Medicaid Benefits at a Glance

Transcription

1 Medicaid Benefits at a Glance Mountain Health Trust Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, as well as private practitioners. Practitioner services; lab and X-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs and DME are excluded. Inpatient Services Inpatient hospital care: Inpatient care under the direction of a practitioner. All elective, tertiary, facility-to-facility and out-of-area requires pre-authorization. Inpatient rehabilitation: Services related to inpatient facilities that provide rehabilitation services for Medicaid eligible individuals under the age of 21 (in a rehabilitation facility; limited to 60 days per calendar year) requires preauthorization. Inpatient behavioral health and substance abuse related to the treatment of mental disorders or substance abuse disorders. Inpatient psychiatric services: Services furnished at a psychiatric hospital or a distinct part psychiatric unit of an acute care or general hospital under the direction of a practitioner for persons under age 21. Outpatient Services Hospital services, outpatient: Medical services furnished on an outpatient basis by a hospital, regardless of the type of practitioner ordering the service. Includes preventive, diagnostic, Adults (21 years and older) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, as well as private practitioners. Practitioner services; lab and X-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs and DME are excluded. Inpatient Services There may be a copay. Inpatient hospital care: Inpatient care under the direction of a practitioner. All elective, tertiary, facility to facility, and out-of-area requires pre-authorization. Inpatient behavioral health and substance abuse related to the treatment of mental disorders or substance abuse disorders. Outpatient Services Hospital services, outpatient: Medical services furnished on an outpatient basis by a hospital, regardless of the type of practitioner ordering the service. Includes preventive, diagnostic,

2 therapeutic, all emergency services, or rehabilitative medical services. Diagnostic X-ray, laboratory services, and testing: Lab and X-ray services provided in a facility other than a hospital outpatient department. These are ordered and provided by or under the direction of a practitioner and includes lab services related to the treatment of substance abuse. Some may have service limits. o Genetic testing requires prior authorization, subject to limitations. Physical therapy: Limited to the lesser of maintenance level not to exceed 20 visits/calendar year in addition to the evaluation and re-evaluation visits. Speech therapy: For members ages 0-21 prior authorization is needed for therapy. Medical records are required to determine if the therapy meets criteria. The benefit limit is 20 speech therapy visits/calendar year. Occupational therapy: Limited to the lesser of maintenance level not to exceed 20 visits/calendar year in addition to the evaluation and reevaluation visits. Behavioral health: Behavioral health clinics, behavioral health rehabilitation, targeted case management, psychologists, and psychiatrists. (Emergency room services are included in the MCO benefits package.) o Diagnosis, evaluation, therapies, and other program services for individuals with mental illness, mental retardation, and substance abuse. Procedure specific limits on frequency and units. Only assertive community treatment (ACT) providers certified by BMS or the Bureau of Behavioral Health and health facilities may provide ACT services. Excludes children s residential treatment. therapeutic, all emergency services, or rehabilitative medical services. Diagnostic X-ray, laboratory services, and testing: Lab and X-ray services provided in a facility other than a hospital outpatient department. These are ordered and provided by or under the direction of a practitioner and includes lab services related to the treatment of substance abuse. Some may have service limits. o Genetic testing requires prior authorization, subject to limitations. Physical therapy: Limited to the lesser of maintenance level not to exceed 20 visits/calendar year in addition to the evaluation and re-evaluation visits. Speech therapy: For members over age 21, speech therapy services are limited to specific medical/surgical conditions and prior authorization is required. Occupational therapy: Limited to the lesser of maintenance level not to exceed 20 visits/calendar year in addition to the evaluation and reevaluation visits. Behavioral health: Behavioral health clinics, behavioral health rehabilitation, targeted case management, psychologists, and psychiatrists. (Emergency room services are included in the MCO benefits package.) o Diagnosis, evaluation, therapies, and other program services for individuals with mental illness, mental retardation, and substance abuse. Procedure specific limits on frequency and units. Only assertive community treatment (ACT) providers certified by BMS or the Bureau of Behavioral Health and health facilities may provide ACT services. Excludes children s residential treatment.

