YOURCARE OPTION. Covered in full. No co-payment.

Transcription

1 YOURCARE OPTION Benefits Description ABA Treatment for Autism Spectrum Disorder Abortion Covered in Full. No co-payment. Accidental Dental Full coverage for accidental dental services provided in an inpatient and ambulatory surgery settings. Prior Authorization No co-payment. Excludes professional services of a dentist. Acupuncture, Hypnosis, Biofeedback Adult Day Care/AIDS Adult Day Care Covered in Full. No co-payment. Coverage based on medical necessity. A physician's order must be received. Prior Authorization is Allergy Immunotherapy and Testing Ambulance-Ground or Air Covered by Medicaid Fee for Service Anesthesia Assertive Community Treatment Services (ACT) Effective 7/1/16: All members over 21 years of age-covered All ACT services- contact Beacon Health Options at Asthma Services: Self-Management Education Referral Allowed up to 10 hours of self-management training (individual or group). Audiograms/Hearing Test Autologous Blood and Autologous Blood Storage

2 Bone Mass Measurement Covered every 2 years when medically necessary (significant risk factors for developing osteoporosis). Cardiac Rehab Phase II covered in full. No co-payment. No Prior Authorization. Chemotherapy, Inhalation & Radiation Therapy-Facility & Physician Chiropractic Care Colonoscopy Contraceptive Devices Cosmetic Surgery Crisis Intervention Services Effective 7/1/16: All members over 21 years of age-covered All crisis intervention services- contact Beacon Health Options at Custodial Care Covered in full for age 21 or older who meet eligibility requirements for institutional long-term care on or after July 1, Prior Authorization is No copayment. Dental-Routine For benefit details contact HealthPlex at Diabetic Services: Diabetic Equipment Services See: DME benefits Diabetic Services: Self-Management Education Allowed up to 10 hours of self-management training (individual or group). Diabetic Services: Supplies, Insulin, or Oral Agents Covered in full Diagnostic Testing and Treatment Dialysis and Hemodialysis-Facility and Physician

3 Durable Medical Equipment (DME) Covered in full. Includes equipment servicing. A par provider must order DME. No co-payment. Prior authorization may be Refer to emedny manual for specifics. Emergency Care Experimental & Investigational Services Evaluated on a case by case basis. Prior authorization Eye Exams Routine: Limit 1x/24 months, to the exact date. Member may self-refer to a participating provider. Sick Eye: Covered in full. No copayment. Must be medically necessary. Family Planning No co-payment. Member may self-refer. If services are provided by a non par provider, services will be covered by Medicaid Fee For Service. Frames/Lenses/Contacts No co-payment. Limit 1x/24 months, to the exact date. More frequently if medically necessary. Includes repairs, replacement if lost, damaged, or destroyed. Members must choose within standard group of frames or pay full cost out of pocket. Replacement glasses must duplicate the original prescription and frame and must be dispensed by original provider. Eyewear fitting is inclusive to the eyewear reimbursement. Contacts only covered if medically necessary. Lasik Surgery only covered if medically necessary. Prior Authorization is Genetic Testing Prior Authorization is Gym Membership Gynecological Exam-Routine Hearing Aids Includes repairs & batteries. Prior Authorization is Hearing Exam Hemophilia Factor Effective 7/1/17 Hemophilia Factors are covered in full. The blood factor product will be processed under the medical benefit. Providers and Pharmacies should bill the appropriate Jcode to YourCare. HIV Counseling and Testing Member may self-refer.

4 Home and Community Based Services (HCBS) Home Health Care Prior Authorization is Services must be provided by a Certified Home Health Agency (CHHA). Home Health Aide: Covered in full. Hospice Care No Prior Authorization Hospital Inpatient No co-payment. Unlimited days in a semi-private room, based on medical necessity. Includes Acute Inpatient Rehab and Detox. Prior Authorization Required. Hospital Outpatient Immunizations All vaccines for children up through age 18 must be purchased, free of charge, through the Vaccines for Children (VFC) Program. Immunizations required for foreign travel covered. Infertility Services Interpretation Services Covered for members with limited English proficiency (LEP) and communication services for people who are deaf or hard of hearing. Lab Services Lactation Counseling Covered in full when provided by professionals who are certified as IBCLCs (International Board Certified Lactation Consultants) credentialed by the IBLCE (International Board of Lactation Consultant Examiners). No co-payment. Mammography Coverage based on medical necessity. Maternity (Prenatal/Postnatal & Delivery, including ultrasound*) *additional ultrasounds when medically necessary Medical Supplies Covered when dispensed by a participating provider physician as part of an office or clinic visit or from a participating DME vendor. Medicinal Marijuana Not a covered benefit

