FACILITY BASED SERVICES
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1 FACILITY BASED SERVICES Inpatient Hospital Care Elective Inpatient Admission or Elective Inpatient Surgery Inpatient Rehabilitation Care Skilled Nursing Facility Admission Non-Custodial Nursing Home Care Custodial Nursing Home Care Long Term Acute Care (LTAC) Emergency Room Care Observation Care Must meet CMS/MDHHS Observation Criteria Urgent Care
2 Allergy Testing/Injections OUTPATIENT SERVICES Ambulance-Emergency Services (Air) Ambulance-Emergency Services (Land) Ambulance-Non Emergency Services Anesthesia for Outpatient Dental Procedures Angiography Bariatric Surgery Blepharoplasty (Eye lid surgery) Bone Density Breast Reconstruction Cardiac Catherization (Must meet medical necssity criteria) (Must meet medical necessity criteria) (Covered only after mastectomy for treatment of Breast Cancer) Cardiac Rehabilitation
3 Cardiac Stress Testing/Imaging Chiropractic Care Cochlear Implant Cosmetic Procedures (Keloid & Scar Revision, Panniculectomy, Septoplasty/Rhinoplasty) Dental Care (Must meet medical necssity criteria) Limited to 1 annual preventative dental visit: Includes oral exam, fluoride treatment, X-rays and cleaning. Call Diabetes Education (Certified Diabetic Educator) Diagnostic Imaging: CT Scan, MRI Diagnostic Imaging: PET Scan Dialysis: Hemodialysis & Peritoneal Dialysis Eye Exams and Glasses Family Planning Services (Including Vasectomy & Tubal Ligation) MANAGED BY HERITAGE OPTICAL CALL Genetic Testing Hearing Aids
4 Home Health Care (Skilled Nursing, PT, OT, Speech Therapy) Hospice Immunizations (CDC/ACIP Recommended) Infusion & Injection Therapy (Remicaid, IVIG, Xolair, Embrel, Humera) Lab Services (Genetic Testing requires Prior Authorization) (SERVICES MUST BE BILLED DIRECTLY TO MEDICARE FFS) (Contact Medicare Health Services for Additional Meds) Long Term Support Services Maternal Infant Health Program (MIHP) OB Care (Office Visits, Ultrasound, NSTs) Outpatient Diagnostic or Screening Procedures (Bronchospcopy, Colonoscopy, EGD, Hysteroscopy, Ultrasound, Doppler Studies, Echocardiograms, X-rays etc.) Outpatient Surgery (Knee Arthroscopy, Cataract, ORIF, D&C, etc.) (Does not include Outpatient Dental Surgery - See Dental) Outpatient Therapy Evaluation Only: OT, PT & Speech Therapy Outpatient Therapy: Physical Therapy, Occupational Therapy & Speech Therapy Outpatient Treatment (Chemotherapy, Radiation Therapy) Parenteral and Enteral Nutrition
5 Podiatry Pulmonary Rehabilitation Reduction Mammoplasty (Females Only) Sleep Studies Second Surgical Opinion Specialty Care (Must meet specific criteria) Transportation (Non-emergency) MANAGED BY HAP MIDWEST CUSTOMER SERVICES WITH 4 BUSINESS DAYS NOTICE. CALL Transplant Services: Organ Transplant, Bone Marrow Travel Vaccines Vein Procedures: Sclerotherapy, Stripping/Ligation, etc. (Must meet specific criteria) Well Woman Care (Mammogram, Pap Smear, etc.) DURABLE MEDICAL EQUIPMENT (DME) Braces (arm, leg, back & neck)
6 Canes (excludes white canes for the blind) Commode chairs Continuous passive motion (CPM) machine Crutches Enteral nutrition equipment (feeding pump) Home oxygen equipment Hospital beds and Mattresses Infusion pumps Implantable Automatic Defibrillators INR (Home Monitoring) Insulin Pumps Life Vest (DME) Nebulizers and nebulizer medications Patient Lifts
7 Pneumatic Compression Devices (Lymphedema Pump) Positive Airway Pressure Devices: CPAP, BiPAP Power Mobility Devices Prosthetics & Orthotics Seat Lift Speech Generating Devices Suction pumps Stimulators: Bone, Electrical, Neuromuscular, Transcutaneous Electrical Nerve Stimulators (TENS) Therapeutic shoes or inserts Traction equipment Walkers Wheelchairs MEDICAL SUPPLIES
8 Diabetic Supplies: Glucometers, strips, lancettes, syringes/needles, alcohol wipes. Diabetic Insulin Pump Supplies Enteral nutrition (feeding) supplies Incontinence supplies: Diapers, briefs, wipes, gloves, pads Nebulizer supplies Ostomy & Tracheostomy supplies Oxygen supplies Positive airway pressure (CPAP, BiPAP) supplies Urology supplies Wound Care supplies Supplies covered by Pharmacy Benefit BEHAVIORAL HEALTH SERVICES Inpatient Psychiatric and Substance Abuse Admission Outpatient Behavioral Health Services Behavioral Health Office Visits (PCP TO REFER MEMBER TO IN NETWORK PROVIDER) (PCP TO REFER MEMBER TO IN NETWORK PROVIDER)
9 Substance Abuse Treatment- Outpatient (PCP TO REFER MEMBER TO IN NETWORK PROVIDER) Partial Hospitalization
CUSTODIAL NURSING HOME CARE
CUSTODIAL NURSING HOME CARE Chiropratic Services Custodial Nursing Home Care DME Equipment and Supplies Incontinence Supplies: Diapers, briefs, wipes, gloves, pads Infusion (IV, Enteral) Services Outpatient
FACILITY BASED SERVICES
CUSTODIAL NURSING HOME CARE Chiropratic Services Custodial Nursing Home Care DME Equipment and Supplies Incontinence Supplies: Diapers, briefs, wipes, gloves, pads Infusion (IV, Enteral) Services Outpatient
Must meet specific criteria. Prior authorization required. Must meet specific criteria
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HOPE COLLEGE - HOURLY ORANGE 007013084/0011/0012/0013/0014/0015/0016/0017 Simply Blue PPO HSA ASC Effective Date: On or after July 2018 Benefits-at-a-glance This is intended as an easy-to-read summary