3 Physician/NP/NMW/FQHC/RHC Services Services provided by a nurse midwife, nurse anesthetist, family or pediatric nurse practitioner within a specialty. Primary/preventive care visits. Preventive screenings: Annual pap smear for cervical cancer screening beginning at age 18, earlier if medically necessary. Physician office visits Specialty care: Nutritionist visit; medical nutritionist for weight loss, only if part of evaluation for bariatric surgery requires pre-authorization and subject to limitations. Medical nutritionist visits related to diabetes and ESRD are limited to six visits per calendar year. Podiatry surgical procedures other than in-office require pre-authorization. Ambulance Emergency transport Behavioral Health Rehabilitation Psychiatric residential treatment: Diagnosis, evaluation, therapies, and other program services for individuals with mental illness, mental retardation, and substance abuse. Procedure limits on frequency and units. Physician/NP/NMW/FQHC/RHC Services There may be a copay. Services provided by a nurse midwife, nurse anesthetist, family or pediatric nurse practitioner within a specialty. Primary/preventive care visits. Preventive screenings: Annual pap smear for cervical cancer screening beginning at age 18, earlier if medically necessary. Mammography screening: Performed in an approved/participating accredited facility to detect presence of breast cancer; ages at least once; ages one every two years unless medically determined that member is at risk, one every year and 50+ one every year. Prostate cancer screening beginning at age 50. Colorectal screening (asymptomatic age 50 & older or under age 50 with symptoms). Physician office visits. Specialty care: Nutritionist visit; medical nutritionist for weight loss only if part of evaluation for bariatric surgery requires pre authorization and subject to limitations. Medical nutritionist visits related to diabetes and ESRD are limited to six visits per calendar year. Podiatry surgical procedures other than in-office require pre-authorization. Ambulance Emergency transport

4 Cardiac Rehabilitation Supervised exercise sessions with EKG monitoring, must meet plan guidelines limited to a maximum of 12 weeks or 36 visits per heart attack or heart surgery. Pulmonary Rehabilitation Must meet plan guidelines limited to a maximum of 12 weeks or 36 visits per calendar year. Chiropractic Services Requires pre-authorization from PCP only for children under age 18 and/or out-of-network; limited services, subject to plan review, limited to a maximum of 24 visits per calendar year. Manual manipulation of the spine. X-ray exam related to service. Clinic Services General clinics, birthing centers and health department clinics, including vaccinations for children. Dental Services Must use participating practitioners (See practitioner directory or call Scion Dental). Orthodontics covered for the entire duration of treatment regardless of loss in eligibility. Requires pre-authorization. Diabetes Management An enrollee who has been diagnosed with diabetes has the right to access optometrist or ophthalmologist services without a PCP referral for an annual examination. If the annual diabetic eye examination reveals abnormal conditions, any follow up appointment with a specialist will require pre-authorization from the member s PCP. Cardiac Rehabilitation Supervised exercise sessions with EKG monitoring, must meet Plan guidelines limited to a maximum of 12 weeks or 36 visits per heart attack or heart surgery. Pulmonary Rehabilitation Must meet plan guidelines limited to a maximum of 12 weeks or 36 visits per calendar year. Chiropractic Services There may be a copay. Requires pre-authorization from PCP only for out-of-network; limited services, subject to plan review, limited to a maximum of 24 visits per calendar year. Manual manipulation of the spine. X-ray exam related to service. Clinic Services General clinics, birthing centers and health department clinics, including vaccinations for children. Dental Services (Emergent Treatment) Adults covered only for accident or injury, tumor removal, or emergency extraction. Diabetes Management An enrollee who has been diagnosed with diabetes has the right to access optometrist or ophthalmologist services without a PCP referral for an annual examination. If the annual diabetic eye examination reveals abnormal conditions, any follow up appointment with a specialist will require pre-authorization from the member s PCP.

5 Durable Medical Equipment Requires pre-authorization. Limited replacement. Some limitations may apply. Must meet The Health Plan guidelines. Orthotics and Prosthetics Requires pre-authorization and must meet The Health Plan guidelines. Well-Child Visits Early and periodic screening, treatment, and diagnostic services to determine psychological or physical conditions in recipients under age 21. Based on a periodicity schedule. Includes services identified during an inter-periodic and/or periodic screen if they are determined to be medically necessary. Family Planning Services & Supplies Services to aid recipients of child bearing age to voluntarily control family size or to avoid or delay an initial pregnancy. All family planning providers, services, and supplies. Hearing Requires pre-authorization. Audiology screening (only if referred by a PCP or ENT practitioner). One hearing aid/five years. Hearing aid evaluations, hearing aid supplies, batteries, and repairs. Hearing aid evaluations, hearing aids, hearing aid supplies, batteries and repairs are limited to recipients under age 21. Certain procedures may have service limits, or require prior authorization. Augmentation communication devices limited to children under 21 years of age and require prior approval. Home Health Covered for nursing, physical therapy, occupational therapy, and speech therapy. Requires pre-authorization for all visits. Durable Medical Equipment Requires pre-authorization. Limited replacement. Some limitations may apply. Must meet The Health Plan guidelines. Orthotics and Prosthetics Requires pre-authorization and must meet The Health Plan guidelines. Family Planning Services and Supplies Services to aid recipients of child bearing age to voluntarily control family size or to avoid or delay an initial pregnancy. All family planning providers, services, and supplies. Hearing Requires pre-authorization. Covered for specific medical diagnosis. Home Health Covered for nursing, physical therapy, occupational therapy, and speech therapy. Requires pre-authorization for all visits.

