2017 Comparison of the State of Iowa Medicaid Enterprise Basic Benefits Based on Eligibility Determination
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1 General Plan Provisions Benefits Available from Out-of-Network Providers 2017 Comparison of the State of Iowa Enterprise Cost Sharing: A variety of methods are used to share expenses between the state and a member. These methods include monthly cost shares, copays, and premiums. Copayments Please contact Member Services to determine the requirements for using an out-of-network provider. Variable copayments based on eligibility are not listed. Please contact Member Services for further details. Please contact Member Services to determine the requirements for using an out-of-network provider. Variable copayments based on eligibility are not listed. Please contact Member Services for further details. Persons under age 21, all services $0.00 $0.00 $0.00 Persons over age 21, most services Persons receiving long-term care institutional Copayment Exceptions Family planning services or supplies regardless of age $1.00 to $3.00 based on types of services Based on family income level Please contact Member Services to determine the requirements for using an out-of-network provider. Variable copayments based on eligibility are not listed. Please contact Member Services for further details. $0.00 Not applicable Not applicable $0.00 $0.00 $0.00 Pregnant women, all services $0.00 $0.00 $0.00 Emergency services $0.00 $0.00 $0.00 Members under the age of 21 $0.00 $0.00 $0.00 Not applicable Comm. 519 (7/17) Page 1 of 10
2 Preventative Services 2017 Comparison of the State of Iowa Enterprise Affordable Care Act (ACA) preventive services Routine check-ups ; limitations may Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) up to age 21 Immunizations ; limitations may Professional Office Services Primary care provider Office visit Allergy testing Allergy serum and injections Certified nurse midwife services Chiropractor ; limitations may ; limitations may Contraceptive devices Diabetic self-management training ; once per member, lifetime maximum ; 10 hours of outpatient selfmanagement training within a 12 month period plus follow-up training of up to 2 hours annually ; limitations may ; limitations may Comm. 519 (7/17) Page 2 of 10
3 Family planning and family planning related services 2017 Comparison of the State of Iowa Enterprise Gynecological exam ; limited to one visit per year Injections ; limitations may ; limitations may Laboratory tests Newborn child - office visits Podiatry Routine eye exam One routine vision exam per calendar year. Routine hearing exam One routine hearing exam per calendar year. Specialist office visit Hospital Services Inpatient Hospital Admissions Preapproval of inpatient admissions ; routine foot care is not covered unless it is part of a member's overall treatment related to certain health care conditions. ; routine foot care is not covered unless it is part of a member's overall treatment related to certain health care conditions. ; limitations may ; PCP referral may be Required for non-emergent admissions ; PCP referral may be Required for non-emergent admissions ; PCP referral may be Required for non-emergent admissions Comm. 519 (7/17) Page 3 of 10
4 2017 Comparison of the State of Iowa Enterprise Inpatient Hospital Services Room and board Inpatient physician services ; includes anesthesia ; includes anesthesia Inpatient supplies Inpatient surgery Bariatric surgery for morbid obesity ; limitations may Breast reconstruction, following breast cancer and mastectomy ; limitations may Organ/bone marrow transplants ; limitations ; limitations ; limitations Outpatient Hospital Services Abortions Certain circumstances must. Contact Member Services. Prior authorization. Certain circumstances must. Contact Member Services. Prior authorization. ; certain circumstances must. Contact Member Services. Prior authorization. Ambulatory surgical center ; includes anesthesia ; includes anesthesia ; includes anesthesia Chemotherapy Dialysis Outpatient diagnostic lab, radiology Comm. 519 (7/17) Page 4 of 10
