Covered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered.
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1 Covered Benefits Services Abortions Allergy Testing Audiology Birth Control Services Blood & Blood Plasma Bone Mass Measurement (bone density) Case Management Chemotherapy Chiropractor Services (manipulation/subluxation) Colorectal Screening Exams Cosmetic Services Custodial Services Dental Services (preventive and routine services, crowns, dentures, surgical extractions, orthodontia) Diabetic Education, Home Visits & Monitoring Diabetic Supplies and Equipment Diapers for Disabled Children (over age 3) Durable Medical Equipment Must meet current federal and state guidelines. Prior authorization required. Maximum of 18 doctor visits combined per year, from July 1 through June 30. Depends on service. Prior authorization required for some services. Benefit limits may apply. Adult benefits may be dependent on category of assistance and geographic location. Please call member services for specific information about your dental coverage Prior authorization required. Prior authorization required if greater than $200 per month. Prior authorization required ifover $
2 Covered Benefits (cont.) Services ESPDT Services & Immunizations (under age 21) Emergency Room Care Emergency Transportation (ambulance) Family Planning Basic Services Hearing Exams Hearing Aids & Batteries Hemodialysis HIV/AIDS Testing Home Assessment Home Adaptation Home Delivered Meals Home Health Care & Infusion Therapy Hospice Care Immunizations (pneumococcal, flu, hepatitis A & B) Infertility Inpatient Hospitalization (semi-private, unless medically necessary) Lab Tests & X-rays Mammograms Nutrition Obstetrical (Maternity) Care Occupational Therapy Covered, if under age 21. Prior authorization required. Prior authorization required. Prior authorization required. Prior authorization required. Prior authorization required. Prior authorization required. Prior authorization required after 28 Medicaid Member Handbook
3 Services Organ Transplant Evaluation Orthodontia Orthopedic Shoes Outpatient Surgery, Same-Day Surgery, Ambulatory Surgical Center Pain Clinic Services Pap Smears & Pelvic Exams Parenting & Child Birth Education Personal Emergency Response System Physical Therapy Podiatry Care: Medically Necessary, Routine, Preventive (office-based, non-surgical) Prescription Drugs Preventive Services PCP Visits Private Duty or Skilled Nursing Care Prostate Cancer Screening Exams Prosthetics & Orthotics (less than $500) Prosthetics & Orthotics (more than $500) Radiation Therapy Prior authorization required. Covered under 21 years old. Prior authorization required. Prior authorization required. Prior authorization required. Prior authorization required. Maximum of 18 doctor visits combined per year, from July 1 through June 30. Prior authorization required after Maximum of 18 doctor visits combined per year, from July 1 through June 30. Limits and copays may apply. See Preferred Drug List. Prior authorization required. Prior authorization required. 29
4 Covered Benefits (cont.) Services Radiology Scans, MRI, MRA, PET Rehabilitation (occupational, physical & speech therapy; in-house therapy) Reproductive Health (procedures & devices) Second Opinions (Medical & Surgical) Skilled Nursing Facility Sleep Apnea Studies Smoking Cessation Products & Classes Specialty Physician Services (except OB/GYN) Speech Therapy Transportation: Non-Emergency Ambulance Transplants Urgent Care Behavioral Health (inpatient psychiatric, inpatient substance abuse, outpatient substance abuse and mental health, and partial hospitalization care, including testing) Prior authorization required. Prior authorization required after Covered up to 30 days. Prior authorization required. Prior authorization required. Limits may apply. See drug formulary. Maximum of 18 doctor visits combined per year, from July 1 through June 30. Prior authorization required after Prior authorization required. Prior authorization required. Covered by HealthChoices behavioral health MCO. 30 Medicaid Member Handbook
5 Services Vision Care Two exams per year. Daily-wear contacts or standard glasses (in-plan frames). Members under age 21 are covered for 4 lenses and 2 frames per year. Members age 21 and over are covered for 2 lenses and 1 frame per year. In-plan frames are covered in full. Out-of-plan frames are covered up to $20; member must pay cost over $20. Medically necessary exceptions can be made. Benefit Limits Most benefit limits do not apply if you are pregnant, under age 21 or in a nursing home. Covered Benefit Outpatient Visits (ex. doctor, podiatrist, chiropractor) Inpatient Medical Rehabilitation Hospital Prescription Assistance Up to 18 visits per year 1 admission per year Adults can receive up to 6 prescriptions per month, including refills Dental Limited for adults over 21 31
6 Benefit Limits (cont.) The yearly limits on your medical care refer to services received between July 1 and June 30 of following year. The yearly limits will start again on July 1 of every year. Your provider can ask UnitedHealthcare Community Plan to approve services above these limits for you. This is called an exception. An exception can be granted if: You have a serious chronic illness or health condition and without the additional service, your life would be in danger; or You have a serious chronic illness or health condition and without the additional service, your health would get much worse; or You would need more expensive services if the exception is not granted; or, It would be against federal law for UnitedHealthcare to deny the exception. To have your provider ask for an exception, call UnitedHealthcare Community Plan at , or send your request to: Member Services UnitedHealthcare Community Plan 1001 Brinton Road Pittsburgh, PA We will let you know whether or not the exception is granted within the time listed below. If your provider asks for an exception before you receive the service, you will get a response within 21 days of the date we get the request. If your provider asks for an exception before you receive the service, and your provider tells us you have an urgent need for a quick response, you will get a response within 48 hours of the date and time we get the request. If your provider asks for an exception after you received the service, you will get a response within 30 days of the date we get the request. If you disagree with the response you get from UnitedHealthcare Community Plan, you can file a complaint or a grievance. You can file a complaint with UnitedHealthcare Community Plan if you think you were charged the wrong copay or if a service is denied and you think you have not reached the limit. You can file an appeal if you or your provider asks for an exception and the exception is denied. You can also ask for a DPW fair hearing. 32 Medicaid Member Handbook
7 Non-Covered Services There are some things that UnitedHealthcare Community Plan does not cover. These include: Care for which you do not have a referral, except for self-referral services and emergency care. Care from out-of-network providers who are not prior-approved, except for emergency or family planning services. Services covered by other insurance, worker s compensation or programs like Veterans Administration. Boarding home expenses (residential care that is not medically necessary). Experimental procedures. Infertility services. Mental health or drug and alcohol treatment services (covered by your HealthChoices behavioral health plan). Skilled nursing or intermediate care facilities over 30 consecutive days. Members will be disenrolled from UnitedHealthcare Community Plan and placed into Fee-For-Service after 30 consecutive days in a skilled nursing facility. Personal convenience items (telephone, television, etc.) while in a hospital room, unless medically necessary. Plastic or cosmetic surgery, except in case of injury or surgery that causes disfigurement. Prescription drugs for members over age 21 who are eligible for only limited Medical Assistance benefits. Services that are not medically necessary. 33
Fee-For-Service Fee-For-Service Fee-For-Service Fee-For-Service Fee-For-Service
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$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other. deductibles for specific No.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at capbluecross.com or by calling 1-800-730-7219. Important
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