SERVICES COVERED BY PHP FamilyCare
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1 SERVICES COVERED BY PHP FamilyCare PHP FamilyCare cvers the same services that Medicaid des. Cverage is nt available unless the service is medically necessary. Cverage is als nt available unless the service is prvided by r n the referral f yur PCP. The services listed belw, and the times when they are cvered are described in mre detail in yur COC. Review yur COC t get a better understanding f what services are cvered. Cvered Services are: Ambulance and ther emergency medical transprtatin Ambulatry (Outpatient) surgery Artificial limbs and rthtics Bld tests fr children t check fr lead Certified Nurse Midwife services Certified Pediatric and Family Nurse Practitiner services Childhd and adult preventative immunizatins Chirpractic services Dental services (nly fr treatment related t an accident) Early peridic screening, diagnsis and treatment services (EPSDT) Emergency services Family planning services Health educatin and utreach Hearing aids, under 21 years f age Hearing services Hme health care services Hspice services Inpatient hspital services Intermittent r shrt-term restrative r rehabilitative services; up t 45 days in a nursing facility Kidney failure, including dialysis services Labratry, x-ray, and ther diagnstic services Maternity care Medical supplies and equipment Medically necessary weight reductin services Mental health services (up t 20 utpatient visits per year) Out f State services with apprval Outpatient hspital services Parenting and birthing classes Physical, Speech and ther therapies Physician and ther practitiner services Pdiatry services Prescriptin drugs Preventative care and screenings
2 Restrative r rehabilitative services; in a place f service ther than a nursing facility Tbacc Cessatin services, including drug and supprt services Transplant services Transprtatin Treatment fr sexually transmitted disease (STD) Visin services Well Child/EPSDT services fr persns under 21 Eye Exams and Glasses PHP FamilyCare cvers visin services when prvided by a PHP FamilyCare netwrk prvider. PHP FamilyCare will cver eye exams and certain types f prescriptin eyeglasses. One rutine eye exam is cvered nce every tw years. One pair f glasses is cvered nce every year fr members under 21 years f age. Fr members 21 years and ver ne pair f glasses is cvered every tw years. Services needed as a result f eye trauma and eye disease will be cvered fr all members. Replacements and repairs t yur glasses are cvered as fllws: Tw pair per year fr members under 21 years f age. Yu d nt need a referral frm yur PCP fr a rutine eye exam. Eye exams fr a medical prblem will be cvered as lng as yur PCP refers yu. Durable Medical Equipment PHP FamilyCare cvers necessary durable medical equipment such as crutches r wheelchairs. Yur PCP must arrange fr any durable medical equipment yu may need. In mst cases, yu must get yur durable medical equipment frm a prvider in the PHP FamilyCare netwrk. Hspice Services Hspice service is a medical prgram designed t prvide fr and relieve the suffering f terminally ill peple. PHP FamilyCare cvers hspice services. Please call yur PCP t arrange fr hspice services. Mental Health PHP Family Care cvers 20 utpatient visits fr mental health services. Be sure t g t a mental health prvider in ur netwrk. Yu can find this infrmatin in the PHP Family Care Prvider Directry. Call PHP Family Care Custmer Service at fr help with mental health services. Yu d nt need a referral frm yur PCP t get mental health services when yu g t a mental health prvider in the netwrk. If yu have a serius mental health illness, yu may be referred t the Cmmunity
3 Mental Health Services in yur cunty. Pharmacy Benefits PHP FamilyCare prvides cverage fr prescriptin drugs. Yur dctr will decide if and when yu need a drug. Yu will need a prescriptin t get the drug yu need. Yu will need t shw bth yur PHP FamilyCare ID card and yur Medicaid mihealth card when yu g t the pharmacy. There are many lcal pharmacies in the PHP FamilyCare netwrk. Please lk in yur PHP FamilyCare Prvider Directry fr the pharmacy nearest yu. PHP FamilyCare has a list f cvered and nn-cvered drugs. There are sme drugs that yur dctr must call PHP FamilyCare t get apprved befre yu can get them. PHP FamilyCare will als cver certain ver-the-cunter (OTC) medicatins as lng as yu have a prescriptin frm yur dctr. Please call the PHP FamilyCare Custmer Service Department at if yu have any questins abut yur prescriptin drug cverage. Pregnancy Services The first step t having a healthy baby is t learn all yu can abut yur health. Prper care during pregnancy is the best way t be sure yu have a healthy baby. If yu think yu may be pregnant, call yur dctr right away. Yur baby's health and yur health depend n it. Discuss yur health backgrund and lifestyle with yur dctr. This will help yur dctr see if yu are at risk f early labr. Maternal Infant Health Prgram (MIHP) Yur prenatal care prvider may refer yu t the Maternal Infant Health Prgram (MIHP). This is a prgram that prvides a nurse, scial wrker and nutritinist t help yu wrk tward a healthy delivery. Yur dctr may als refer yur newbrn. This prgram helps babies have a healthy first year. All pregnant wmen are eligible fr an assessment. Check with yur dctr r call PHP FamilyCare Custmer services t learn hw t get this service. Wmen, Infant and Children (WIC) Supplemental Fd & Nutritin Prgram Wmen, Infants, and Children (WIC) is a gvernment nutritin prgram. WIC will teach yu hw t eat healthy and help by giving yu and yur children nutritinal fd. The WIC prgram is fr pregnant wmen, wmen wh have just had a baby, wmen wh are breast-feeding babies, infants, and children up t 5 years ld. If yu wuld like t knw mre abut WIC, call the PHP Custmer Service Department. Early, Peridic Screening Diagnsis and Treatment (EPSDT) Yur children are imprtant t us at PHP FamilyCare. There is a special prgram fr children under age 21, cvered by Medicaid. It is called Early and Peridic Screening, Diagnsis, and Treatment (EPSDT). This prgram prvides regular health checkups fr yur child. These well child checkups are imprtant!