5 Emergency Care 2017 Comparison of the State of Iowa Enterprise Ambulance Urgent care center ; may require prior authorization Hospital emergency room ; $3.00 per visit for non-emergent medical services ; $3.00 per visit for non-emergent medical services Non-Emergency Medical Transportation (NEMT) Behavioral Health Services Assertive Community Treatment (ACT) Behavioral Health Intervention Services (BHIS), including applied behavior analysis (b)(3) services (intensive psychiatric rehabilitation, community support services, peer support, and residential substance use treatment) Inpatient mental health and substance abuse treatment (MCO members only) ; residential treatment is not covered ; residential treatment is not covered ; emergency services for non-emergent conditions are subject to a $25 copay if the family pays a premium for the program Office visit Outpatient mental health and substance abuse Comm. 519 (7/17) Page 5 of 10
6 Psychiatric Medical Institutions for Children (PMIC) Outpatient Therapy Services Cardiac rehabilitation Occupational therapy Oxygen therapy Physical therapy Pulmonary therapy Respiratory therapy Speech therapy 2017 Comparison of the State of Iowa Enterprise for 19 to 20 year olds. Limitations may Limited to 60 visits per year Limited to 60 visits in a 12-month period Limited to 60 visits per year Limited to 60 visits per year Limited to 60 visits per year Limited to 60 visits per year Comm. 519 (7/17) Page 6 of 10
7 Prescription Drug Coverage Quantity 2017 Comparison of the State of Iowa Enterprise 31-day supply for all prescriptions except contraceptives which is a 90-day supply 31-day supply for all prescriptions except contraceptives which is a 90-day supply 31-day supply for all prescriptions except contraceptives which is a 90-day supply Prescription Drug Copay Generic copay ; $1.00 copay ; $0.00 copay ; $0.00 copay Preferred brand-name ; $1.00 copay ; $0.00 copay ; $0.00 copay Non-preferred brand-name $1.00 copay for prescriptions under $25.00 $2.00 copay for prescriptions between $25.01 to $50.00 or the preferred copay with a Prior Authorization $3.00 copay for prescriptions $50.01 or more or the preferred copay with a Prior Authorization ;$0.00 copay Prescription oral contraceptives ; $0.00 copay Prescription and non-prescription drugs for smoking cessation Comm. 519 (7/17) Page 7 of 10
8 Radiology Services 2017 Comparison of the State of Iowa Enterprise Mammography Routine radiology screening and diagnostic services Sleep study testing ; sleep apnea diagnostic services only Laboratory Services Colorectal cancer screening Diagnostic genetic testing ; Prior Authorization Pap smears Pathology tests Routine laboratory screening and diagnostic services Sexually Transmitted Infection (STI) and Sexually Transmitted Disease (STD) testing Durable Medical Equipment (DME) Medical equipment and supplies Diabetes equipment and supplies ; limitations may Eye glasses ; limitations may for ages 19 to 20, limitations may ; limitations may Comm. 519 (7/17) Page 8 of 10
9 2017 Comparison of the State of Iowa Enterprise Hearing aids for ages 19 to 20, limitations may Orthotics ; limitations may Long Term Services Supports (LTSS) Community Based Case management for individuals with a developmental disability and HCBS Waiver populations only ; limitations may ; limitations may and Prior authorization Child care medical services Private duty nursing/personal cares per EPSDT authority Section 1915(C) Home- and Community-Based Services (HCBS) up to age 21 under EPSDT up to age 21 under EPSDT Section 1915(I) Habilitation Services Home health services: Home health aid Skilled nursing Therapies (PT/OT/Speech) Comm. 519 (7/17) Page 9 of 10
10 2017 Comparison of the State of Iowa Enterprise Long Term Services and Support (LTSS) Institutional ICF/ID (Intermediate Care Facility for individuals with Intellectual Disabilities) Nursing Facility (NF) and Nursing Facility for the Mentally Ill (NF/MI) ; limitations ; limitations Skilled Nursing Facilities (SNF) ; limitations ; limitations, limited to 120 day stays Special Population Skilled Nursing Facility Out of State (Skilled preapproval) Hospice Daily categories: Routine care If member is residing in a Nursing Facility, room and board charges covered at 95% Facility respite Inpatient hospital Continuous Health Homes ; limitations ; limitations Chronic condition health homes if member has been determined to be medically exempt Integrated Health Homes if member has been determined to be medically exempt Comm. 519 (7/17) Page 10 of 10
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