Benefits Overview

Allergy Services

Services to treat conditions such as sneezing or rashes that are not caused by an illness.

We cover medically necessary blood or skin allergy testing and up to 156 doses per calendar year of allergy shots.

No

Ambulance Transportation Services

Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities.

Covered as medically necessary.

No

Ambulatory Surgical Center Services

Surgery and other procedures that are performed in a facility that is not the hospital (outpatient).

Covered as medically necessary.

Yes, for some procedures.

Anesthesia Services

Services to keep you from feeling pain during surgery or other medical procedures.

Covered as medically necessary.

Yes, for dental procedures not done in an office.

Assistive Care Services

Services provided to adults (ages 18 and older) to help with activities of daily living and taking medication.

We cover 365/366 days of services per calendar year, as medically necessary.

Yes

Behavioral Health Assessment Services

Services used to detect or diagnose mental illnesses and behavioral health disorders.

We cover, as medically necessary:

• One initial assessment per calendar year
• One reassessment per calendar year
• Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)

No

Behavioral Health Overlay Services

Services provided in a group home setting for children ages 0 – 21 who have experienced trauma and are in the child welfare system.

We cover 365/366 days of services per calendar year, as medically necessary.

Yes

Cardiovascular Services

Services that treat the heart and circulatory (blood vessels) system.

We cover the following as prescribed by your doctor, when medically necessary:

• Cardiac testing
• Cardiac surgical procedures
• Cardiac devices

Yes, for some services.

Child Health Services Targeted Case Management

Services provided to children ages 0-3 to help them get health care and other services.

OR

Services provided to children (ages 0–20) who use medical foster care services.

Your child must be enrolled in the DOH Early Steps program.

OR

Your child must be receiving medical foster care services.

No

Chiropractic Services

Diagnosis and manipulative treatment of misalignments of the joints, especially the spinal column, which may cause other disorders by affecting the nerves, muscles and organs.

We cover, as medically necessary:

• 24 patient visits per calendar year, per member.
•  X-rays.

No

Clinic Services

Health care services provided in a county health department, federally qualified health center, or a rural health clinic.

Medically necessary services must be provided in a county health department, federally qualified health center or a rural health clinic.

No

Community- Based Wrap- Around Services*

Individualized care planning and care management service to support children with complex needs who are at risk of placement in a mental health treatment facility.

Children and youth up to age 21.

One per day with no limits per calendar year.

Yes

Crisis Stabilization Unit Services*

Emergency mental health services that are performed in a facility that is not a regular hospital.

All ages.

One per day and no limit per calendar year.

No prior authorization required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions.

Detoxification or Addictions Receiving Facility Services*

Emergency substance abuse services that are performed in a facility that is not a regular hospital.

All ages.

Up to a total of 15 days per month.

Dialysis Services

Medical care, tests and other treatments for the kidneys. This service also includes dialysis supplies and other supplies that help treat the kidneys.

We cover the following as prescribed by your treating doctor, when medically necessary:

• Hemodialysis treatments
• Peritoneal dialysis treatments

No

Drop-In Center Services*

A social club offering peer support and a flexible schedule of activities.

Covered as medically necessary.

No

Durable Medical Equipment and Medical Supplies Services

Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches and other items.

Medical supplies are items meant for one-time use and then thrown away.

Yes, for some equipment or services.

Early Intervention Services

Services to children ages 0 - 3 who have developmental delays and other conditions.

We cover medically necessary:

• One initial evaluation per lifetime, completed by a team
• Up to 3 screenings per calendar year
• Up to 3 follow-up evaluations per calendar year

Up to 2 training or support sessions per week

No

Emergency Transportation Services

Transportation provided by ambulances or air ambulances (helicopters or airplanes) to get you to a hospital because of an emergency.

Covered as medically necessary.

No

Evaluation and Management Services

Services for doctor’s visits to stay healthy and prevent or treat illness.

We cover medically necessary:

• One adult health screening (check-up) per calendar year
• Well Child Visits are provided based on age and developmental needs
• One visit per month for people living in nursing facilities
• Up to two office visits per month for adults to treat illnesses or conditions

No

Family Therapy Services

Services for families to have therapy sessions with a mental health professional.

