Covered Benefits Matrix for Children
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- Melinda Goodwin
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1 Medicaid Managed Care The matrix below lists the available for children (under age 21) enrolled in the West Virginia Mountain Health Trust and s. Ambulance Ambulatory surgical center services Some services require prior authorization. Behavioral health rehabilitation Residential treatment (see Behavioral Health Benefits Matrix) Chiropractic services Covered 24 visits per calendar year Clinic services Dental services Dental services are covered for children younger than age 21 when provided by a dentist, orthodontist or oral surgeon. Diabetes care Durable medical equipment (DME) Prior authorization is required. Orthotics and prosthetics Custom DME Early and periodic screening, diagnosis and treatment (EPSDT) services Health and developmental history during well-child visits Physical exam Hearing, vision and dental screenings Lab tests (including blood lead levels) Immunizations Ambulance Ambulatory surgical center services Some services require prior authorization. Behavioral health rehabilitation Residential treatment (see Behavioral Health Benefits Matrix) Chiropractic services Covered 24 visits per calendar year Clinic services Dental services Dental services are covered for children ages 19 and 20 when provided by a dentist, orthodontist or oral surgeon. Diabetes care Durable medical equipment (DME) Prior authorization is required. Orthotics and prosthetics Custom DME Early and periodic screening, diagnosis and treatment (EPSDT) services Health and developmental history during well-child visits Physical exam Hearing, vision and dental screenings Lab tests (including blood lead levels) Immunizations UniCare Health Plan of West Virginia, Inc. WEBPUWV July
2 Page 2 of 6 Family planning Family planning clinics Private physicians Services and supplies Family planning, education and Medical visits for birth control Human papillomavirus (HPV) testing for women age 18 and older Pregnancy tests Lab tests Tests for sexually transmitted infections (STIs) Screening, testing, and referral for treatment for members at risk for HIV The following items are not considered family planning: Hysterectomies Abortions* * Abortions are covered directly by the state s fee-for-service. Hearing One hearing aid is covered every five years. Prior authorization is required for some services. Hearing aid evaluations, hearing aids, hearing aid supplies, batteries and repairs are limited to recipients under age 21. Family planning Family planning clinics Private physicians Services and supplies Family planning, education and Medical visits for birth control Human papillomavirus (HPV) testing for women age 18 and older Pregnancy tests Lab tests Tests for sexually transmitted infections (STIs) Screening, testing, and referral for treatment for members at risk for HIV The following items are not considered family planning: Hysterectomies Abortions* * Abortions are covered directly by the state s fee-for-service. Hearing One hearing aid is covered every five years. Prior authorization is required for some services. Hearing aid evaluations, hearing aids, hearing aid supplies, batteries and repairs are limited to recipients under age 21.
3 Page 3 of 6 Home health (including skilled nursing) Services are provided at the recipient s place of residence on orders of a physician. Place of residence is not any of the following: Hospital nursing facility Intermediate care facility State institution 60 visits per benefit year (prior authorization Hospice Nursing care Physician services Medical social services Short-term inpatient care DME Drugs Biologicals Home health aide and homemaker There must be physician certification that the recipient has a life expectancy of six months or less. Inpatient services Prior authorization is required. Unlimited, medically necessary days are covered.* Inpatient hospital care Inpatient rehabilitation Inpatient behavioral health and substance abuse treatment * Members who are awaiting or have received an organ or tissue transplant are covered directly by the state s fee-for-service Medicaid program. Nonemergency medical transportation Nursing home services Home health (including skilled nursing) Services are provided at the recipient s place of residence on orders of a physician. Place of residence is not any of the following: Hospital nursing facility Intermediate care facility State institution 100 visits per benefit year (prior authorization Hospice Nursing care Physician services Medical social services Short-term inpatient care DME Drugs Biologicals Home health aide and homemaker There must be physician certification that the recipient has a life expectancy of six months or less. Inpatient services Prior authorization is required. Unlimited, medically necessary days are covered.* Inpatient hospital care Inpatient rehabilitation Inpatient behavioral health and substance abuse treatment * Members who are awaiting or have received an organ or tissue transplant are covered directly by the state s fee-for-service Medicaid program. Nonemergency medical transportation Nursing home services
