SERVICES COVERAGE LIMITS/ EXCLUSIONS Alcohol, Drug, and Substance Abuse Services
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1 SERVICES COVERAGE LIMITS/ EXCLUSIONS Alcohol, Drug, and Substance Abuse Services Alcohol, drug, and substance abuse treatment services are provided by the Department of Alcohol and Other Drug Abuse Services (DAODAS). Ambulance Services Emergency transportation given by: Ambulance Air ambulance Ancillary Medical Services Example: anesthesiology MyMolina.com 25
2 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Audiological Services Autism Spectrum Disorder Chiropractic Services Communicable Disease Services Covered only for children under 21 years of age. Services include: Examinations Fittings and related audiology services Diagnosis, screening, preventive and corrective services for members with hearing disorder or to determine hearing disorder Behavior Identification Assessment (ABA) Adaptive Behavior Treatment Protocol Modification Observational Behavioral Follow-up Assessment Exposure Behavioral Follow-up Assessment Adaptive Behavioral Treatment by Protocol Family Adaptive Behavior Treatment Guidance Family Training and Related Program Development Limited to manual manipulation of the spine using the hands to put the bones of the spine back in line. Exams and reviews including but not limited to: Taking steps to find out what s wrong with you and treat you Contact tracing Counseling and health education Directly Observed Therapy (DOT) for tuberculosis (TB) cases. Help controlling and preventing diseases such as TB, syphilis, and other sexually transmitted infections (STIs) and HIV/AIDS Only covered for children under 21 years of age. Limited to 8 visits per year. 2 x-ray procedures per fiscal year. NOTE: These services can also be received at Department of Health and Environmental Control (DHEC). 26 (855)
3 SERVICES COVERAGE LIMITS/ EXCLUSIONS Disease Management Durable Medical Equipment and Supplies This includes keeping track of any medical conditions/ diseases, and educating you regarding available treatment options. Covered when medically necessary. Equipment may require Prior Approval from your doctor. Medically necessary equipment and supplies, including: Medical products Surgical supplies Wheelchairs Traction equipment Walkers Canes Crutches Ventilators Prosthetic devices Orthotic devices Oxygen Hearing aids and accessories Diabetes supplies Incontinence supplies Any other items when ordered by a doctor as medically necessary MyMolina.com 27
4 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Emergency Medical Services Family Planning Health Care Screenings for Adults Call your Primary Care Provider (PCP) as soon as possible. All emergency services are covered. You do not need approval from Molina Healthcare of South Carolina for any emergency services. This includes medical visits for birth control: Teaching you about family planning Counseling Birth control drugs and supplies Pregnancy tests Lab tests Tests for sexually transmitted infections (STIs) Sterilization Teen pregnancy prevention program Mammography screening Prostate cancer screening Cholesterol screening Influenza, pneumococcal and hepatitis vaccines Cervical cancer screenings Chlamydia screening Prenatal visits We do not cover: Surgery to reverse sterilization Hysterectomy for sterilization reasons 28 (855)
5 SERVICES COVERAGE LIMITS/ EXCLUSIONS Hearing Exams, Hearing Aids and Hearing Aid Accessories Covered for members under age 21. Hearing exams Hearing aids and supplies Only for children under 21 years of age. Home Health Services Medical visits that take place in the home from time to time which can include: Skilled nursing Home health aides Medical supplies and equipment fit for use in the home Physical, occupational and speech therapy Supplies ordered by a doctor Limited to 50 visits per year. MyMolina.com 29
6 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Hospitalization including services normally provided by the hospital All hospital services must be ordered by a doctor. These hospital services may include: A semi-private room Maternity services Special treatment rooms Operating rooms Supplies Medical tests and x-rays Drugs the hospital gives you during your stay Giving you someone else s blood Radiation therapy Chemotherapy Dialysis treatment Meals and special diets General nursing services Anesthesia Anesthesia for dental procedures when it is an emergency Setting up a plan for when you leave the hospital (this includes future care if you need it) Rehabilitation in the hospital Private rooms are not covered unless medically necessary. $25.00 co-payment per hospital admission. Co-pay only applies to members ages 19 and older who are not pregnant. 30 (855)
7 SERVICES COVERAGE LIMITS/ EXCLUSIONS Hysterectomies, Sterilizations and Abortions Covered when they are non-elective and medically necessary. We do not cover: Surgery to reverse sterilization Hysterectomy for sterilization reasons Abortion services (unless they are needed to save a mother s life or to end a pregnancy caused by rape or incest) Laboratory Exams and x-rays Medically necessary lab and x-ray services ordered by your provider. MyMolina.com 31