Up to 26 hours per calendar year, as medically necessary

No

Family Training and Counseling for Child Development*

Educational services for family members of children with severe emotional problems focused on child development and other family support.

Ages 0 to 21.

Covered as medically necessary.

No

Gastrointestinal Services

Services to treat conditions, illnesses, or diseases of the stomach or digestion system.

Covered as medically necessary.

Yes, for some services.

Genitourinary Services

Services to treat conditions, illnesses, or diseases of the genitals or urinary system.

Covered as medically necessary.

Yes, for some services.

Group Therapy Services

Services for a group of people to have therapy sessions with a mental health professional.

We cover as medically necessary:

• Unlimited units for group therapy and unlimited units for brief group medical therapy.

No

Hearing Services

Hearing tests, treatments and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs.

We cover hearing tests and the following as prescribed by your doctor, when medically necessary:

• Cochlear implants
• One new hearing aid per ear, once every 3 years
• Repairs

Yes, for some services.

Home Health Services

Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury.

We cover, when medically necessary:

• Up to 4 visits per day for pregnant members and members ages 0 to 20
• Up to 3 visits per day for all other members

Yes

Hospice Services

Medical care, treatment and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers.

Covered as medically necessary.

Yes

Individual Therapy Services

Services for people to have one-on-one therapy sessions with a mental health professional.

We cover, when medically necessary:

• Up to 26 hours per calendar year for adults ages 21 and over.
• For children up to 21 there are no limits if medically necessary

No

Infant Mental Health Pre and Post Testing Services*

Testing services by a mental health professional with special training in infants and young children.

Covered as medically necessary.

No

Inpatient Hospital Services

Medical care that you get while you are in the hospital. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.

We cover the following inpatient hospital services based on age and situation, when medically necessary:

• Up to 365/366 days for members ages 0-20
• Up to 45 days for all other members (extra days are covered for emergencies)

Yes

Integumentary Services

Services to diagnose or treat skin conditions, illnesses or diseases.

Covered as medically necessary.

Yes, for some services.

Laboratory Services

Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases.

Covered as medically necessary.

Yes, for some services.

Medical Foster Care Services

Services that help children with health problems who live in foster care homes.

Must be in the custody of the Department of Children and Families.

No

Medication Assisted Treatment Services

Services used to help people who are struggling with drug addiction.

Covered as medically necessary.

No

Medication Management Services

Services to help people understand and make the best choices for taking medication.

Covered as medically necessary.

No

Mental Health Targeted Case Management

Services to help get medical and behavioral health care for people with mental illnesses.

Covered as medically necessary.

No

Mobile Crisis Assessment and Intervention Services*

A team of health care professionals who provide emergency mental health services in the home, community, or school.

Covered as medically necessary.

No

Neurology Services

Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system.

Covered as medically necessary.

Yes, for some services.

Non-Emergency Transportation Services

Transportation to and from all of your medical appointments. This could be on the bus, a van that can transport people with disabilities, a taxi, or other kinds of vehicles.

We cover the following services for those who have no transportation:

• Out-of-state travel
• Transfers between hospitals or facilities
• Escorts when medically necessary

Yes, for any trip over 100 miles.

Nursing Facility Services

Medical care or nursing care that you get while living full-time in a nursing facility. This can be a short-term rehabilitation stay or long-term.

• We cover 365/366 days of services in nursing facilities as medically necessary.
• See information on Patient Responsibility for room & board.

Yes

Occupational Therapy Services

Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself and using items around the house.

We cover for children ages 0 to 20 and for adults under the $1,500 outpatient services cap, as medically necessary:

• One initial evaluation per calendar year
• Up to 210 minutes of treatment per week
• One initial wheelchair evaluation per 5 years

We cover for people of all ages, as medically necessary:

• Follow-up wheelchair evaluations, one at delivery and one 6 months later

Yes, for some services.

Oral Surgery Services

Services that provide teeth extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity.

Covered as medically necessary.

Yes, for some services.

Orthopedic Services

Services to diagnose or treat conditions, illnesses or diseases of the bones or joints.

Covered as medically necessary.