6 Hospice Requires pre-authorization for all visits. If you revoke three times, you are no longer eligible for hospice. Psychological Services Services provided by a licensed psychologist in the treatment of psychological conditions. Evaluation and testing procedures may have frequency restrictions. Private Duty Nursing Requires pre-authorization (has limits). Tobacco Cessation Diagnostic, therapy, counseling services, quit line services, and pharmacotherapy for cessation. The children s benefit also includes the provision of anticipatory guidance and risk-reduction counseling with regard to tobacco use during routine well-child visits. Vision Must use participating vision services practitioners (See practitioner directory or call Customer Service Department). Vision screening & therapy. One eye exam covered once every 12 months. Limited one frame/year. Contact lenses covered for certain diagnosis. Repairs. Hospice Requires pre-authorization for all visits. If you revoke three times, you are no longer eligible for hospice. Psychological Services Services provided by a licensed psychologist in the treatment of psychological conditions. Evaluation and testing procedures may have frequency restrictions. Tobacco Cessation Diagnostic, therapy, counseling services, quit line services, and pharmacotherapy for cessation. Vision Adults limited to medical treatment only. Medical contact lenses for adults and children covered for certain diagnosis. One pair glasses up to 60 days after cataract surgery. The services below are covered through Medicaid, but are not provided through your plan. For information on how to use these services, look at the section of the handbook that explains what Medicaid covers. Abortion Abortion Birth-to-Three Services Organ Transplant Services Personal Care Services Organ Transplant Services Personal Care Services

7 School-Based Services Non-Emergency Transportation Nursing Home Services and all services received while in nursing home Non-Emergency Transportation Nursing Home Services and all services received while in nursing home *There are additional services to those included on this list. If you have questions on whether a service is covered, look at the section of the handbook that explains what Medicaid covers or give us a call. Mountain Health Bridge Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, as well as private practitioners. Practitioner services; lab and X-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs and DME are excluded. Inpatient Services Inpatient hospital care: Inpatient care under the direction of a practitioner. All elective, tertiary, and out-of-area requires pre-authorization. Inpatient rehabilitation: Services related to inpatient facilities that provide rehabilitation services for Medicaid eligible individuals (in a rehabilitation facility; limited to 60 days per calendar year) require pre-authorization. Inpatient behavioral health and substance abuse related to the treatment of mental disorders or substance abuse disorders. Outpatient Services Hospital services, outpatient: Medical services furnished on an outpatient basis by a hospital, regardless of the type of practitioner ordering the service. Includes preventive, diagnostic, Adults (21 years and older) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, as well as private practitioners. Practitioner services; lab and X-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs and DME are excluded. Inpatient Services There may be a copay. Inpatient hospital care: Inpatient care under the direction of a practitioner. All elective, tertiary, and out-of-area requires pre-authorization. Inpatient rehabilitation: Services related to inpatient facilities that provide rehabilitation services for Medicaid eligible individuals (in a rehabilitation facility; limited to 60 days per calendar year) requires pre-authorization. Inpatient behavioral health and substance abuse related to the treatment of mental disorders or substance abuse disorders. Outpatient Services Hospital services, outpatient: Medical services furnished on an outpatient basis by a hospital, regardless of the type of practitioner ordering the service. Includes preventive, diagnostic,

