Covered Service Description

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1 Advanced registered nurse practitioner (ARNP) Ambulatory surgical center (ASC) These are given by an ARNP who s licensed to practice in the State of Florida The ARNP and a doctor must make decisions about your care as a team One long-term care facility visit by an ARNP each month, except for emergencies Ten prenatal visits and two postpartum visits, if you re pregnant (each pregnancy) Two routine care visits each month, if you re not pregnant One visit to an ARNP if you re a new patient for him/her These centers provide medically necessary surgical care when you don t need to stay in a hospital ASC shouldn t be used: When you need emergency care If the service is minor enough to be done by your doctor in his/her office Assistive care These are available if you live in an assisted living facility, adult family care home or residential treatment facility A health assessment must be completed: By a licensed practitioner To confirm medical necessity for at least two of the four service components and the need for at least one specific service each day Components include health support and help with: Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Giving yourself medication

2 Mental health s include: Day treatment for adults and children Evaluations Individual and family assessments Individual, family, marital and group therapy Psychosocial rehabilitation Mental health-related inpatient hospital care is limited to: Targeted and intensive case management Therapeutic mental on-site for children and adolescents Treatment planning If you re over age 21 and not pregnant up to 45 days each year for non-emergency and up to 365 days for emergencies Children and adolescents up to age 21 up to 365 days If you re pregnant up to 365 days You don t need to get a PA or referral from your PCP to see a mental health provider, but certain do require a PA You may also choose an alternative mental health case manager or direct service provider who s in our network Parental or guardian informed consent is required for psychotropic medications for children under age 13 (examples of psychotropic medications include tranquilizers, sedatives and antidepressants) See the Emergency Care section later in this handbook for more details about mental health emergencies PA is required for psychological testing, electroconvulsive therapy, psychosocial rehabilitation, therapeutic mental on-site (TBOS) and all inpatient mental health

3 Birthing center and licensed midwife Child health checkup (CHCUP) (for members under age 21) These are facilities where you can go for obstetrical, gynecological and family planning One family planning visit each year at a birthing center One ultrasound during each pregnancy Ten prenatal visits and two postpartum visits during each pregnancy One newborn checkup at the facility See the Planning Your Care section later in this handbook for more details about child health checkups Chiropractic These are given by a chiropractor who s licensed to practice in the State of Florida s include: One visit to a chiropractor if you re a new patient with him/her Manual manipulation of the spine Spinal X-rays One visit each day 24 visits each year s that are not covered: Massages or heat treatments Experimental or investigational chiropractic There is a $1 co-pay for these

4 Clinic These clinics provide primary care Clinics include: Rural health clinics (RHCs) Federally qualified health centers (FQHCs) s you can get at these clinics include: Adult health screenings Child health checkups (CHCUPs) Chiropractic Family planning Mental health Podiatry Vision Dental for adults (over age 21) s include: Care to lessen pain or infection because of a dental emergency (for example, draining an abscess) Full and removable partial dentures Denture-related procedures Dental for children (under age 21) s include: Checkups Crowns Endodontic care (soft tissue and nerves within the teeth) Full and partial dentures Oral surgery Orthodontic treatment Periodontal care Preventive care Restorations s that are not covered: Bridge work Sealants on baby teeth PA is required for orthodontic care

5 Emergency (including mental health emergencies) Family planning and supplies Healthy Start See the Emergency Care section later in this handbook for more details about emergencies There is a 5% coinsurance for non-emergency received in an emergency room (ER) setting: Up to the first $300 for the cost of the care Your out-of-pocket cost won t be more than $15 s include: One visit each year Lab testing Family planning and HIV counseling Contraceptive supplies Pregnancy testing You don t need to get a PA for these and you can get them from any participating Medicaid provider These are provided to help you have a healthy pregnancy and give birth to a healthy baby s include: Coordination of care with the Healthy Start Program Referrals to the Women, Infants and Children (WIC) and Children s Medical s (for children with special health care needs) Programs

6 Hearing s include: Cochlear implants Hearing aids, including fitting, repairs and testing Newborn hearing test Testing One hearing test every two years One hearing aid for each ear every two years One cochlear implant in either ear, not both s that are not covered: Hearing aid repairs while it s covered under the manufacturer s warranty (when the warranty runs out, repairs will be covered) Regular maintenance, batteries, cord or wire replacement or cleaning of hearing aids PA is required for cochlear implants Home health and nursing care These are provided in your home to help improve your health or lessen the effects of a disability s include: Home visits by a registered nurse (RN), licensed practical nurse (LPN) or qualified home health aide (HHA) Medical supplies and durable medical equipment (DME) s for members under age 20 include: Private-duty nursing Personal care Therapies in the home occupational, physical and speech Three home health visits each day