Yes, for some services.

Outpatient Hospital Services

Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.

• Emergency services are covered as medically necessary.
• Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 and over.

Yes, for some services.

Pain Management Services

Treatments for long- lasting pain that does not get better after other services have been provided.

Covered as medically necessary. Some service limits may apply.

Yes

Partial Hospitalization Services*

Structured mental health treatment services provided in a hospital 4-6 hours each day for 5 days per week.

All ages.

One per day and no limit per calendar year.

Yes

Physical Therapy Services

Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition.

We cover for children ages 0-20 and for adults under the $1,500 outpatient services cap, as medically necessary:

• One initial evaluation per year.
• Up to 210 minutes of treatment per week.
• One initial wheelchair evaluation per 5 years.

We cover for people of all ages, as medically necessary:

• Follow-up wheelchair evaluations, one at delivery and one 6-months later.

Yes, for some services.

Podiatry Services

Medical care and other treatments for the feet.

We cover, as medically necessary:

• Up to 24 office visits per calendar year.
• Foot and nail care.
•  X-rays and other imaging for the foot, ankle and lower leg.
• Surgery on the foot, ankle or lower leg.

Yes, for some services.

Prescribed Drug Services

This service is for drugs that are prescribed to you by a doctor or other healthcare provider.

We cover, as medically necessary:

• Up to a 34-day supply of drugs, per prescription
• Refills, as prescribed

Yes, for some drugs.

Private Duty Nursing Services

Nursing services provided in the home to members 0-20 who need constant care.

Up to 24 hours per day, as medically necessary.

Yes

Psychological Testing Services

Tests used to detect or diagnose problems with memory, IQ or other areas.

10 hours of psychological testing per calendar year, as medically necessary.

Yes, for some services

Psychosocial Rehabilitation Services

Services to assist people to re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.

Up to 480 hours per calendar year, as medically necessary.

No

Radiology and Nuclear Medicine Services

Services that include imaging such as x-rays, MRIs or CAT scans. They also include portable x-rays.

Covered as medically necessary.

Yes, for some services

Regional Perinatal Intensive Care Center Services

Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions.

Covered as medically necessary.

Yes, for some services

Reproductive Services

Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family.

We cover medically necessary family planning services. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. You do not need prior approval for these services. These services are free. These services are voluntary and confidential, even if you are under 18 years old.

No

Residential Outpatient Treatment

Short term residential treatment program for pregnant women with substance use disorder.

Ages 21 and older

Up to 60 days/calendar year

Yes

Respiratory Services

Services that treat conditions, illnesses or diseases of the lungs or respiratory system.

We cover medically necessary:

• Respiratory testing
• Respiratory surgical procedures
• Respiratory device management

Yes, for some services.

Respiratory Therapy Services

Services for members ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease.

We cover medically necessary:

• One initial evaluation per calendar year
• One therapy re-evaluation per 6 months
• Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)

No

Self-Help/ Peer Services*

Services to help people who are in recovery from an addiction or mental illness.

As medically necessary and recommended by us.

No

Skilled Nursing

Medical care or skilled nursing care that you get while you are in a nursing facility.

This can be a short- term or long-term rehabilitation stay.

All ages.

Up to 60 days per calendar.

Yes

Specialized Therapeutic Services

Services provided to children ages

0-21 with mental illnesses or substance use disorders.

For children under the age of 21, we cover the following medically necessary services:

• Comprehensive Behavioral Health Assessments
• Specialized Therapeutic Foster Care Services
• Therapeutic Group home services

Yes

Speech- Language Pathology Services

Services that include tests and treatments to help you to talk or swallow better.

We cover the following medically necessary services for children ages 0 to 20:

• Communication devices and services
• Up to 210 minutes of treatment per week
• One initial evaluation per calendar year

We cover the following medically necessary services for adults:

• One communication evaluation per 5 years

Yes

Statewide Inpatient Psychiatric Program Services

Services for children with severe mental illnesses that need treatment in a secured facility.

Covered as medically necessary for ages 0 to 20.

Yes

Substance Abuse Intensive Outpatient Program*

Substance abuse treatment of detoxification services provided in an outpatient setting.

