Benefit Plan Comparison*
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- Eustacia Wright
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1 Benefit Plan Comparison* Services Category 1: Ambulatory Services Primary Care Provider No Limits No Limits No Limits Physician Office 4 visits per calendar year Certified Registered Nurse Practitioner 3 visits per calendar year Federally Qualified Health Center/Rural Health Clinic except for Dental Care Services as described below except for Dental Care Services as described below except for Dental Care Services as described below Independent Clinic 5 visits per calendar year Outpatient Hospital Clinic 9 visits per calendar year Podiatrist Services 4 visits per calendar year Chiropractor Services 9 visits per calendar year 10 visits per calendar year 20 visits per year Optometrist Services 1 visit per calendar year 1 visit per calendar year 1 visit per two years Hospice Care Radiology (For example: X-Rays, MRIs, CTs) The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60- day certification period. The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60- day certification period.. Respite care is not provided. 6 tests per calendar year Draft Page 1 of 5 Draft Updated: 14 NOV 2014
2 Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation. Key Limitations: Key Limitations: Dental Care Services Dentures 1 per lifetime, Dentures 1 per lifetime, Exams/prophylaxis 1 per 180 days, Exams/prophylaxis 1 per 180 days, Crowns, Periodontics and Endodontics only via approved benefit limit exception Crowns, Periodontics and Endodontics only via approved benefit limit exception Outpatient Hospital Short Procedure Unit (SPU) Outpatient Ambulatory Surgical Center (ASC) 5 visits per calendar year 2 visits per calendar year Non-Emergency Medical Transport Only to and from MA covered Only to and from MA covered Family Planning Clinic Renal Dialysis Initial training for home dialysis is limited to 24 sessions per patient per calendar year. Backup visits to the facility limited to no more than 26 per calendar year Initial training for home dialysis is limited to 24 sessions per patient per calendar year. Backup visits to the facility limited to no more than 75 per calendar year Category 2: Emergency Services Emergency Room on emergency Non-emergency services are not covered. Draft Page 2 of 5 Draft Updated: 14 NOV 2014
3 Ambulance Category 3: Hospitalization on emergency ambulance Non-emergency ambulance services are not covered. Inpatient Acute Hospital 2 non-emergency admits per calendar year Inpatient Rehab Hospital 1 admit per calendar year Inpatient Psychiatric Hospital 30 days per calendar year Inpatient Drug & Alcohol 30 days per calendar year Category 4: Maternity and Newborn Maternity Physician, Certified Nurse Midwives, Birth Centers Category 5: Mental Health and Substance Abuse (Behavioral Health) Outpatient Psychiatric Clinic Mobile Mental Health Treatment 31 visits per calendar year Outpatient Drug and Alcohol Treatment Opiate Detox: 42 visits per 365 days Chemotherapy/Drug-free visits: 3 visits per 30 days Residential Treatment Facility (Non-Hospital Residential Drug & Alcohol) NOT COVERED Methadone Maintenance One visit per day / 7 visits per week Draft Page 3 of 5 Draft Updated: 14 NOV 2014
4 Clozapine Limited to persons with Schizophrenia Psychiatric Partial Hospital 540 hours per calendar year Peer Support 4 hours per day / 900 hours per year Crisis No Limits Targeted Case Management other than Behavioral Health Limited to individuals identified in the target group () Limited to individuals identified in the target group () Targeted Case Management Behavioral Health Only NOT COVERED SMI only () Category 6: Prescription Drugs Prescription Drugs 6 per month Nutritional Supplements Category 7: Rehabilitation and Habilitation Services and Devices Skilled Nursing Facility 365 days per calendar year 365 days per calendar year 120 days per calendar year Home Health Care ICF/IID and ICF/ORC 60 visits per calendar year NOT COVERED Unlimited for first 28 days; limited to 15 days every month thereafter Requires an institutional level of care () 60 visits per year Durable Medical Equipment $1,000 per calendar year Eyeglass Lenses Draft Page 4 of 5 Draft Updated: 14 NOV 2014
5 Eyeglass Frames 2 frames per calendar year 2 frames per calendar year Contact Lenses Medical Supplies $1,000 per calendar year $2500 per calendar year Diabetic supplies provided by pharmacies are not limited (Except diabetic supplies provided by pharmacies, which are not limited) Therapy (Physical, Occupational, Speech)- Rehabilitative and Habilitative Only when provided by a hospital, outpatient clinic, or home health provider combined for Physical and Occupational Therapy for Speech Therapy combined for Physical and Occupational Therapy for Speech Therapy Category 8: Laboratory Services Laboratory $350 per calendar year Category 9: Preventative / Wellness Services and Chronic Care Tobacco Cessation 70 visits per calendar year 70 visits per calendar year * NOTE: Children s benefit plan will include all medically necessary services without limitation. **NOTE: PCO plans may opt to cover these services; please refer to your specific plan s benefit documents for coverage details. *** NOTE: If a recipient needs additional services beyond the service limit, the recipient or provider may request an exception to the benefit limit. Draft Page 5 of 5 Draft Updated: 14 NOV 2014
Benefit Plan Comparison*
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