8 therapeutic, all emergency services, or rehabilitative medical services. Diagnostic X-ray, laboratory services, and testing: Lab and X-ray services provided in a facility other than a hospital outpatient department. These are ordered and provided by or under the direction of a practitioner and includes lab services related to the treatment of substance abuse. Some may have service limits. Physical therapy: Limited to the lesser of maintenance level not to exceed 30 visits/calendar year in addition to the evaluation and re-evaluation visits. A referral is needed only when visits exceed the limit of 30/calendar year combined for PT/OT rehab and habilitative. EPSDT services for children under age 21 are not subject to these limitations. Speech therapy: For members ages 0-21 prior authorization is needed for therapy. Medical records are required to determine if the therapy meets criteria. The benefit limit is 20 speech therapy visits/calendar year. Occupational therapy: Limited to the lesser of maintenance level not to exceed 30 visits/calendar year in addition to the evaluation and reevaluation visits. A referral is needed only when visits exceed the limit of 30/calendar year combined for PT/OT rehab and habilitative. EPSDT services for children under age 21 are not subject to these limitations. Behavioral health: Behavioral health clinics, behavioral health rehabilitation, targeted case management, psychologists, and psychiatrists. (Emergency room services are included in the MCO benefits package.) o Diagnosis, evaluation, therapies, and other program services for individuals with mental illness, mental retardation, and substance abuse. therapeutic, all emergency services, or rehabilitative medical services. Diagnostic X-ray, laboratory services, and testing: Lab and X-ray services provided in a facility other than a hospital outpatient department. These are ordered and provided by or under the direction of a practitioner and includes lab services related to the treatment of substance abuse. Some may have service limits. Physical therapy: Limited to the lesser of maintenance level not to exceed 30 visits/calendar year in addition to the evaluation and re-evaluation visits. A referral is needed only when visits exceed the limit of 30/calendar year combined for PT/OT rehab and habilitative. Speech therapy: For members over age 21, speech therapy services are limited to specific medical/surgical conditions and prior authorization is required. Occupational therapy: Limited to the lesser of maintenance level not to exceed 30 visits/calendar year in addition to the evaluation and reevaluation visits. A referral is needed only when visits exceed the limit of 30/calendar year combined for PT/OT rehab and habilitative. Behavioral health: Behavioral health clinics, behavioral health rehabilitation, targeted case management, psychologists, and psychiatrists. (Emergency room services are included in the MCO benefits package.) o Diagnosis, evaluation, therapies, and other program services for individuals with mental illness, mental retardation, and substance abuse. Procedure specific limits on frequency and units. Only assertive community treatment (ACT) providers certified by BMS or the Bureau of Behavioral Health and health facilities may provide ACT services.

9 Procedure specific limits on frequency and units. Only assertive community treatment (ACT) providers certified by BMS or the Bureau of Behavioral Health and health facilities may provide ACT services. Excludes children s residential treatment. Physician/NP/NMW/FQHC/RHC Services Services provided by a nurse midwife, nurse anesthetist, family or pediatric nurse practitioner within a specialty. Primary/preventive care visits Preventive screenings: Annual pap smear for cervical cancer screening beginning at age 18, earlier if medically necessary. Physician office visits. Specialty care: Nutritionist visit require pre-authorization. Podiatry surgical procedures other than in-office require pre-authorization. Ambulance Emergency transport. Behavioral Health Rehabilitation Residential treatment: Diagnosis, evaluation, therapies, and other program services for individuals with mental illness, mental retardation, and substance abuse. Procedure limits on frequency and units. Physician/NP/NMW/FQHC/RHC Services There may be a copay. Services provided by a nurse midwife, nurse anesthetist, family or pediatric nurse practitioner within a specialty. Primary/preventive care visits. Preventive screenings: Annual pap smear for cervical cancer screening beginning at age 18, earlier if medically necessary. Mammography screening: Performed in an approved/participating accredited facility to detect presence of breast cancer; ages at least once; ages one every two years unless medically determined that member is at risk, one every year and 50+ one every year. Prostate cancer screening beginning at age 50. Colorectal screening (asymptomatic age 50 and older or under age 50 with symptoms). Physician office visits. Specialty care: Nutritionist visit require pre-authorization. Podiatry surgical procedures other than in-office require pre-authorization. Ambulance Emergency transport.