7 Hospice Hospital, including: Inpatient Outpatient These provide palliative care to you and your family (palliative care is care that s given to provide relief from symptoms, like pain and stress, caused by a terminal illness; it s not meant to cure the illness) A person is considered to be terminally ill if he or she has a medical diagnosis with a life expectancy of six months or less if the disease runs its normal course These are provided by a hospice agency and care is coordinated by a hospice nurse These must be provided under the supervision of a doctor or dentist Inpatient hospital include: Room and board Medical supplies Diagnosis and therapies Drugs Nursing care 45 days each year if you re over age 21 (if you re under age 21 or pregnant, there are no limits) Outpatient hospital include: Drugs Medical supplies Nursing care Therapies PA is required for inpatient hospital

8 Lab and X-ray Medical supplies and durable medical equipment (DME) These include medically needed: Lab tests Portable X-rays Diagnostic imaging MRI (magnetic resonance imaging) CT (computed tomography) PET (positron emission tomography) Medical supplies include: Items that are usable and disposable in your home Durable medical equipment (DME) is medically necessary items that you can use over and over for medical reasons, like: Cane, crutches or a walker Blood glucose meters and strips Diabetic supplies Hospital bed Orthotics and prosthetics Wheelchair You can buy, rent or rent-to-own DME PA is required for custom and power wheelchairs, hospital beds and scooters

9 Physician and physician s assistant Podiatry Prescription drugs These are provided by a doctor or physician s assistant who s licensed to practice in the State of Florida These are provided in your home, a doctor s office, hospital or nursing home to treat an injury, illness or disease These are provided by a podiatrist who s licensed to practice in the State of Florida s include: Routine foot care if you have a metabolic disease (like diabetes), bad circulation, wounds or infections See our Preferred Drug List (PDL) for the drugs we cover The PDL also lists drugs that may have limits, such as: Require a PA Quantity limits Step therapy Age or gender limits Drugs not on our PDL may be covered with a PA You can access our PDL on our website at florida.wellcare.com PA is required for certain drugs (please refer to our PDL)

10 Quality enhancement (QE) / programs Renal dialysis Rural health clinic These /programs are meant to help you improve your health and/or your children s health These /programs include: Children s programs (wellness and prevention) Domestic violence (prevention and intervention) Pregnancy prevention Prenatal/postpartum (after birth) Mental health These include: Dialysis (hemodialysis and peritoneal) Dialysis-related supplies Lab tests These clinics provide primary care if you live in a rural area s you can get at these clinics include: Adult health screenings Child health checkups (CHCUPs) Chiropractic Family planning Mental health Podiatry Vision

11 Therapy occupational Therapy physical Therapy respiratory These are provided by an occupational therapist who s licensed to practice in the State of Florida Occupational therapy : Include evaluation and treatment to prevent or correct physical and emotional deficits or to lessen the effect of these deficits Are available in your home or in an outpatient facility, regardless of your age These are provided by a physical therapist who s licensed to practice in the State of Florida Physical therapy : Include evaluation and treatment related to range-of-motion, muscle strength, functional abilities and use of therapeutic equipment Are available in your home if you re under age 21 and in an outpatient facility if you re over age 21 These are provided by a respiratory therapist who s licensed to practice in the State of Florida Respiratory therapy : Include evaluation and treatment of problems related to your lungs Are available in your home or in an outpatient facility, regardless of your age PA is required for occupational therapy PA is required for physical therapy

12 Therapy speech Transportation emergency Transportation non-emergency These are provided by a speech-language pathologist who s licensed to practice in the State of Florida Speech therapy : Include evaluation and treatment of speech-language conditions Are available in your home or in an outpatient facility, regardless of your age These provide medically needed ground or air ambulance transportation in emergency situations See the Emergency Care section later in this handbook for more details about emergencies These are available when you need transportation to medically needed appointments and you: Have no way to get a ride (in your own car or from a family member or friend) Live in an area where there s no public transportation Cannot get to public transportation because of your medical condition Pre-arranged transportation in an ambulance because of life-support needs is not emergency transportation When setting up your transportation: Call (TTY ) You must call at least 24 hours ahead of your appointment If you call less than 24 hours before your appointment, we ll review your request to decide if it s urgent PA is required for speech therapy

13 Vision These are given by an ophthalmologist, optometrist or optician who s licensed to practice in the State of Florida s include: Eyeglasses Eyeglass repairs Eye exams Medically needed contact lenses Prosthetic eyes Two pairs of eyeglasses (two frames and four lenses) each year (if you re under age 21) One pair of eyeglasses every two years (if you re over age 21) PA is required for a second pair of eyeglasses within a two-year period (if you re over age 21)

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