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.

 

Blue Choice Option

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.

 

Child Health Plus

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

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.