Glossary of Terms

PCP: Primay Care Physician. Applies to internists, family physicians and general practitioners.

Provider: Refers to anyone providing medical services. It usually means a doctor.

Covered Services: Medical and supply services will be provided and paid for by the county health plan.

Copay: The part of a medical expense that you must pay for.

Emergency: A medical condition with acute symptoms. Any condition that could cause serious injury if you do not get immediate medical attention.

Eligibility: When you qualify for coverage under the county health plan.

Enrollment: To be covered under the Bay Health Plan. You will receive an enrollment card after you are enrolled in the plan.This means your medical and pharmacy bills will be paid by Bay Health Plan.

Enrollee: A person who is a member of Bay Health Plan.

Enrollment Card (ID Card): A card that you receive when you are enrolled in the county health plan.The card lets providers know you belong in the county health plan.

Medical Emergency: See Emergency.

Prior Authorization: A medical service that requires approval by Bay Health Plan before the enrollee may receive it.

Referral: Permission from your Primary Care Physician to see another provider in the health plan network.

Specialist: A physician (not your Primary Care Physician) who provides certain services that your PCP does not provide. Some examples of a specialist are dermatologist (skin doctor), cardiologist (heart doctor) or ophthalmologist (eye doctor).
Bay Health Plan Benefits — Plan A

The covered services listed in this table are a summary. This does not mean that all related services will be covered. Covered services are subject to change. For specific exclusions, use the Services Not Covered link above.

Service

Coverage

Copay

Ambulance

Limited to emergency ground ambulance transport to the hospital Emergency room

N/A

Case Management

Not covered

N/A

Chiropractor

Not covered

N/A

Dermatology

Covered if ordered by an MD, DO or NP

$3 copay

Dental

Routine dental services non-covered except for services of oral surgeons.

$3 copay

Emergency Department

Covered

$0 copay

Eyeglasses

Not covered

N/A

Family Planning

  • Infertility screening
  • Contraceptive devices

Covered

Infertility treatment is not covered

N/A

Hearing Aids

Not covered

N/A

Home Health

Not covered

N/A

Home Help (personal care)

Not covered

N/A

Hospice

Not covered

N/A

 

 

 

Inpatient Hospital

Not covered

N/A

Lab & X-Ray

  • Diagnostic and therapeutic EKG, x-ray, radium isotope and radiation therapy
  • CAT, MRI, MRA and PET
  • Chelation therapy for certain diagnoses

Covered if ordered by an MD, DO or NP for diagnostic and treatment purposes.

$0 copay

Medical Supplies/Durable Medical Equipment (DME)

Limited coverage. Medical supplies are covered except for the following:

  • Gradient surgical garments, formulas and feeding supplies, and supplies related to any noncovered DME item.
  • DME items are not covered except for glucose monitors
  • Oxygen or oxygen supplies are not covered

No copays for diabetic supplies

Mental Health Services

Covered. Services must be provided through the local community mental health center.

N/A

Nursing Facility

Not covered

N/A

Optometrist

Not covered

N/A

Outpatient Hospital (Non emergency department)

  • Surgery
  • Dialysis
  • Chemotherapy
  • Sterilization
  • Radiation

Covered. Diagnostic and treatment services and diabetes education services.

$0 copay

$3 copay for professional services

Pharmacy

Covered: Mental Health prescriptions covered under the FFS benefit using the MIHEALTH card

Not covered: Injectables used in clinics or physician offices.

$1 copay. No copays for diabetic drugs or supplies

Physician

Nurse Practitioner

Oral Surgeon

Medical Clinic

Specialist
  • Office visits
  • Annual physical exams (including a pelvic and breast exam and Pap test). Women who qualify for screening/services under Breast and Cervical Cancer Programs administered by the local health department may be referred to that program for services as appropriate.
  • Diagnostic and treatment services. May refer to local health department for STD or HIV-related services, as available and appropriate.
  • General ophthalmologic services (procedure codes 92002-92014).
  • Immunizations per ACIP guidelines. May be referred to the local health department. Travel immunizations are excluded.
  • Injections administered in a physician’s office per current Medicaid policy.

$3 copay

Podiatrist

Limited services.

  • When referred by a primary care physician for foot care related to diabetes. Diagnosis codes 250.00-250.93 with procedure codes G0247 and G0246.
  • When referred by a primary care physician for foot care related to vascular insufficiency. Diagnosis codes for rates 355.7-355.8 for procedure codes G0247 and G0246.

$3 copay

Prosthetics/Orthotics

Not covered

N/A

Private Duty Nursing

Not covered

N/A

Substance Abuse

Covered through local Mental Health/Substance Abuse programs.

N/A

Therapies

Occupational, physical and speech therapy evaluations are covered when provided by physicians or in the outpatient hospital setting. Therapy services are not covered in any setting.

N/A

Transportation (non ambulance)

Not covered

N/A

Urgent Care Clinic

Professional services provided in a freestanding facility are covered.

$3 copay
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