4 Page 4 of 6 Nutritional education Self-enrollment in Weight Watchers program (for children age 13 and older) Outpatient services Diagnostic X-rays, lab services and testing* Services for Birth to Three program (covered directly by the state s fee-for-service ) Occupational, speech and physical therapies Augmentation communication devices (prior authorization Cardiac rehabilitation Pulmonary rehabilitation Chemical dependency and mental health services (prior authorization Behavioral health Diabetes education and nutritional * CTs, MRIs, PET MRAs and SPECTs require prior authorization. For combined therapies (includes physical and occupational therapy services billed as professional and outpatient): 10 visits per 12 rolling months without prior authorization For speech therapy: 10 visits per 12 rolling months without prior authorization There is no limit to medically necessary services with prior authorization. Personal care services Nutritional education Self-enrollment in Weight Watchers program (for children age 13 and older) Outpatient services Diagnostic X-rays, lab services and testing* Occupational, speech and physical therapies Augmentation communication devices (prior authorization Cardiac rehabilitation Pulmonary rehabilitation Chemical dependency and mental health services (prior authorization Behavioral health Diabetes education and nutritional * CTs, MRIs, PET MRAs and SPECTs require prior authorization. For combined therapies (includes physical and occupational therapy services billed as professional and outpatient): 30 visits per 12 rolling months without prior authorization For speech therapy: 10 visits per 12 rolling months without prior authorization There is no limit to medically necessary services with prior authorization. Personal care services Not covered
5 Page 5 of 6 Physicians, nurse practitioners, midwives, rural health clinics (RHCs) and federally qualified health centers (FQHCs) Diabetes education and nutrition (includes annual dilated retinal eye exam for diabetic members) Intermittent visiting nurse care (in designated shortage areas) Primary care office visits Physician office visits (including specialty care) Physicians and physician assistants Podiatry services:* o Treatment for acute conditions (infections, inflammations, ulcers and bursitis) o Surgeries for bunions and ingrown toenails o Reduction of fractures, dislocation and treatment of sprains o Orthotics Nurse practitioners Nurse midwife services Supplies Well-child visits * Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered. Prescriptions Prescriptions are covered and paid by the state s fee-for-service. Private duty nursing/skilled nursing care Prior authorization is required. Psychological services For more details, see the Behavioral Health Benefits Matrix. Physicians, nurse practitioners, midwives, rural health clinics (RHCs) and federally qualified health centers (FQHCs) Diabetes education and nutrition (includes annual dilated retinal eye exam for diabetic members) Intermittent visiting nurse care (in designated shortage areas) Primary care office visits Physician office visits (including specialty care) Physicians and physician assistants Podiatry services:* o Treatment for acute conditions (infections, inflammations, ulcers and bursitis) o Surgeries for bunions and ingrown toenails o Reduction of fractures, dislocation and treatment of sprains o Orthotics Nurse practitioners Nurse midwife services Supplies Well-child visits * Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered. Prescriptions Prescriptions are covered and paid by the state s fee-for-service. Private duty nursing/skilled nursing care Prior authorization is required. Psychological services For more details, see the Behavioral Health Benefits Matrix.
6 Page 6 of 6 Right From the Start (RFTS) RFTS is a statewide home visitation program committed to improving birth outcomes for pregnant women and their families. Coordinating childbirth and parenting classes Arranging transportation to medical appointments Assisting with quitting smoking Guiding healthier eating habits for patients and their babies School-based services Services for children who are handicapped/ children with special health care needs Tobacco cessation Information on smoking and tobacco cessation is available through the UniCare Health Plan of West Virginia, Inc. Health Education program (includes access to the Quit Line). Vision services Exam (every 12 months) Lenses, frames and needed repairs (every 12 months) Contact lenses (for certain diagnoses) Vision care excludes prescription sunglasses and designer frames. Right From the Start (RFTS) RFTS is a statewide home visitation program committed to improving birth outcomes for pregnant women and their families. Coordinating childbirth and parenting classes Arranging transportation to medical appointments Assisting with quitting smoking Guiding healthier eating habits for patients and their babies School-based services Services for children who are handicapped/ children with special health care needs Tobacco cessation Information on smoking and tobacco cessation is available through the UniCare Health Plan of West Virginia, Inc. Health Education program (includes access to the Quit Line). Vision services Exam (every 12 months) Lenses, frames and needed repairs (every 12 months) Contact lenses (for certain diagnoses) Vision care excludes prescription sunglasses and designer frames.
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