Benefits Matrix for Adults Covered and Non-Covered Services
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1 Covered and Non-Covered Services UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care The matrix below lists the available benefits for adults enrolled in West Virginia Medicaid. These benefits are identified by the three programs offered by the state of West Virginia: Basic, Traditional and Enhanced. If you would like detailed information about the benefits, please see our Provider Operations Manual, available on UniCare s West Virginia Medicaid website. Please note, an asterisk (*) denotes a value-added benefit that is provided by UniCare, that is not covered by the state of West Virginia. Ambulance Ambulance Ambulance Behavioral Health Services Inpatient Unlimited days based upon We do not cover: Services given at psychiatric residential treatment facilities (covered directly by the state through fee for services) Behavioral Health Services Outpatient These types of service when provided in an outpatient or office setting. Unlimited visits based upon Chemical Dependency/Mental Health Services Behavioral Health Services Inpatient Unlimited days based upon We do not cover: Services given at psychiatric residential treatment facilities (covered directly by the state through fee for services) Behavioral Health Services Outpatient These types of service when provided in an outpatient or office setting. Unlimited visits based upon Chemical Dependency/Mental Health Services Behavioral Health Services Inpatient Unlimited days based upon We do not cover: Services given at psychiatric residential treatment facilities (covered directly by the state through fee for services) Behavioral Health Services Outpatient These types of service when provided in an outpatient or office setting. Unlimited visits based upon Chemical Dependency/Mental Health Services In UniCare Health Plan of West Virginia, Inc., Registered mark of WellPoint, Inc WVW3082 Rev:11/15/2012
2 Covered and Non-Covered Services Page 2 of 7 Chiropractic Services Not covered. Chiropractic Services 24 visits per calendar year. Coverage includes: Chiropractic Services 24 visits per calendar year. Coverage includes: Manipulation to correct subluxation Manipulation to correct subluxation Radiological examinations related to the service. Radiological examinations related t othe service. Dental Services Coverage includes emergency services provided by a dentist or oral surgeon and is limited to the treatment of fractures of mandible and maxilla, biopsy, removal of tumors and emergency extractions. Preventive dental services and orthodontia services are covered directly by the state for members up to age 21. Dental services do not include temporomandibular joint (TMJ) surgery and treatment. Diabetes Care Diabetes education / nutrition for members up to age 21 Annual dilated retinal eye exam for diabetic members Dental Services Coverage includes emergency services provided by a dentist or oral surgeon and is limited to the treatment of fractures of mandible and maxilla, biopsy, removal of tumors and emergency extractions. Preventive dental services and orthodontia services are covered directly by the state for members up to age 21. Dental services do not include temporomandibular joint (TMJ) surgery and treatment. Diabetes Care Diabetes education / nutrition Annual dilated retinal eye exam for diabetic members Dental Services Coverage includes emergency services provided by a dentist or oral surgeon and is limited to the treatment of fractures of mandible and maxilla, biopsy, removal of tumors and emergency extractions. Preventive dental services and orthodontia services are covered directly by the state for members up to age 21. Dental services do not include temporomandibular joint (TMJ) surgery and treatment. Diabetes Care Diabetes education / nutrition Annual dilated retinal eye exam for diabetic members
3 Covered and Non-Covered Services Page 3 of 7 Durable Medical Equipment (DME) $1,000 per year. Requires prior authorization if exceeded. All custom DME also requires prior authorization. Orthotics and Prosthetics UniCare covers medical equipment and supplies, including medical equipment for home use, when medically necessary and within the limits of Medicaid Enteral nutrition and total parental nutrition are covered only when the nutritional supplement is the only form of nutrition (except for enrollees under 21, where the supplement must be the main source of nutrition). The following DME is not covered: Equipment used for exercise Equipment or supplies used only for making the room or home comfortable, such as air conditioning, air filters, air purifiers, spas, swimming pools, elevators and supplies for hygiene or appearance Experimental or research equipment More than one piece of equipment that serves the same function Durable Medical Equipment (DME) All custom DME also requires prior authorization. Orthotics and Prosthetics UniCare covers medical equipment and supplies, including medical equipment for home use, when medically necessary and within the limits of Medicaid Enteral nutrition and total parental nutrition are covered only when