Blue Choice Option/ Medicaid fee-for-service/
Child
Health Plus/Family Health Plus
June 2002
This
is a summary of benefits only. The
member contract governs what is covered.
The
following chart is a benefit comparison between Blue Choice Option, Medicaid
fee-for service, Child Health Plus and Family Health Plus.
A brief description of each program has also been included.
All
services must be considered medically necessary in order to be covered by the
plan. Some services require prior
authorization.
Depending
on the category of eligibility, people who have Medicaid may have the option
to join a Medicaid managed care program.
Medicaid managed care provides members with a “provider network”
from which they can receive health care services.
The provider panel consists of Primary Care Physicians (PCP),
specialists, labs, hospitals and other health care facilities.
The name of our Medicaid managed care program is HMOBlue Option.
Medicaid
fee-for-service
Medicaid
clients receive services from providers in the community who accept Medicaid.
Clients are not restricted to managed care rules and may see any
provider who accepts Medicaid payment. Primary
Care Providers (PCPs) are not required and referrals for services do not need
to be in place.
This
is a managed care program for children in families who are not eligible for
Medicaid. Members receive their care through providers who are part of the
managed care network. A member
chooses a Primary Care Physician (PCP) who coordinates all his/her medical
care. Child Health Plus members
choose a PCP from our managed care network.
Family Health Plus is a program that provides health coverage to adults who do not have insurance through their employer, but have incomes too high for Medicaid. The product has a comprehensive prepaid package, similar to that provided under the Child Health Plus program. It is administered like Medicaid managed care, however, and the network of providers for these members is the Medicaid managed care network.
|
Services |
Blue Choice Option |
Medicaid fee-for-service |
Child Health Plus |
Family Health Plus |
|
Inpatient
Hospital Services |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Emergency
Services |
Covered in full. Triage fee applies. |
Covered in full |
Covered in full |
Covered in full. Triage fee applies. |
|
Maternity |
|
|
|
|
|
Hospital and Physician Charges for mother |
Covered in full |
Covered in full |
Covered in full |
Covered in full. Encourage application for Medicaid. |
|
Newborn Nursery Care |
Covered in full |
Covered in full |
No coverage |
No coverage. Newborn should be Medicaid fee-for-service or managed care. |
|
Transportation |
|
|
|
|
|
Emergency Ambulance |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Non-emergent
transportation |
Subject to county rules |
Subject to county rules |
No coverage |
No coverage |
|
Preventive
Care |
|
|
|
|
|
Well child visit |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Adult routine physicals |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Annual pelvic exams and Pap screenings |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Mammograms |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Other
Services |
|
|
|
|
|
Acupuncture |
No coverage |
No coverage |
No coverage |
No coverage |
|
Allergy Tests and injections (including serum) |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Chemotherapy and Radiation Therapy |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Chiropractic Services |
No coverage |
No coverage |
No coverage |
No coverage |
|
Dental Braces |
Covered under regular Medicaid using the plastic ID card No coverage |
Covered in full No coverage |
Covered in full No coverage |
No coverage No coverage |
|
Diagnostic laboratory |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Diagnostic x-ray |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Durable Medical Equipment Orthotics and Prosthetics |
Covered in full when ordered by a physician. Some items covered under regular Medicaid using the plastic ID card. Covered in full |
Covered in full from any provider who accepts Medicaid Covered in full |
Covered in full when ordered by a physician Covered in full |
Covered in full when ordered by a physician Covered in full |
|
Eye Exams |
One eye exam every 2 years covered in full |
Covered in full |
One eye exam per calendar year covered in full |
One eye exam every 2 years covered in full |
|
Eye Glasses |
One pair every 2 years |
Covered in full |
One pair in any 12-month period |
One pair every 2 years |
|
Family Planning |
Covered in full |
Covered in full |
Covered in full |
Covered in full |
|
Hearing Evaluations |
Covered in full |
Covered in full |
One hearing examination per year covered in full |
Covered in full |
|
Hearing Aids |
Covered in full, excluding batteries |
Covered in full (includes batteries) |
Covered in full, excluding batteries |
Covered in full, excluding batteries |
|
Home Care |
Covered in full after an acute episode |
Covered in full for long term services rendered by home health care agency, approved by local DSS and ordered by PCP |
40 visits per calendar year in lieu of skilled nursing facility or hospitalization |
40 visits per calendar year in lieu of skilled nursing facility or hospitalization |
|
Hospice |
Covered by Medicaid fee for service |
Covered in full |
No coverage |
No coverage |
|
Physical Therapy and Occupational Therapy |
Covered in full according to guidelines |
Covered in full for long term services rendered by home health care agency, approved by local DSS and ordered by PCP. |
Up to 20 visits covered in full per calendar year for short-term therapy only |
Up to 20 visits covered in full per calendar year for short-term therapy only |
|
Podiatry |
No coverage for routine foot care. Coverage for children under age 21 and people with special problems |
No coverage for routine foot care |
No coverage for routine foot care |
No coverage for routine foot care |
|
Prescription Drugs |
Covered under regular Medicaid using the plastic ID card |
Covered in full |
Prescription drugs and over-the-counter (OTC) drugs included in the Medicaid formulary will be covered in full. |
Prescription drugs covered in full for generic only. OTC are excluded except for diabetic supplies, insulin, hearing aid batteries and smoking cessation agents. |
|
Private Duty Nursing |
Covered in full when ordered by a physician |
Covered in full |
No coverage |
No coverage |
|
Skilled Nursing Facility |
Short term rehab covered in full |
Covered in full |
No coverage |
Short term rehab covered in full |
|
Speech Therapy |
Covered in full according to guidelines. |
Covered in full for long term services rendered by home health care agency, approved by local DSS and ordered by PCP. |
Covered in full. However, must show significant clinical improvement within two-month period |
Covered in full. However, must show significant clinical improvement within two-month period |
|
Psychiatric
and Substance Abuse |
|
|
|
|
|
Day Treatment |
Covered in full |
Covered in full |
No coverage |
No coverage |
|
Inpatient Acute Psychiatric and Substance Abuse |
Covered in full for acute, short term. SSI covered under Medicaid fee for service. |
Covered in full for chronic long term. SSI - covered in full. |
A combined 30 days per calendar year for inpatient mental health services, detoxification and inpatient rehabilitation. |
A combined 30 days per calendar year for inpatient mental health services and inpatient rehabilitation. |
|
Outpatient Acute Psychiatric Outpatient Substance Abuse |
Covered in full SSI and non SSI covered under Medicaid fee for service |
Covered in full Covered in full |
A combined 60 outpatient visits per calendar year for mental health and substance abuse covered in full. |
A combined 60 outpatient visits per calendar year for mental health and substance abuse covered in full. |
|
Inpatient detoxification |
SSI and non SSI covered in full |
Covered in full |
A combined 30 days per calendar year for inpatient mental health services, detoxification and inpatient rehabilitation covered in full. |
Covered in full |
|
Outpatient detoxification |
SSI and non SSI covered in full |
Covered in full |
A combined 60 outpatient visits per calendar year for mental health and substance abuse covered in full. |
A combined 60 outpatient visits per calendar year for mental health and substance abuse covered in full. |