Covered as medically necessary.

Yes

Substance Abuse Short-term Residential Treatment Services/ Residential Outpatient Services*

Short-term substance abuse treatment in a residential program.

Covered as medically necessary. Maximum 60 days per calendar year.

Yes

Therapeutic Behavioral On- Site Services

Therapeutic services provided in the home or community to prevent children with mental illnesses from being placed in a hospital or other facility.

Covered as

medically

necessary for ages 0 to 20.

Up to 9 hours per month.

Yes

Transplant Services

Services that include all surgery and pre- and post- surgical care.

Covered as medically necessary.

Yes

Visual Aid Services

Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes.

We cover the following medically necessary services when prescribed by your doctor:

-          Two pairs of eyeglasses for children ages 0-20

-          Contact lenses

-          Prosthetic eyes

Yes, for some services.

Visual Care Services

Services that test and treat conditions, illnesses and diseases of the eyes.

Covered as medically necessary.

Yes, for some services.

Biometric Equipment

Digital blood pressure cuff and weight scale

One (1) digital blood pressure cuff every three (3) years; One (1) weight scale every three (3) years

No

Care grant

Up to $150 per calendar year per child for services or supplies for educational use, social use or physical activities.

Ages 0 to 21.

Up to $150 per calendar year.

Yes

Durable Medical Equipment/Supplies

Unlimited  hypoallergenic bedding; one (1) HEPA filter vacuum cleaner.

Must be diagnosed with asthma.

Yes

Doula services

Pregnancy, postpartum and newborn care and assessment provided in your home by a doula.

Ages 13 and older. No limits.

Yes

Flu/Pandemic Prevention Kit

1 Flu/Pandemic Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer

Ages 18 years and older.

Eligible for the first 1,000 members who have received their flu vaccine.

No

Home Delivered Meals (Disaster Preparedness/ Relief)

Emergency meal kit

One (1) annually

Yes

Ages 0 to 21.

No limits.

Legal Guardianship

Maximum of five hundred dollars ($500) per eligible enrollee per lifetime

This is available to members who are in a SNF or PDN setting and parent is obtaining guardianship to protect those who are unable to care for their own well-being. Available for members aged 17 through 18.5.

Contact your care manager
to determine eligibility.

Life Skills Development

For children or adolescents

with development disabilities to provide life skills development that help the child or adolescent keep, learn or improve skills and

functioning for daily living. These services will be provided in the home or outpatient setting.

Ages 12 to 21.

Must have a diagnosed developmental disability.

Up to 160 hours per calendar year.

Yes

Meal Stipend

Available for long distance medical appointment day-trips.

Up to $25/day for member and $25/day for escort for trips greater than 100 miles; max/fiscal year $250.

Yes

Medically Related Home Care Services/ Homemaker

Carpet cleanings

Up to two cleanings per year.

Must be diagnosed with asthma.

Yes

Newborn circumcision

Can be provided in a hospital, office or outpatient setting.

Birth to 28 days old.

1 per lifetime if medically necessary.

No

Non-emergency transportation – non-medical purposes

Transportation provided for non-medical purposes such as social outings or family visits.

Ages 5 to 21.

Three round-trips per month.

Yes

Over-the-counter benefit

Coverage for cold, cough, allergy, vitamins, supplements, ophthalmic/otic preparations, pain relievers, gastrointestinal products, first aid care, hygiene products, insect repellant, oral hygiene products and skin care.

Ages 0 to 21.

Up to $25 per household, per month.

No

Prenatal/Postpartum

• 14 visits for low-risk pregnancy
• 18 visits for high-risk pregnancy
• Breast pump, hospital grade rental
• Breast pump

• One per calendar year

• One every 2 calendar years

• No

• No

• Yes

• No

Swimming Lessons (Drowning Prevention)

Children under 21 years old can receive swimming lessons.

Up to $200 per year.

Yes

Transition Assistance

One-time payment of up to $500 per youth who is transitioning out of foster care at age 18 or out of extended foster care at age 21. Funds to support moving to a new home.

Ages 18 to 21.

Must be in out-of-home licensed foster care for a minimum of 6 months before transitioning out of foster care.

Yes