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- Doctor Office Visits and Screenings
- Routine and sick office visits
- Specialist Office Visits
- Well baby and child visits
- Early Periodic Screening, Diagnostic and Treatment (EPSDT) services (Members under 21 years of age)
- Periodic preventative health screenings
- Necessary diagnostic and treatment services
- Vaccines
- Pediatric or family nurse practitioners’ services
- Preventative Services
- Mammogram
- Colonoscopy
- OB/GYN exam and annual Pap tests
- Tests and Studies
- Laboratory work
- X-Rays
- Radiology services, including invasive and non-invasive imaging (when medically necessary)
- Maternity Care
- Prenatal and postpartum care
- Delivery
- Birthing center admission
- Newborn Care
- Early discharge home visits for new mothers
- Nurse-midwife services
- Family Planning
- Pharmacy
- Care Management and care coordination services
- Vision services (members under 21)
- Routine eye exam - once per every 12 months
- One pair of eyeglasses or medically necessary contact lenses - once every calendar year
- Vision services (members 21+)
- Dental services
- Ages 21 & Older
- *Benefit may not exceed $1,000 of dental care per year
- Preventative care:
- Regular exams and cleaning (twice a year)
- X-rays (one per year)
- Deep cleaning (one per year)
- Basic restorative care: Fillings and regular tooth extractions.
- Limited periodontics care: Scaling, debridement, and maintenance.
- Denture repair
- Oral and maxillofacial Surgery
- Potential additional $1,500 per member per calendar year for dental work that meets the extended benefit criteria.
- Ages 6 months to 5 years
- Fluoride varnish one time every 6 month, when completed on the same day as a well-child visit.
- Ages 20 and under:
- Behavioral Health
- Behavioral Health and substance disorder services
- Covered for adults ages 18 and older
- Children 17 & under limited to 30 outpatient visits per calendar year
- Behavioral services to treat autism spectrum disorder (ASD) for members under age 21 are not subjected to the 30-visit limit.
- Inpatient behavioral health in general hospital or psychiatric hospital
- Covered for adults ages 18 and older
- Services provided by Department of Services for Children, Youth, and Their Families (DSCYF) for members 17 and under
- Behavioral services to treat autism spectrum disorder pursuant to EPSDT
- Organ and tissue transplants
- Chiropractor services when medically necessary
- Ambulatory surgery center services
- Physical, speech, occupational therapy when medically necessary
- Hospice services
- Skilled Nursing Facility Services
- Limited to 30 days per calendar year
- Hospital services
- Inpatient services
- Outpatient services
- Federally Qualified Health Center
- Podiatrist Services
- Routine foot care only covered when member has diabetes, circulatory or vascular disorders
- Lactation counseling services
- Crisis intervention for adults
- Transportation services
- Emergency medical transportation only
- Emergency hospital services
- Home health services
- Orthotic and prosthetic devices as well as other durable medical equipment and assistive technology services
- Doctor Office Visits and Screenings
- Routine and sick office visits
- Specialist Office Visits
- Well baby and child visits
- Early Periodic Screening, Diagnostic and Treatment (EPSDT) services (Members under 21 years of age)
- Periodic preventative health screenings
- Necessary diagnostic and treatment services
- Vaccines
- Pediatric or family nurse practitioners’ services
- Preventative Services
- Mammogram
- Colonoscopy
- OB/GYN exam and annual Pap tests
- Tests and Studies
- Laboratory work
- X-Rays
- Radiology services, including invasive and non-invasive imaging (when medically necessary)
- Maternity Care
- Prenatal and postpartum care
- Delivery
- Birthing center admission
- Newborn Care
- Early discharge home visits for new mothers
- Nurse-midwife services
- Family Planning
- Pharmacy
- Care Management and care coordination services
- Vision services (members under 21)
- Routine eye exams – 1 every 12 months
- Eyeglasses/Contacts – covered every 12 months
- Vision services (members 21+)
- Dental services
- Ages 21 & Older
- Annual Maximum: $1,000 in dental services per member per calendar year
- Potential additional $1,500 per member per calendar year on an emergency basis
- Ages 6 months to 5 years
- Fluoride varnish one time every 6 month
- Ages 20 and under:
- Behavioral Health
- Behavioral Health and substance disorder services
- Covered for adults ages 18 and older
- Children 17 & under limited to 30 outpatient visits per calendar year
- Behavioral services to treat autism spectrum disorder (ASD) for members under age 21 are not subjected to the 30-visit limit.
- Inpatient behavioral health in general hospital or psychiatric hospital
- Covered for adults ages 18 and older
- Services provided by Department of Services for Children, Youth, and Their Families (DSCYF) for members 17 and under
- Behavioral services to treat autism spectrum disorder pursuant to EPSDT
- Members under age 18
- Limited to 30 units outpatient behavioral health benefits
- Organ and tissue transplants
- Chiropractor services when medically necessary
- Ambulatory surgery center services
- Physical, speech, occupational therapy when medically necessary
- Hospice services
- Skilled Nursing Facility Services
- Hospital services
- Inpatient services
- Outpatient services
- Federally Qualified Health Center
- Podiatrist Services
- Routine foot care only covered when member has diabetes, circulatory or vascular disorders
- Lactation counseling services
- Crisis intervention for adults
- Transportation services
- Emergency medical transportation only
- Emergency hospital services
- Home health services
- Orthotic and prosthetic devices as well as other durable medical equipment and assistive technology services
- Community-based residential alternatives that include assisted living facilities
- Attendant Care Services
- Include bathing, dressing, personal hygiene, transferring, toileting, skin care, eating and assisting with mobility
- Respite Care
- Both at home and in nursing and assisted living facilities
- Limited to no more than 14 calendar days per year
- Limit may be exceeded with prior authorization
- Adult day services
- Not available to members residing in assisted living and nursing facilities
- Day habilitation
- Not available to members residing in assisted living and nursing facilities
- Cognitive services
- Limited to 20 visits per year plus an assessment
- Not available to members residing in assisted living and nursing facilities
- Personal emergency response system (PERS) [electronic device that enables a member to secure help in an emergency]
- Not available to members residing in assisted living and nursing facilities
- Support for Self-Directed HCBS
- Self-Directed Attendant Care for Children
- Legally responsible family members are limited to providing 40 hours of service per week
- Independent activities of daily living (Chore) services
- Not available to members residing in assisted living and nursing facilities
- Nutritional supports
- Prior authorization required
- Not available to members residing in assisted living and nursing facilities
