Benefit. Benefits Covered by UnitedHealthcare Community Plan
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1 Benefits Covered by UnitedHealthcare Community Plan As member of UnitedHealthcare Community Plan, you are covered for the following services. (Remember to always show your current member ID card when getting services. It confirms your coverage.) If a provider tells you a service is not covered by UnitedHealthcare and you still want these services, you may be responsible for payment. You can always call Member Services at , TTY: 711, to ask questions about benefits. A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Benefit Bed Liners Behavioral Health Inpatient Behavioral Health Outpatient Blood and Plasma Products Covered for members age 4 and up; prior authorization for quantities greater than 200. Inpatient Hospitalization (use your Medicaid ID card). Under age 18: Covered by the Delaware Department of Prevention and Behavioral Health Services (DDPBHS) for the Delaware Healthy Children Program (DHCP) members and Medicaid members. Outpatient Mental Health and Substance Abuse. Under age 18: 30 visits per fiscal year. Self-referred service. 32
2 Benefit Bone Mass Measurement (bone density) Case Management Chemotherapy Colorectal/Prostate Screening Exams CT Scans Dental Services Diabetic Education Diabetic Equipment Diabetic Supplies Dialysis Diapers (for members age 4 and up) Self-referred service. Self-referred service. Age 20 and younger: Covered by the State of Delaware Medical Assistance Program Card. Please call for information. Age 21 and over: Covered by UnitedHealthcare. One cleaning (prophylaxis) and one periodic evaluation per year, one full mouth series x-ray per three years, removal of bony impacted wisdom teeth. Self-referred service. Insulin pump and supplies; prior authorization on amounts over $500 and all rentals. Glucose/Strips (covered by Delaware Medicaid: use your Medicaid ID card). Self-referred service. Prior authorization on quantities over 200. Drugs Prescribed by a Doctor Prior authorization on amounts over $ Health Plan Highlights Going to the Doctor Hospitals & Emergencies Pharmacy Benefits Other Plan Details
3 Benefit Durable Medical Equipment Prior authorization on amounts over $500. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services (for under age 21) Emergency Medical Transportation Emergency Room Care Eye Exam, Medical (for conditions such as diabetes and eye infections) Eye Exam, Routine Family Planning Services Genetic Testing Glaucoma Screening Gynecology Visits Hearing Aids and Batteries Hearing Exams HIV/AIDS Testing Home Health Care and Infusion Therapy Hospice Care Hospitalization Self-referred service. Self-referred service. Air and ambulance. Self-referred service. Covered, all members. Covered if age 20 and younger. Self-referred service. Self-referred service. Self-referred service. Covered if age 20 and younger. Self-referred service. Self-referred service. Self-referred service. 34
4 Benefit Immunizations Lab Tests and X-rays Mammograms Medical Supplies MRI, MRA, PET Scan Nursing Home Obstetrical/Maternity Care Self-referred service. Self-referred service. Self-referred service. Prior authorization on amounts over $300 and all rentals. Covered for the first 30 days, when medically necessary. Additional days are considered long-term care; an application must be submitted to and approved by the Delaware Medical Assistance Program. Orthopedic Shoes Prior authorization on amounts over $500. Outpatient Surgery, Same Day Surgery, Ambulatory Pain Management Services Parenting/Child Birth Education Personal Care (in home)/ Aide Services Podiatry Care (routine diabetic care or peripheral vascular disease) Prior authorization. Self-referred service. Prescription Drugs Additional copays may apply. See page 28. Primary Care Provider Visits Private Duty Nursing Self-referred service. 35 Health Plan Highlights Going to the Doctor Hospitals & Emergencies Pharmacy Benefits Other Plan Details
5 Benefit Prosthetics and Orthotics Prior authorization on amounts over $500. Radiation Rehabilitation (inpatient hospital) Skilled Nursing Facility Care Sleep Apnea Studies/ Sleep Therapy Smoking Cessation Counseling Specialty Physician Services Surgical Center Therapy Outpatient Occupational, Physical, Speech Transportation Up to 30 days per year. Self-referred service. Self-referred service. Covered for all fully Medicaid eligible members by Delaware Medicaid. Non-emergency transportation service is not a benefit for members under Delaware Healthy Children Program. 36
6 Enhanced Benefits The long term care services you can receive depend on your needs and whether you are receiving care in a nursing home or receiving care at home. The following long term care services are available to Diamond State Health Plan Plus members when the services have been determined to be cost-effective and medically necessary. Long term care includes help doing everyday activities that you may no longer be able to do for yourself as you grow older, or if you have a disability like bathing, dressing, getting around your home, preparing meals, or doing household chores. Long term care services include care in a nursing home. Long term care also includes care in your own home or in the community. These are called Home and Community Based Services or HCBS. A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Benefit Description Requirements Adult Day Care Cognitive Services A place that provides supervised care and activities during the day. Services that: Assess your ability to care for yourself. Assess your ability to interact with others. Help you create a plan to help you do these things. Help improve the member s behavior or thinking disorders. 37 Health Plan Highlights Going to the Doctor Hospitals & Emergencies Pharmacy Benefits Other Plan Details
7 Benefit Description Requirements Community-Based Residential Alternatives That Include Assisted Living Facilities Day Habilitation A place where you live that provides help with personal care needs and taking your medicine. You must pay for your room and board. A place, other than your private home, where you receive help to: Reinforce skills you learned in another setting. Gain additional skills that give you more independence and control of your life. This service is often for people who have problems acting or thinking clearly because of an injury. A common example is a traumatic brain injury. Home-Delivered Meals Up to 1 meal per day. In-Home Respite Care In-Patient Respite Care Minor Home Modifications Someone to come and stay with you in your home for a short time, so your caregiver can get some rest. A short stay in a nursing home or assisted care living facility, so your caregiver can get some rest. Changes to your home to help you get around easier and safer when medically necessary. For example, a wheelchair ramp. Max $ Limits. 38
8 Benefit Description Requirements Nursing Facility Care Personal Care Attendant/Care Services Personal Emergency Response System (PERS) Specialized Durable Medical Equipment and Supplies These residential facilities provide all personal and 24 hour nursing care for those with long term care needs. Help with Activities of Daily Living (ADL), such as: Getting out of bed. Bathing. Getting dressed. Using the bathroom. May also include help with Instrumental Activities of Daily Living (IADLs). This kind of help is available if it s part of your plan of care. Examples: Light housekeeping chores. Shopping. Fixing a meal. A call button so you can get help in an emergency. Use it when your caregiver is not around. This service is not available if you: Live in an assisted care living facility. Live in a nursing home. These facilities already have a way to help you when you need it. Items or devices that help you do things easier or safer in your home. For example, grabbers to reach things. Not covered under the Medicaid State Plan. 39 Health Plan Highlights Going to the Doctor Hospitals & Emergencies Pharmacy Benefits Other Plan Details
9 Benefit Description Requirements Support for Consumer Direction Transition Services (Money Follows the Person Only) Transition Services Workshops Information and assistance to: Direct your Personal Care/Attendant services yourself. Help managing the money to do this. Help with the initial costs of a move from a nursing home back to a home in the community. Examples: Security deposit. Telephone connection fee. Groceries to get you started. Furniture. Bedding. Workshops that help prepare you and your family and other caregivers for community living. Available under the Money Follows the Person only. Max $ Limits. 40
Covered Benefits. Covered. Must meet current federal and state guidelines. Abortions. Covered. Allergy Testing. Covered. Audiology. Covered.
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)
Preauthorization Requirements * (as of January 1, 2016)
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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 www.studentplanscenter.com or by calling 1-800-756-3702.
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