the nutritional supplement is the only form of nutrition (except for enrollees under 21, where the supplement must be the main source of nutrition). The following DME is not covered: Equipment used for exercise Equipment or supplies used only for making the room or home comfortable, such as air conditioning, air filters, air purifiers, spas, swimming pools, elevators and supplies for hygiene or appearance Experimental or research equipment More than one piece of equipment that serves the same function Durable Medical Equipment (DME) All custom DME also requires prior authorization. Orthotics and Prosthetics UniCare covers medical equipment and supplies, including medical equipment for home use, when medically necessary and within the limits of Medicaid Enteral nutrition and total parental nutrition are covered only when the nutritional supplement is the only form of nutrition (except for enrollees under 21, where the supplement must be the main source of nutrition). The following DME is not covered: Equipment used for exercise Equipment or supplies used only for making the room or home comfortable, such as air conditioning, air filters, air purifiers, spas, swimming pools, elevators and supplies for hygiene or appearance Experimental or research equipment More than one piece of equipment that serves the same function
4 Covered and Non-Covered Services Page 4 of 7 Family Planning Family planning clinics Private physicians Services Supplies Family planning, education and Medical visits for birth control Annual cervical cancer screenings Human papillomavirus (HPV) testing for women 18 years of age and older Pregnancy tests Lab tests Tests for sexually transmitted infections (STIs) Screening, testing, and referral for treatment for members at risk for HIV Sterilization The following items are not covered: Treatment for members who cannot get pregnant Sterilization for recipients in institutions, or for those who are mentally incompetent Hysterectomies, unless medically necessary Pregnancy terminations Home Health 60 units per year, prior authorization required. Provided at the recipients place of residence on orders of a physician. Residence does not include: Hospital nursing facility Intermediate care facility/mental retardation State institution Family Planning Family planning clinics Private physicians Services Supplies Family planning, education and Medical visits for birth control Annual cervical cancer screenings Human papillomavirus (HPV) testing for women 18 years of age and older Pregnancy tests Lab tests Tests for sexually transmitted infections (STIs) Screening, testing, and referral for treatment for members at risk for HIV Sterilization The following items are not covered: Treatment for members who cannot get pregnant Sterilization for recipients in institutions, or for those who are mentally incompetent Hysterectomies, unless medically necessary Pregnancy terminations Home Health 60 units per year, prior authorization required. Provided at the recipients place of residence on orders of a physician. Residence does not include: Hospital nursing facility Intermediate care facility/mental retardation State institution Family Planning Family planning clinics Private physicians Services Supplies Family planning, education and Medical visits for birth control Annual cervical cancer screenings Human papillomavirus (HPV) testing for women 18 years of age and older Pregnancy tests Lab tests Tests for sexually transmitted infections (STIs) Screening, testing, and referral for treatment for members at risk for HIV Sterilization The following items are not covered: Treatment for members who cannot get pregnant Sterilization for recipients in institutions, or for those who are mentally incompetent Hysterectomies, unless medically necessary Pregnancy terminations Home Health 60 units per year, prior authorization required. Provided at the recipients place of residence on orders of a physician. Residence does not include: Hospital nursing facility Intermediate care facility/mental retardation State institution
5 Covered and Non-Covered Services Page 5 of 7 Hospice Services include: Nursing care Physician services Medical social services Short-term inpatient care Durable medical equipment Drugs Biologicals Home health aide and homemaker Must have physician certification that recipient has a life expectancy of six months or less. Recipient waives right to other Medicaid services related to the terminal illness. Inpatient Services Inpatient Hospital Care Inpatient Psychiatric Services (Psychiatric residential treatment centers covered directly by the state) Inpatient Rehabilitation (up to age 21) Non-Emergency Medical Transportation Five trips per year, covered directly Nursing Home Services by the state through their fee-forservice Nutritional Education With physician s orders, enrollment in Weight Watchers * Hospice Services include: Nursing care Physician services Medical social services Short-term inpatient care Durable medical equipment Drugs Biologicals Home health aide and homemaker Must have physician certification that recipient has a life expectancy of six months or less. Recipient waives right to other