4 EPSDT can help with: Finding yur child's health prblems early. If yu think yur child has a medical prblem, talk with yur dctr abut EPSDT. Prviding infrmatin abut all the special health services available fr yur children. Keeping yur children healthy by giving them the shts they need, when they need them. Pediatric Care Care fr yur children may be received frm a pediatrician r any ther PCP r certified nurse practitiner. Yur children may be seen by a PHP FamilyCare netwrk pediatrician fr rutine/general services withut prir authrizatin r referral. Family Planning Services Yu can get family planning services frm yur PHP FamilyCare dctr. Yu can als get family planning services frm ther prviders. This may include anther dctr, a nurse practitiner, a family planning clinic, adlescent health center r yur lcal health department. Yu d nt need a referral frm yur PCP t see anther PHP FamilyCare dctr r nurse fr family planning services. Child and Adlescent Health Center Yu can als chse t btain services cvered by PHP FamilyCare frm a Child and Adlescent Health Center and Prgram (CAHCP). If yu chse t btain services at a lcal CAHCP yu d nt need a referral t see the prvider there. If there is a service that des require a referral yu and the prvider shuld fllw the rules listed in this Member Handbk. Sexually Transmitted Disease (STDs) Services STDs are spread thrugh sexual cntact. If yu think that yu have an STD, there is help fr yu. Yur dctr can ffer yu testing, treatment and cunseling. All infrmatin abut yur care will be cnfidential. Yu can get care frm yur PCP, yur lcal health department r a family planning clinic listed in yur PHP FamilyCare Prvider Directry. Yu d nt need a referral frm yur PCP fr these services. Centers fr Disease Cntrl and Preventin Natinal Immunizatin Prgram The Centers fr Disease Cntrl and Preventin (CDC) ffers a tll free service fr peple t request infrmatin n bth childhd and adult immunizatin shts. Infrmatin available includes: When shts shuld be taken and hw t keep track f them Pssible side effects Why shts are imprtant t yur health Answers t frequently asked questins
5 The number t call is: (English) (Spanish) Phnes are answered frm 8:00 a.m. t 11:00 p.m. EST Mnday thrugh Friday. At ther times, yu can leave a recrded message and get a respnse in 2-3 business days. Transprtatin Services PHP FamilyCare can help yu with nn-emergency transprtatin. PHP FamilyCare will prvide transprtatin fr cvered services nly. Yu can get help with getting a ride if: Yu d nt have a way t get t and frm yur dctr visit; r Yu d nt have a way t get cvered medical items r services. Cntact PHP FamilyCare's Custmer Service Department fr help. Let us knw 5 days in advance if yu need bus passes, tkens r special transprtatin. Please call PHP FamilyCare at as sn as pssible if yu need t cancel yur ride. Members may lse their right t use transprtatin services if they abuse the service. Sme examples are: Letting a nn-member use the service. Repeatedly missing the rides. Getting rides fr unrelated services. All emergency ambulance services are cvered by PHP FamilyCare. Care Management Prgram We want t make sure that yu receive quality health care. We will wrk with yur prviders t: Make sure we knw abut all yur hspital stays and the services yu may receive. Make sure yu receive any services yu need after yu leave the hspital. Make sure yu receive care management services if needed. If yu have any questins, please call Children s Special Health Care Services (CSHCS) Prgram CSHCS is a state f Michigan prgram that serves children, and sme adults, with special health care needs. CSHCS cvers mre than 2,700 medical diagnses. Additinal Benefits fr Medical Health Plan Enrllees with Children s Special Health Care Services 1. Help frm yur Lcal Health Department with: Cmmunity resurces schls, cmmunity mental health, financial supprt, childcare, Early On, and the Wmen Infants and Children (WIC) prgram
6 Transitining t adulthd Orthdntia Only fr specific CSHCS qualifying diagnsis, such as Cleft Palate/Cleft lip Medically necessary, related t cnditin Nt fr csmetic purpses Respite CSHCS cvers 180 hurs f respite care annually when a beneficiary requires skilled nursing and a CSHCS nurse cnsultant determines apprpriate 2. Help frm the Family Center fr Children and Yuth with Special Health Care Needs CSHCS Family Phne Line a tll-free phne number ( ) available Mnday thrugh Friday frm 8 a.m. t 5 p.m. Parent-t-parent supprt netwrk Parent/Prfessinal training prgrams Financial help t g t cnferences abut CSHVS medical cnditins and Relatively Speaking, a cnference fr siblings f children with special needs. 3. Help frm the Children s Special Needs (CSN) Fund The CSH Fund helps CSHCS families get items nt cvered by Medicaid r CSHCS. T see if yu qualify fr help frm the CSN Fund, call Examples include: Wheelchair ramps Van lifts and tie dwns Therapeutic tricycles Air Cnditiners Adaptive recreatinal equipment Electrical service upgrades fr eligible equipment
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