8 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Long Term Care Facilities/Nursing Home Facilities Covered for first 90 days (or until disenrollment from plan) when you are approved for and admitted to a longterm care facility. Limited to the first 90 days in a row. Maximum limit of covered days is 120 Maternity Services This may include the following services: Doctor visits and all expert care for pregnancy, problems that have to do with pregnancy and afterdelivery care when medically necessary Services you get from a certified nurse- midwife Tests you need such as sonograms HIV testing, treatment and counseling (A pregnant member may refuse to take an HIV test) Birthing center services Vaginal childbirth and Cesarean section (C-section) Newborn hearing screenings 32 (855)
9 SERVICES COVERAGE LIMITS/ EXCLUSIONS Newborn Hearing Screening Covered for members up to six months of age in either inpatient or out-patient setting without Prior Authorization. Must be performed within the first six (6) months of life. Outpatient Pediatric AIDS Clinic Services (OPAC) Services for HIV-related and exposed children and their families including: Specialty care Consults Counseling Clinical and lab tests MyMolina.com 33
10 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Outpatient Services Services must be ordered by a doctor and may include: Care to prevent illness Care to treat your health issue Rehabilitation Surgical care Emergency care Psychiatric assessment Substance abuse assessment Treatment of renal disease Neurodevelopmental or mental developmental assessment and testing Dialysis Emergency room use for emergency conditions Drugs ordered by a doctor Giving you replacement blood Services to prevent problems or find out what is wrong with you Surgery without an overnight hospital stay Sterilization Neurodevelopmental or mental developmental assessments and testing are only for eligible members under 21 years of age. $3.40 co-pay per visit (except emergency room visits). Co-pay only applies to members ages 19 and older who are not pregnant. 34 (855)
11 SERVICES COVERAGE LIMITS/ EXCLUSIONS Prescription Drugs An approval from Molina is required for some drugs. Some drugs are not covered, check the Preferred Drug List (PDL). Under certain circumstances the four (4) prescription limit may not apply for members ages 19 and older. $3.40 co-pay per prescription/refill excludes contraceptives. Physician Services This includes services provided by a Physician or Nurse Practitioner or Rural Health Clinic RHC or Federally Qualified Health Center FQHC. Co-pay only applies to members ages 19 and older who are not pregnant. MyMolina.com 35
12 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Psychiatric Assessment/ Treatment Services Psychiatric assessment services that you may get in your doctor s office. The following visits may be given by the following types of providers: Psychiatric interview exam provided by a doctor and private psychiatrist Psychiatric interview by a private psychiatrist only Behavioral health services given in the emergency room Psychiatric Residential Treatment Facility (PRTF) Services The following services are covered: General Room and Board Semi Private Ward Psychiatric and psychological sessions, screenings, medication training and support, crisis intervention, alcohol and drug services, monitoring of medical conditions such as diabetes and waiver services not otherwise specified. Therapeutic Home Time (THT) limited to 15 days per year. 36 (855)
13 SERVICES COVERAGE LIMITS/ EXCLUSIONS Rehabilitative Behavioral Health Services (RBHS)/Mental Health Services Psychological Evaluations Outpatient Psychotherapy Medication Management (provided by Medical Doctor or Nurse Practitioner) Specialty Pharmacy Drugs (injectable) Community Support Consultations/Conferences Psychological Testing Neuropsychological Testing Crisis Intervention Services Rehabilitative Services for Children Services include: physical therapy, occupational therapy, speech therapy, audiology and nursing services. Children who may have medical risk factors can have their: Health status assessed Risk factors identified Goal-oriented plan of care written or changed MyMolina.com 37
14 Your Policy SERVICES COVERAGE LIMITS/ EXCLUSIONS Transplant Services Vision Services Well Child Visits for Children including Early and Periodic Screening, Diagnosis and Treatment/Well Child Services (EPSDT) Please see page 43 for more details on EPSDT Must have approval from a doctor before transplant can be performed. Types of transplants include: Kidney Corneal Bone Marrow (Autologous Inpatient and Outpatient, Allogeneic Related and Unrelated, Cord, and Mismatched) Pancreas Heart Liver Liver with Small Bowel Liver/Pancreas Liver/Kidney Kidney/Pancreas Lung and Heart/Lung Multivisceral Small Bowel Covered only for children through the month of their 21st birthday. Preventive health care services include: Health screens Physical exams Vaccines Lab tests, including blood lead level Teaching about health topics Hearing tests Dental and vision screenings Well Child visits end on the month of the child s 21st birthday. 38 (855)
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