10 Cardiac Rehabilitation Supervised exercise sessions with EKG monitoring, must meet plan guidelines. Limited to a maximum of 12 weeks or 36 visits per heart attack or heart surgery. Requires pre-authorization for additional visits. Pulmonary Rehabilitation Must meet plan guidelines. Limited to a maximum of 20 sessions per calendar year. Chiropractic Services Requires pre-authorization from PCP only for children under age 18 and/or out-of-network; limited services, subject to Plan review, limited to a maximum of 24 visits per calendar year. Manual manipulation of the spine. X-ray exam related to service. Clinic Services General clinics, birthing centers and health department clinics, including vaccinations for children. Dental Services Must use participating practitioners (See practitioner directory or call Scion Dental). Orthodontics covered for the entire duration of treatment regardless of loss in eligibility. Requires pre-authorization. The MCO must cover WVHB members under 21 for the full scope of the dental services under the EPSDT coverage requirements. Diabetes Management An enrollee who has been diagnosed with diabetes has the right to access optometrist or ophthalmologist services without a PCP referral for an annual examination. If the annual diabetic eye examination reveals abnormal conditions, any follow up appointment with a specialist will Cardiac Rehabilitation Supervised exercise sessions with EKG monitoring, must meet plan guidelines. Limited to a maximum of 12 weeks or 36 visits per heart attack or heart surgery. Requires pre-authorization for additional visits. Pulmonary rehabilitation Must meet plan guidelines. Limited to a maximum of 20 sessions per calendar year. Chiropractic Services There may be a copay. Requires pre-authorization from PCP only for out-of-network; limited services, subject to Plan review, limited to a maximum of 24 visits per calendar year. Manual manipulation of the spine. X-ray exam related to service. Clinic Services General clinics, birthing centers and health department clinics, including vaccinations for children. Dental Services (Emergent Treatment) Adult coverage limited to treatment of fractures of mandible and manila, biopsy, removal of tumors, and emergency extractions. TMJ surgery and treatment not covered for adults. Diabetes Management An enrollee who has been diagnosed with diabetes has the right to access optometrist or ophthalmologist services without a PCP referral for an annual examination. If the annual diabetic eye examination reveals abnormal conditions, any follow up appointment with a specialist will

11 require pre-authorization from the member s PCP. Durable Medical Equipment Require pre-authorization. Limited replacement. Some limitations may apply. Must meet The Health Plan guidelines. Orthotics and Prosthetics Requires pre-authorization and must meet The Health Plan guidelines. Well-Child Visits Early and periodic screening, treatment, and diagnostic services to determine psychological or physical conditions in recipients under age 21. Based on a periodicity schedule. Includes services identified during an inter-periodic and/or periodic screen if they are determined to be medically necessary. Family Planning Services and Supplies Services to aid recipients of child bearing age to voluntarily control family size or to avoid or delay an initial pregnancy. All family planning providers, services, and supplies. Hearing Requires pre-authorization. Audiology screening (only if referred by a PCP or ENT practitioner). One hearing aid/five years. Hearing aid evaluations, hearing aid supplies, batteries, & repairs. Home Health Requires pre-authorization for all visits. Psychological Services Services provided by a licensed psychologist in the treatment of psychological conditions. Evaluation and testing procedures may have frequency restrictions. Private Duty Nursing require pre-authorization from the member s PCP. Durable Medical Equipment Requires pre-authorization. Limited replacement. Some limitations may apply. Must meet The Health Plan guidelines. Orthotics and Prosthetics Requires pre-authorization and must meet The Health Plan guidelines. Family Planning Services and Supplies Services to aid recipients of child bearing age to voluntarily control family size or to avoid or delay an initial pregnancy. All family planning providers, services, and supplies. Home Health Requires pre-authorization for all visits. Psychological Services Services provided by a licensed psychologist in the treatment of psychological conditions. Evaluation and testing procedures may have frequency restrictions.

12 Requires pre-authorization (has limits). Tobacco Cessation Diagnostic, therapy, counseling services, quit line services, and pharmacotherapy for cessation. The children s benefit also includes the provision of anticipatory guidance and risk-reduction counseling with regard to tobacco use during routine well-child visits. Vision Must use participating vision services practitioners (See practitioner directory or call Customer Service Department). Vision screening and therapy. Limited one frame/year. One eye exam covered once every 12 months. Contact lenses covered for certain diagnosis. Repairs. Tobacco Cessation Diagnostic, therapy, counseling services, quit line services, and pharmacotherapy for cessation. Vision Adults limited to medical treatment only. Contact lenses for adults and children covered for certain diagnosis. The services below are covered through Medicaid, but are not provided through your plan. For information on how to use these services, look at the section of the handbook that explains what Medicaid covers. Abortion Non-Emergency Transportation Nursing Home Services Organ Transplant Services Personal Care Services Abortion Non-Emergency Transportation Nursing Home Services Organ Transplant Services Personal Care Services School-Based Services *There are additional services to those included on this list. If you have questions on whether a service is covered, look at the section of the handbook that explains what Medicaid covers or give us a call.