5 Mental Health Inpatient Prior Authorization Effective 7/1/16: All members over 21 years of age-covered All mental health services- contact Beacon Health Options at Mental Health Outpatient All mental health services- contact Beacon Health Options at Newborn Care-In Hospital Covered in full for all newborns. No co-payment. They must be enrolled in the mother's Plan. Effective on the first day of the newborn's month of birth. Nutritional Counseling Observation Stay Occupational Therapy No co-payment. Limit of 20 visits per calendar year. Provider may self-refer for the initial evaluation. Prior authorization is required for visits after the initial evaluation. Exception to limits: Children under the age of 21 & developmental disabled adults or TBI. Organ Transplant Prior authorization is Orthopedic Footwear Prescription footwear (L3201-L3649)- Coverage is limited to treatment of foot complications in children under age 21 and diabetics, or when a shoe is part of a leg brace (orthotic). Prior authorization is required when dispensed by a vendor. Diabetic footwear (A5500-A5513): Prior authorization is Orthotics/Orthosis Must be medically necessary and ordered by a par provider. No co-payment. Refer to emedny manual for specifics. Palliative Care Covered as part of the Hospice Benefit. Member must be enrolled in a Hospice program. Pap Smear

6 Partial Hospitalization All partial hospitalization services- contact Beacon Health Options at Personal Care/Consumer Direct Personal Care Coverage is based on medical necessity. A physician's order is Prior authorization is Personal Recovery Oriented Services (PROS) All PROS services- contact Beacon Health Options at Physical Therapy No co-payment. Limit of 20 visits per calendar year. No authorization required for the first 20 visits. May include Land or Aqua therapy. Exception to limits: Children under the age of 21 & developmental disabled adults or TBI. Physical-Routine Unlimited, including those which are necessary for school and camp. Physical Exams for employment purposes are not covered. Podiatry Routine-Covered in full when enrollee's physical condition poses a hazard due to the presence of localized illness, injury or symptoms involving the foot, or when performed as a necessary and integral part of otherwise covered devices. Services provided by a podiatrist for persons under 21 must be covered upon referral. No co-payment. Prior Authorization and a Referral are Prescription Covered by Express Scripts. $3.00 co-payment for Brand Name drugs. $1.00 co-payment for generic drugs. Over the counter medications will have a $.50 co-payment. Diabetic Supplies and enteral formula-no co-payment. Primary Care Office Visit to treat an injury or illness Private Duty Nursing Covered in full when medically necessary. No copayment. Prior Authorization is Prostate Cancer Screening

7 Prosthetic Devices Must be medically necessary and ordered by a par provider. No co-payment. Vendor does not need to be participating to dispense. Pulmonary Rehab Radiology/Diagnostic Imaging Prior Authorization may be required-contact Evicore at Rehabilitation-Medical-Inpatient Covered in full up to 365 days a year when medically necessary. No co-payment. Prior Authorization is Second Surgical Opinion Skilled Nursing Facility-Custodial Covered in full when medically necessary. No copayment. Prior Authorization is Age 21 and older only. Skilled Nursing Facility-Inpatient, Rehab and Non-Custodial Covered in full when medically necessary. No copayment. Prior Authorization is Sleep Study Prior Authorization is Smoking Cessation Programs Medications covered in full under pharmacy benefit. Smoking Cessation Programs covered under the Preventative Health Services portion of the contract. Allowed 8 counseling sessions during any 12 continuous months. Smoking Cessation is not a covered service when performed in an Emergency Room setting. Specialist Office Visit Referral may be See: Referral List. Speech Therapy No co-payment. Limit of 20 visits per calendar year. Provider may self-refer for the initial evaluation. Prior authorization is required for visits after the initial evaluation. Exception to limits: Children under the age of 21 & developmental disabled adults or TBI. Sterilization Medicaid Sterilization Consent Form Form must be signed 30 days prior to procedure. (Reversal of elected sterilization is a non-covered benefit.) Hysterectomy: Covered. Requires Hysterectomy Consent Form. Does not need to be signed 30 days prior to procedure. Prior Authorization is required for non-cancer diagnosis (Inpatient and Outpatient).

8 Substance Use Disorder - Outpatient (includes outpatient clinic, outpatient rehabilitation, and opioid treatment) All substance use disorder services- contact Beacon Health Options at Substance Use Disorder - Residential Addiction Treatment Services All substance use disorder services- contact Beacon Health Options at Substance Use Disorder/Detoxification Services - Inpatient Rehab Coverage is unlimited based on medical necessity. No copayment. Prior Authorization is Detoxification is covered in full under the medical benefit. No co-payment. Prior Authorization is Detox does not count against allotted mental health visits. For Inpatient Rehab- All substance use disorder services- contact Beacon Health Options at Surgery: Outpatient Facility/Physician/Freestanding All covered in full. No co-payment. Telehealth/Telemedicine Program Covered in full effective 1/1/16. TMJ Prior Authorization is Transgender Related Care & Services Covered effective 3/11/15 for members at least 18 years of age for the following services: Cross-sex hormone therapy, surgical gender re-assignment-including posttransition care, counseling services for diagnosis of gender dysphoria. Prior Authorization is Transportation-Non Emergent and Emergency Covered by Medicaid Fee For Service. Urgent Care Visits

9 Weight Loss Program Well Child Care (to age 19) Unlimited, including those which are necessary for school and camp. V1 8/23/17