MedStar Family Choice Benefits Summary District of Columbia- Healthy Families WHAT YOU GET WHO CAN GET THIS BENEFIT BENEFIT
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1 Primary Care Services Specialist Services Laboratory & X-ray Services Hospital Services Pharmacy Services (prescription drugs) Emergency Services Preventive, acute, and chronic health care Services generally provided by your PCP Health care Services provided by specially trained doctors or advanced practice nurses. Referrals are usually required Does not include cosmetic Services and surgeries except for surgery required to correct a condition resulting from surgery or disease, created by an accidental injury or a congenital deformity, or is a condition that impairs the normal function of your body Lab tests and X-rays Outpatient Services (preventive, diagnostic, therapeutic, rehabilitative, or palliative Services) Inpatient Services (hospital stay) Prescription drugs included on the MedStar Family Choice drug formulary. You can find the drug formulary at medstarfamilychoice.com or by calling Member Services. Only includes medications from network pharmacies Includes the following non-prescription (overthe-counter) medicines for colds, fever and rashes. A complete list is available on the website or by calling Member Services. A Screening exam of your health condition and stabilization if you have an Emergency Medical Condition, regardless if the Provider is in or out of the MedStar Family Choice network. Treatment for emergency conditions Any Member with a Referral from their PCP or who has an emergency other than dually eligible(medicaid/medicare) Members whose prescriptions are covered under Medicare Part D 1
2 Family Planning Podiatry Rehabilitation Services Pregnancy Testing: Counseling for the woman Routine and Emergency Contraception Voluntary sterilizations for Members over 21 years of age (requires signature of an approved sterilization form by the Member 30 days prior to the procedure) Screening, Counseling and Immunizations (including for HPV) Screening and preventive treatment for all sexually transmitted diseases Does not include sterilization procedures for Special care for foot problems Regular foot care when medically needed. Rehabilitation Services, including physical, speech and occupational therapy as appropriate Prosthetic devices Replacement, corrective, or supportive devices prescribed by a licensed provider Vision Care Eye exams at least once every year and as needed; and eye glasses (corrective lenses) as needed One pair of eyeglasses every two years except when the Member has lost his or her eyeglasses or when the prescription has changed by more than 0.5 diopter Members age 21 and older 2
3 Home Health Services In-home health care Services, including: Nursing and home health aide care Home health aide Services provided by a home health agency Physical therapy, occupational therapy, speech pathology and audiology Services Personal care Services Services provided to a Member by an individual qualified to provide such Services who is not a member of the individual s family, usually in the home, and authorized by a physician as a part of the Member s treatment plan. Is not available to Members in a hospital or nursing home Nursing Home Care Full-time skilled nursing care in a nursing home up to 30 consecutive days Hospice Care Support Services for people who are dying Transportation Services Transportation to and from medical Appointments 3
4 Adult Wellness Services Immunizations Routine Screening for Sexually Transmitted Diseases HIV/AIDS Screening, testing and counseling Breast cancer Screening (women only) Cervical cancer Screening (women only) Osteoporosis Screening (post-menopausal women) HPV Screening (women only) Prostate cancer Screening (men only) Abdominal aortic aneurysm Screening (men only) Screening for obesity Diabetes Screening Screening for high blood pressure and cholesterol (lipid disorders) Screening for depression Colorectal cancer Screening (Members 50 years and older) Smoking cessation counseling Diet and exercise counseling Mental Health counseling Alcohol and drug Screening Members over age 21 as appropriate 4
5 Child Wellness Services Dental Benefits Whatever is needed to take care of sick children and to keep healthy children well, including Screening and assessments such as: Health and development history and Screenings Physical and mental health development and Screenings Comprehensive health exam Immunizations Lab tests including of blood lead levels Health education Dental Screening Services Vision Screening Services Hearing Screening Services Alcohol and drug Screening and counseling Mental health Services Does not include any health Services furnished to a child in a school setting Under age 21 General dentistry (including regular and emergency treatment) and orthodontic care for special problems Check-Ups twice a year with a dentist are covered for children ages 3 through 20. A child s PCP can perform dental Screenings for a child up to age 3 Does not include routine orthodontic care 5
6 Dental Benefits Over age 20 General dental exams and routine cleanings every six (6) months Surgical services and extractions; Emergency Dental care; Fillings; X-rays (full series limited to once (1) every three (3) years Full mouth debridement; Prophylaxis limited to two times (2) per year; Bitewing series; Palliative treatment; Sealant application; Removable partial and full dentures; Root canal treatment limited to two molars per year; Periodontal scaling and root planning Removal of impacted teeth; Initial placement or replacement of a removable prosthesis (any dental device or appliance replacing one or more missing teeth, including associated structures, if required, that is designed to be removed and reinserted), once every five (5) years some limitations apply Removable partial prosthesis Any dental service that requires inpatient hospitalization must be prior authorized Elective surgical procedures requiring general anesthesia Members over age 20 6
7 Hearing Benefits Alcohol & Drug Abuse Treatment Alcohol & Drug Abuse Treatment Durable Medical Equipment (DME) & Disposable Medical Supplies (DMS) Diagnosis and Treatment of conditions related to hearing, including hearing aids and hearing aid batteries Inpatient detoxification Other alcohol/drug abuse services are provided by the Addiction, Prevention and Recovery Administration (APRA) Help with getting care from APRA Inpatient and outpatient substance abuse treatment Other alcohol/drug abuse Services are provided by the Addiction, Prevention and Recovery Administration (APRA) Help with getting care from APRA Durable Medical Equipment (DME) Disposable medical supplies (DMS) 7
8 Mental Health Services Services provided by mental health providers, including: Diagnostic and assessment services Physician and mid-level visits, including: o Individual counseling o Group counseling o Family counseling o FQHC Services Medication/Somatic treatment Crisis Services Inpatient Hospitalization and Emergency Department Services Day Services Intensive Day Treatment Case management Services Services for individuals 65 years and older in an institution for mental disease Treatment for any mental condition that could complicate pregnancy Patient Psychiatric Residential Treatment Facility Services (PTRF) for Members under 22 years of age for thirty (30) consecutive days Mental health Services for children that are included in an IEP or IFSP during holidays, school vacations, or sick days when the child is not in school Care coordination for Members receiving the following Services from DMH: Community based interventions Multi-systemic therapy (MST) Assertive Community Treatment (ACT) Community Support 8
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