Other
AL | CA | FL | GA | MS | MT | NE | NY | NC | WV "Section Nine: Medicaid Benefits
A. Benefits
Patient 1st enrollees have the same range scope, amount of services and copayments as other Medicaid recipients. There are some services that are excluded from the Patient 1st program and do not require authorization by the PMP. These are obtained through the same procedure as used by other Medicaid recipients outside the Patient 1st program. The Patient 1st Program does not extend or supersede any existing program benefit or program requirement. Attachment Four is a matrix or what services will and will not require referrals.It is anticipated; however, that the enrollee will look to the PMP for advice and/or coordination of these services. Patient 1st enrollees should be offered the same level of service coordination for non-authorized services as would other patient populations." Alabama PMP, page 17.
"PATIENT 1ST REFERRED SERVICES
The following services DO REQUIRE a referral from the Patient's Primary Medical Provider...
Service...Children's Rehab Services.Audiologist. Speech Therapy. Podiatrist. Occupational Therapy. Physical Therapy. Chiropractor. Optometry. Ophthalmologist. Private Duty Nursing. Ambulatory Surgical Center. ICF. ICF-MR. Health Education. HCBS Waiver.CRNA. Professional Component. Dialysis. Ambulance. Eyeglasses...Vision Exams. Spectacle Fittings. Prenatal Clinics. Oral Surgeons. Family Planning. Pregnancy-Related Services. Immunizations. Hospice. Lilhotripsy...Hearing Aids. Services Provided by an OB/GYN." Alabama PMP, Attachment 4, unnumbered pages.
"Article II...
O. Covered Services for the purpose of this contract means all Medi-Cal covered services, with the following exceptions: ...
2. Services in any federal or state governmental hospital...
4. Services rendered to members who have been institutionalized for more than one calendar month after the month of admission in a skilled nursing or an intermediate care facility...
7. Short-Doyle/Medi-Cal Services." California Contract, page 4."Services to be managed
1. General Services. It is agreed that the MediPass provider will provide patient management for the following services for each patient:GAAmbulatory Surgical Center Services Birth Center Services County Health Department Services Chiropractic Services... Home Health Services... Podiatry Services... Rural Health Clinic Services Therapy Services X-Ray Services including portable x-rays." Florida Agreement, page 4. "803. Services Exempt from Authorization
The following services do not require authorization by the Primary Care Physician (PCP)...2. Services delivered by providers enrolled in the following Medicaid programs:
Anesthesiology Services (DMA Form-85 Only)...
Dialysis Services...
Family Planning Services
Health Department Services - Diagnostic, Screening & Preventive Services (DSPS)
Hospice Services
Independent Care...
Non-Emergency Transportation & Ambulance Services
Nursing Home, ICF/MR, Swing Bed Services
Optometry Services (Including Eye Glasses)
Pathology (Interpretation and Report)...
Podiatry Services
Pregnancy Related Services...3. Exempted services as defined by certain procedure cods and diagnosis codes: ...
Family Planning Services
Footcare Services...
Immunizations for recipients under 21 years of age
Individualized Education Program Services (provided to children in public schools)
Obstetrics Services
Ophthalmology Services." Georgia Agreement, pages VIII-2 - VIII-3."4.08 Medicaid Benefits
HealthMACS enrollees have the same range, amount of services and co-payments as other Medicaid clients. There are some services that are excluded from the HealthMACS program an do not require the prior or post authorization of the PCP. These are obtained through the same procedure as used by other Medicaid clients outside of the HealthMACS program.
4.08.1 Excluded Services...MTOphthalmology Optometry and eye glasses Podiatry Nursing facilities and ICF/MR Emergency and Non-Emergency Transportation Perinatal High Risk Management." Mississippi Manual, pages 78-79. "E. 'Exempt Services' are those Medicaid services which do not need to be provided or authorized by the enrollee's primary care provider. Exempt services include the following: ...
dietitian...
family planning clinics
freestanding dialysis clinic
hearing aid...
hospice
Indian Health Service clinic...
licensed clinical social worker
nursing homes
optician
optometry
personal care attendant...
podiatry
private duty nursing
rehabilitation
residential treatment facility
respiratory therapy...
therapeutic youth group home
therapeutic family (foster) care
transportation and per diemThe following subcategories of PASSPORT-managed services do not require authorization: ...
blood lead testing
family planning services...
obstetrical care
pathology
radiology
testing and treatment of sexually-transmitted diseases at Department-designated sites
vision services..." Montana Agreement, pages 2-3."1.1.34 The Term 'NHC Benefits Package', also commonly referred to as the Basic Benefits Package, shall include the following medical/surgical services, representing a minimum benefits package, as defined in this contract and 471Nebraska Administrative Code (NAC), that shall be arranged for by the Contractor to clients enrolled in the NHC: ...
