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 B

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

Not covered

N/A

Case Management

Not covered

N/A

Chiropractor

Not covered

N/A

Dental

Not covered

N/A

Emergency Department

Not covered

N/A

Family Planning

 

Not covered. Services may be provided at the Bay County Health Department at 989-895-4000.

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 and X-Ray

Covered if ordered by an MD, DO, or NP to a contracted provider.

$5 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 Not covered DME item.
  • DME items are Not covered except for glucose monitors.

No copays for diabetic supplies

Mental Health Services

Not 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 (Not emergency department)

Not covered. Basic X-rays, Diabetic education (no copay), and PT,OT, ST evaluations are covered.

$5 copay for covered services

Pharmacy

Covered if ordered by an MD, DO, or NP. Please refer to your handbook for brand and generic drug rules.

$5 generic copayment

$10 brand copayment

  • No copays for diabetic drugs or supplies
  • $40 out of pocket maximum copay

Physician/Specialist Nurse Practitioner (NP) Medical Clinic
  • Annual physical exams, including screening tests such as breast exam and Pap tests
  • Flu shots
  • Office visits

Not Covered: sterilization and infertility services

$5 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 G0245 through G0247.
  • When referred by a primary care physician for foot care related to vascular insufficiency. Diagnosis codes 355.7-355.8 for procedure codes G0245 through G0247.

$5 copay

Prosthetics/Orthotics

Not covered

N/A

Private Duty Nursing

Not covered

N/A

Substance Abuse

Covered through local Mental Health/Substance Abuse programs; must qualify through these agencies.

N/A

Therapies

Occupational, physical, and speech therapy evaluations are covered when referred by a Primary Care Physician to a free standing facility. Therapy services are not covered in any setting.

N/A

Transportation (including non emergency ambulance)

Not covered

N/A

Urgent Care Clinic

Not covered

N/A
Go to the Bay Health Plan home page