Medicaid services related to the terminal illness. Inpatient Services Inpatient Hospital Care Inpatient Psychiatric Services (Psychiatric residential treatment centers covered directly by the state) Inpatient Rehabilitation (up to age 21) Non-Emergency Medical Transportation Nursing Home Services by the state through their fee-forservice Nutritional Education With physician s orders, enrollment in Weight Watchers * Hospice Services include: Nursing care Physician services Medical social services Short-term inpatient care Durable medical equipment Drugs Biologicals Home health aide and homemaker Must have physician certification that recipient has a life expectancy of six months or less. Recipient waives right to other Medicaid services related to the terminal illness. Inpatient Services Unlimited, medically necessary days based on diagnosis-related groups. Inpatient Hospital Care Inpatient Psychiatric Services (Psychiatric residential treatment centers covered directly by the state) Inpatient Rehabilitation (up to age 21) Excludes adults in institutions for mental diseases. Non-Emergency Medical Transportation Nursing Home Services by the state through their fee-forservice Nutritional Education With physician s orders, enrollment in Weight Watchers *
6 Covered and Non-Covered Services Page 6 of 7 Outpatient Services Diagnostic X-ray, lab services and testing. CTs, MRIs, PET MRAs and SPECTs require prior authorization. Occupational, speech and physical therapies, prior authorization required when in a home setting. Prostate-specific antigen for men if medically necessary (member is symptomatic); ordered by a provider acting within the scope of his license based on American Cancer Society guidelines. Physicians, Nurse Practitioners, Midwifes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Primary care office visits Physician office visits, specialty care Podiatry services, up to age 21, or if PCP cannot perform services: Treatment for acute conditions (infections, inflammations, ulcers, bursitis) Surgeries for bunions, ingrown toe nails Reduction of fractures, dislocation and treatment of sprains Orthotics Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered. Outpatient Services Cardiac rehabilitation outpatient services, prior authorization required Diagnostic X-ray, lab services and testing. CTs, MRIs, PET MRAs and SPECTs require prior authorization. Occupational, speech and physical therapies, prior authorization required. Prostate-specific antigen for men if medically necessary (member is symptomatic); ordered by a provider acting within the scope of his license based on American Cancer Society guidelines. Pulmonary Rehabilitation, prior authorization required Weight management Physicians, Nurse Practitioners, Midwifes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Primary care office visits Physician office visits, specialty care Podiatry services: Treatment for acute conditions (infections, inflammations, ulcers, bursitis) Surgeries for bunions, ingrown toe nails Reduction of fractures, dislocation and treatment of sprains Orthotics Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered. Outpatient Services Cardiac rehabilitation outpatient services, prior authorization required Diagnostic X-ray, lab services and testing. CTs, MRIs, PET MRAs and SPECTs require prior authorization. Occupational, speech and physical therapies, prior authorization required. Prostate-specific antigen for men if medically necessary (member is symptomatic); ordered by a provider acting within the scope of his license based on American Cancer Society guidelines. Pulmonary Rehabilitation, prior authorization required Health education on weight management Physicians, Nurse Practitioners, Midwifes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Primary care office visits Physician office visits, specialty care Podiatry services: Treatment for acute conditions (infections, inflammations, ulcers, bursitis) Surgeries for bunions, ingrown toe nails Reduction of fractures, dislocation and treatment of sprains Orthotics Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered.
7 Covered and Non-Covered Services Page 7 of 7 Prescriptions Four per month, covered directly by the state s fee-for-service Medicaid Prescriptions Prescriptions Private Duty/Skilled Nursing Covered up to age 21 Tobacco Cessation Access to Quit Line. Vision Services Covers medical services only. Private Duty/Skilled Nursing Covered up to age 21 Tobacco Cessation Information on smoking and tobacco cessation through UniCare s Health Education Access to Quit Line. Vision Services Covers medical services only: Refractions Eyeglasses Preventive eye exams. Vision care excludes prescription sunglasses and designer frames. Private Duty/Skilled Nursing Covered up to age 21 Tobacco Cessation* Information on smoking and tobacco cessation through UniCare s Health Education Access to Quit Line. Vision Services Covers medical services only: Refractions Eyeglasses are limited to first pair received after cataract surgery Preventive eye exams. Vision care excludes prescription sunglasses and designer frames.
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