phone number on the back of your ID card. These services are free of charge for all foreign languages as well as the visually and/or hearing impaired. Maternity services include the following: nursing assessment and counseling, Florida s Health Start Prenatal Risk Screening, nutrition assessment, delivery and follow-up care, Florida s Health Start Infant (Postnatal) Screening, and follow-up care. As soon as you know you are pregnant and again after your baby is born, remember to call: 1. Your Department of Children and Family Care Worker; AND 2. The Plan s Customer Service Department. If you wish to enroll your baby into the Plan, you can contact Medicaid Choice Counseling toll free at , between the hours of 8:00 a.m. and 7:00 p.m., Monday through Friday. Once your baby is enrolled in our Plan, please call Customer Service at to select a pediatrician for your baby. It is your responsibility to call your Case Worker to get Medicaid benefits for your baby. The Women, Infant, and Children (WIC) Program includes referrals for all pregnant breastfeeding and postpartum women, infants and children up to the age of 5. Contact your Case Worker for information. Outpatient services provided in an outpatient hospital setting. Your Primary Care Provider (PCP) can obtain prior notification for health care services that may require notification. Florida 5
6 Covered Services M*Plus MMA Enrollees (cont.) Physician Services Post-Stabilization Services Prescribed Drugs Therapy Services Occupational Therapy Services Physical Therapy Services Respiratory Includes all services and procedures rendered by a participating provider when needed for preventive, diagnostic or therapeutic care, or to treat a particular injury, illness or disease. Excludes experimental procedures and cosmetic surgery. These physician services include: Advanced registered nurse practitioner, physician assistant, podiatry, ambulatory surgical centers, community health departments, rural health clinic services, federally qualified health centers, birthing centers, certified nurse midwives, chiropractic, and psychiatrists. Post-Stabilization services are covered without prior authorization. These are services related to an emergency medical condition that are provided after you are stabilized in order to maintain, improve or resolve your condition. Includes prescribed drugs currently covered by the Medicaid Program, when ordered by a participating provider and supplied by a licensed participating pharmacy. Services include evaluation and treatment to prevent or correct physical and emotional deficits or to minimize the disabling effect of these deficits. Examples are perceptual motor activities, exercises to enhance functional performance, kinetic movement activities, guidance in the use of adaptive equipment and other techniques related to improving motor development. Services include evaluation and treatment of range-of-motion, muscle strength, functional abilities and the use of adaptive and therapeutic equipment. Examples include rehabilitation through exercise, massage, the use of equipment and rehabilitation through therapeutic activities. Services include evaluation and treatment related to pulmonary dysfunction. Examples are ventilatory support; therapeutic and diagnostic use of medical gases; respiratory rehabilitation; breathing exercises and chest physiotherapy. 6 M*Plus MMA Enrollee Addendum
7 Therapy Services Speech Transportation Vision Services Services include the evaluation and treatment of disorders of verbal and written language, voice, fluency, auditory processing, visual processing, memory, comprehension and interactive communication. Examples are techniques and instrumentation to evaluate the recipient s condition, remedial procedures to maximize the recipient s oral motor functions. Reimbursement for ambulance transportation to and from a physician s office or for hospital discharges is covered only when medically necessary. Vision services include eye exams and up to two pairs of standard eyeglasses per year. Contact lenses for cosmetic purposes are not covered. Adult Dental Services Expanded Hearing Services Expanded Home Health Care (Non-Pregnant Adults) Newborn Circumcision Outpatient Services Over-the-Counter Health Care Items (OTC) Expanded s Two (2) exams per year; two (2) x-rays per year; two (2) cleanings per year; maximum nine (9) amalgam fillings: one (1), two (2) and three (3) surface(s), three (3) fillings each every thirty-six (36) months One (1) hearing aid fitting every three (3) years; one (1) hearing aid every three (3) years. One (1) visit per day. Available upon request up to twelve (12) weeks old. No monetary limit on outpatient services; prior authorization may be required. Over-the-Counter benefit service is up to $25 per enrollee per month and will be available to all enrollees. Florida 7
8 Covered Services M*Plus MMA Enrollees (cont.) Post Discharge Meals Prenatal/Perinatal Visits Primary Care Visits (Non-pregnant Adults) Vaccine Adult Influenza Vaccine Adult Pneumonia Vaccine Adult Shingles Vision Services Expanded Waived Copayments Ten (10) home-delivered meals; limited to SSI (without Medicare), and Medicare/Medicaid dual eligible enrollees; subject to prior authorization. Unlimited visits. Unlimited visits. Administered as medically advised. Administered as medically advised. Administered as medically advised. One (1) set of glasses per year; one (1) eye exam (refraction) per year. Enrollees shall not be subject to copayment charges. 8 M*Plus MMA Enrollee Addendum
9 Notes Florida 9
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