(i) Therapy services, including physical therapy, occupational therapy, and speech pathology and audiology (See NAC 17000, 22000 and 23000)...(k) Podiatry services (See 471 NAC 7000);
(l) Ambulance services (See 471 NAC 19000);
(m) Family planning services (See 471 NAC 18000 and 7.41 of this contract)...
(r) Skilled/Rehabilitative and Transitional Nursing Facility Services (See 471 NAC 12000, 13,000 and 3.16 of this contract);
(s) Transitional Hospitalization services (See 471 NAC 10000, 3.10, 3.13 and 3.14 of this contract); and
(t) Transitional Transplantation services (See 471 NAC 10000 and 3.14.3 of this contract)." Nebraska Contract, pages 5-7.
"REFERRED SERVICES:
Referred services are services that are not included in the capitation payment. An enrollee can only access these services if the service was referred and authorized by the Primary Care Practitioner. These services are paid on a fee-for-service basis through MMIS...Medicaid coverage of podiatry excludes routine hygienic care of the feet, including the treatment of corns and calluses, the trimming of nails, and other hygienic care such as cleaning or soaking feet, in the absence of pathological condition.Audiology Ambulatory use of Operating Rooms... Podiatry Services: Provided only to children under 21 years of age. Services include routine foot care procedures only when the Enrollee's physical condition poses a hazard due to the presence of localized illness, injury, or symptoms involving the foot, or when they are performed as a necessary and integral part of otherwise covered services such as the diagnosis and treatment of diabetes, ulcers, and infections. NON -COVERED SERVICESTherapy: Occupational Therapists, Physical Therapists, and Speech-Language Pathologists: Rehabilitation services are rendered for the purpose of maximum reduction of physical or mental disability and restoration of the recipient to his or her best functional level. Rehabilitation services include care and services rendered by physicaltherapists, speech-language pathologists, and occupational therapists... Transportation Services: These include ambulance, ambulette, livery services, and public transportation to transport the client to necessary medical care associated with the provision of covered and related services. Also permitted is the cost of an attendant to accompany the patient, if medically necessary. Public transportation costs are reimbursed through the County Transportation Unit...
The following Medicaid services are not covered by the Contractor. Enrollees may obtain such services directly from Medicaid providers who, in turn, shall bill MMIS directly for payment. The person remains enrolled in Contractor's plan..."10.13 ImmunizationsEye Care: Optical/ Ophthalmic Services: Eye care includes the services of an optometrist and an ophthalmic dispenser. The optometrist may perform an eye examination to detect visual defects and eye disease as necessary or as required by the recipient's condition. An ophthalmic dispenser fills the prescription of an optometrist or ophthalmologist and supplies eyeglasses or other vision aids upon the order of a qualified practitioner... Personal Care Agency Services: Services rendered by a personal care agency which are approved by the local departments of social services are not covered under the Contractor's benefit package. Should it be medically necessary for the primary care physician (PCP) to order personal care agency services, the PCP (or the Contractor on the physician's behalf ) must first contact the county contact person for personal care. The county will determine the applicant's need for personal care agency services and coordinate with the personal care agency a plan of care." New York Contract, Appendix L, pages 2-5.
Immunizations will be included in the prepaid benefit package and the (PCP/Contractor) will be required to reimburse public health agencies within the service area covered by this agreement when members self-refer...10.14 Prevention and Treatment of Sexually Transmitted Diseases
The (PCP/Contractor) will be responsible for educating their members about the risk and prevention of sexually transmitted disease. The (PCP/Contractor) will also be responsible for screening and treating Enrollees for sexually transmitted diseases and reporting information to local health departments in accordance with existing state and local laws and regulations. HIV counseling and testing provided during a STD related visit at a public health clinic will be covered by Medicaid FFS at a rate established by the State." New York Contract, pages 28-29."Introduction
Adult Medicaid recipients receive preventive health care through Adult Health Screenings. An Adult Health Screening is a package of preventive services that can be performed once per year on Medicaid recipients that are 21 years of age or older.Definition
Adult Health Screening is a service that provides preventive health care for adults through annual health assessments with the exception that it will prevent serious illness through early detection and treatment.Adult Health Screenings are delivered through local health department clinics... Physician assistants...are also permitted to perform the screening evaluations. Registered nurses employed by the health department who have successfully completed the Guilford Adult Health Physical Assessment Course may also provide this service." North Carolina Agreement, Adult Health Screening, page 1.
"IV. IT IS AGREED THAT THE PAAS PHYSICIAN OR CLINIC WILL:
A. Provide patient care management for the following services: ...ambulatory surgical center services...Family Planning, obstetrical, routine eye ...chiropractic, podiatric...do not require approval by the PAAS provider." West Virginia PAAS, page 3.