Must meet specific criteria. Prior authorization required. Must meet specific criteria
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1 MIDWEST HEALTH Acupuncture NOT A BENEFIT NOT A BENEFIT NOT A BENEFIT Acute Care Observation Post Operative Emergency Room Allergy Testing/Allergy Injections Ambulance-Emergency Land Plan Notification Not Required Plan Notification Not Required Plan Notification Not Required Ambulance-Emergency Air Ambulance-Non-emergent Anesthesia for Dental Procedures Angiography Bariatric Surgery Behavioral Healthcare (outpatient) (Including prescriptions written by the Community Mental Health Service Program - CMHSP) Bone Density Breast Reconstruction Cardiac Catheterization ; Must meet specific ; Must meet specific ; Must meet specific Cardiac Rehabilitation Chiropractic Care Contraceptives Benefit limited to 18 visits per calendar year Benefit limited to 24 visits per calendar year Benefit limited to 18 visits per calendar year YELLOW = Revised 10/1/ BLUE = Medicaid Benefits Provided by Another Entity Page 1 of 5
2 MIDWEST HEALTH Cosmetic Procedures, such as: Blepharoplasty (Eye lid surgery), Keloid/Scar Revision, Liposuction, Panniculectomy, Septo/Rhinoplasty, etc. Plan notifcation not required NOT A BENEFIT for correction of congenital defects or deformities NOT A BENEFIT Custodial Care NOT A BENEFIT NOT A BENEFIT NOT A BENEFIT Dental Services Contact Michigan Department of Community Health Contact Michigan Department of Community Health Diabetes Education Diabetic Supplies, Monitors & Strips, etc. (NO INSULIN PUMP) COVERED BENEFIT CONTRACTED THROUGH DELTA DENTAL Contact 866- Diabetic Supplies, Monitors & Strips, etc. (WITH INSULIN PUMP) Durable Medical Equipment Emergency Room Family Planning Services: Vasectomy, Tubal Ligation, etc. Genetic Testing Hearing Aid Hemodialysis ; Must meet specific ; Benefit for under age 21 ; Must meet specific ; Benefit for under age 21 YELLOW = Revised 07/14/ BLUE = Medicaid Benefits Provided by Another Entity Page 2 of 5
3 MIDWEST HEALTH Home Care: RN, Therapies for PT, OT, Speech, HHA, IV Therapy, etc. Hospice Care: Inpatient, Home, Hospice Facility Imaging (Advanced), such as: CT scan, MRI, PET Scan, etc. Imaging (Routine), such as: X-Rays-->Chest, Abdominal, Leg, Arm, etc. Immunizations for Adults & Children CDC/ACIP Recommended Infusible/Injectable Medication Therapy Inpatient Acute Care Hospitalization Inpatient Physical Rehabilitation (PM&R) INR (Home Monitoring) NOT A BENEFIT NOT A BENENFIT NOT A BENEFIT Lab Services (Genetic Testing Requires Prior Prescription/Order required Prescription/Order required Prescription/Order required Authorization) Life Vest (DME) Long Term Acute Care (LTAC) Maternal Infant Health Program (MIHP) OB Care, including: Office Visits, Ultrasound, NST s, etc. Other Studies, such as: Ultrasound, Doppler, Echocardiogram, etc. for in or out of network s (OPEN NETWORK ACCESS) for in or out of network s (OPEN NETWORK ACCESS) for in or out of network s (OPEN NETWORK ACCESS) Outpatient Diagnostics/Endoscopies, such as: Bronchoscopy, EGD, Hysteroscopy, etc. Outpatient Surgery, such as: Knee Arthroscopy, ORIF Ankle, Cataract Removal, etc. (Dental not included - see Dental) Check website for Procedures that require Medical Review YELLOW = Revised 07/14/ BLUE = Medicaid Benefits Provided by Another Entity Page 3 of 5
4 MIDWEST HEALTH Outpatient Therapy Evaluations ONLY: PT, OT, Speech Therapy Outpatient Therapy Treatment, such as: PT, OT, Speech Therapy Evaluation must accompany request Outpatient Treatment, such as: Chemotherapy, Radiation Therapy, etc. after initial after initial after initial Podiatry Prosthetics/Orthotics Pulmonary Rehabilitation Reduction Mammoplasty (female only) Routine Eye Exams, Glasses Benefit managed by Heritage Optical; call 800- Benefit managed by Heritage Optical; call 800- Benefit managed by Heritage Optical; call 800- School Services (Services provided by a school district and billed through the Intermediate School District) Screening Colonoscopy Second Surgical Opinion Skilled Nursing Facility Care Sleep Studies Limited to 45 days Limited to 120 days per admission After benefit days are exhausted, a lapse of at least 90 days from discharge date until the next admission Limited to 45 days Specialist - In-Network YELLOW = Revised 07/14/ BLUE = Medicaid Benefits Provided by Another Entity Page 4 of 5
5 MIDWEST HEALTH Specialist - Out of Network Speech Generating Devices (includes eye gazing devices) Substance Abuse Services (detoxification, intensive outpatient counseling & other outpatient services, medications for the purpose Refer to Community Mental Health, county of Refer to Community Mental Health, county of of substance use disorders, methadone, screening and assessment) Supplies, such as: Wound Care, Oxygen, Tube Feeding, Ostomy, Urological, etc. Transportation (medical) When arranged through MHP Customer Service 4 business days in advance Transportation is arranged through MHP Customer Service Department Refer to Community Mental Health, county of Transportation is arranged through MHP Customer Service Department 4 business days in advance Travel Vaccines NOT A BENEFIT NOT A BENEFIT NOT A BENEFIT Urgent Care Vein Procedures: Sclerotherapy, Stripping/Ligation, etc. Weight Loss Counseling NOT A BENEFIT NOT A BENEFIT NOT A BENEFIT Well Child Visits for MHP plan for MHP plan for MHP plan Well Woman Care: Annual Well-Woman exam, Pap Test, Mammogram for MHP plan for MHP plan for MHP plan YELLOW = Revised 07/14/ BLUE = Medicaid Benefits Provided by Another Entity Page 5 of 5
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
FACILITY BASED SERVICES
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
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