Basic Covered Benefits and Services

Transcription

1 Basic Covered Benefits and A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Bed Liners Coverage Covered for members age 4 and up; Prior Authorization for quantities greater than 200. Behavioral Health Outpatient Behavioral Health Inpatient Blood and Plasma Products Bone Mass Measurement (bone density) Care Management Chemotherapy Colorectal/Prostate Screening Exams CT Scans Dental Diabetic Education Outpatient Mental Health and Substance Abuse. 18 and above: 20 visits per fiscal year. Under age 18: 30 visits per fiscal year. Inpatient Hospitalization (Use your Medicaid ID card). 18 and above: 30 days per fiscal year covered for Medicaid members. Under age 18: covered by the Delaware Department of Prevention and Behavioral Health (DDPBHS) for the Delaware Healthy Children Program (DHCP) members and Medicaid members. Self-referred service. on amounts over $250. Self-referred service. Age 20 and younger: covered by the State of Delaware Medical Assistance Program Card. Please call for information. Age 21 and over: removal of bony impacted wisdom teeth is covered by UnitedHealthcare. Self-referred service. Member

2 Basic Covered Benefits and (cont.) 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) (for under age 21) Emergency Medical Transportation Emergency Room Care Eye Exam, Medical (for conditions such as diabetes and eye infections) Eye Exam, Routine Family Planning Genetic Testing Glaucoma Screening Gynecology Visits Hearing Aids and Batteries Coverage Insulin pump and supplies; Prior Authorization on amounts over $300 and all rentals. Glucose/Strips (covered by Delaware Medicaid: use your Medicaid ID card). Self-referred service. on quantities over 200. on amounts over $250. on amounts over $300. Self-referred service. Self-referred service. Air and ambulance. Self-referred service. Covered, all members. Covered if age 20 and younger. Self-referred service. Self-referred service. Covered if age 20 and younger. Self-referred service. 2 Diamond State Health Plan Plus Member Handbook

3 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 Obstetrical/Maternity Care Orthopedic Shoes Outpatient Surgery, Same Day Surgery, Ambulatory Pain Management Parenting / Child Birth Education Personal Care (in home) / Aide Podiatry Care (routine diabetic care or peripheral vascular disease) Coverage Self-referred service. Self-referred service. Self-referred service. Self-referred service. Self-referred service. on amounts over $300 and all rentals. Covered for the first 30 days, when medically necessary. Additional days are considered long term care; an application must be submitted to and approved by the Delaware Medical Assistance Program. on amounts over $300. Self-referred service. Member

4 Basic Covered Benefits and (cont.) Prescription Drugs Primary Care Provider Visits Private Duty Nursing Prosthetics and Orthotics Radiation Rehabilitation (inpatient hospital) Skilled Nursing Facility Care Sleep Apnea Studies / Sleep Therapy Smoking Cessation Counseling Specialty Physician Surgical Center Therapy - Outpatient Occupational, Physical, Speech Transportation Coverage Covered by Delaware Medicaid. Please call Self-referred service. on amounts over $300. Up to 30 days per year. Self-referred service. Routine Non-Emergency (Not covered for Delaware Healthy Children Program (DHCP) members. Covered for Medicaid members by Delaware Medicaid). 4 Diamond State Health Plan Plus Member Handbook

5 Enhanced Benefits The long term care services you can receive depend on your needs and whether you are receiving care in a nursing home or receiving care at home. The following long term care services are available to Diamond State Health Plan Plus members when the services have been determined to be cost-effective and medically necessary. Long term care includes help doing everyday activities that you may no longer be able to do for yourself as you grow older, or if you have a disability like bathing, dressing, getting around your home, preparing meals, or doing household chores. Long term care services include care in a nursing home. Long term care also includes care in your own home or in the community. These are called Home and Community Based or HCBS. Member

6 Enhanced Benefits (cont.) A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Benefit Description Requirements Adult Day Care A place that provides supervised care and activities during the day. Cognitive 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. Community-Based Residential Alternatives That Include Assisted Living Facilities A place where you live that provides help with personal care needs and taking your medicine. You must pay for your room and board. Day Habilitation 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. Home-Delivered Meals Up to 1 meal per day. In-Home Respite Care Someone to come and stay with you in your home for a short time, so your caregiver can get some rest. 6 Diamond State Health Plan Plus Member Handbook

7 Benefit Description Requirements In-Patient Respite Care Minor Home Modifications A short stay in a nursing home or assisted care living facility, so your caregiver can get some rest. Changes to your home to help you get around easier and safer when medically necessary. For example, a wheelchair ramp. Max $ Limits Nursing Facility Care Personal Care Attendant/Care Personal Emergency Response System (PERS) Specialized Durable Medical Equipment and Supplies 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). This kind of help is available if it s part of your plan of care. Examples: Light housekeeping chores. Shopping. Fixing a meal. 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. Live in a nursing home. 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. Member

8 Enhanced Benefits (cont.) Benefit Description Requirements Support for Consumer Direction Transition (Money Follows the Person Only) Transition Workshops Information and assistance to: Direct your Personal Care/Attendant services yourself. 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. Available under the Money Follows the Person only. Max $ Limits Covered Benefit Changes UnitedHealthcare Community Plan may change the benefits and services we cover. If we do change our benefits, we will tell you in writing, when we can, before the change occurs. 8 Diamond State Health Plan Plus Member Handbook