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Ambulance
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Limited to emergency ground ambulance transport to the hospital Emergency room
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N/A
|
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Case Management
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Not covered
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N/A
|
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Chiropractor
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Not covered
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N/A
|
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Dental
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Routine dental services non-covered except for services of oral surgeons.
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$3 Copay
|
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Dermatology
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Covered if ordered by an MD, DO or NP
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$3 Copay
|
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Emergency Services
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Covered.
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N/A
|
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Eyeglasses
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Not covered
|
N/A
|
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Family Planning
- Infertility screening
- Contraceptive devices
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Covered
Infertility treatment is not covered
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N/A
|
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Hearing Aids
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Not covered
|
N/A
|
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Home Health
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Not covered
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N/A
|
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Home Help (personal care)
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Not covered
|
N/A
|
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Hospice
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Not covered
|
N/A
|
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Inpatient Hospital
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Not covered
|
N/A
|
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Lab & X-Ray
- Diagnostic and therapeutic EKG, x-ray, radium isotope and radiation therapy
- CAT, MRI, MRA and PET
- Chelation therapy for certain diagnoses
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Covered if ordered by an MD, DO, or NP for diagnostic and treatment purposes.
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N/A
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Medical Supplies/Durable Medical Equipment (DME)
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Limited coverage. Medical supplies are covered except for the following non-covered categories:
- Gradient surgical garments, formulas and feeding supplies, and supplies related to any noncovered DME item.
- DME items are noncovered except for glucose monitors
- Oxygen or oxygen supplies are not covered
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No copays for diabetic supplies
|
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Mental Health Services
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Covered. Services must be provided through the local community mental health center.
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N/A
|
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Nursing Facility
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Not covered.
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N/A
|
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Optometrist
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Not covered.
|
N/A
|
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Outpatient Hospital (Non emergency services)
- Surgery
- Dialysis
- Chemotherapy
- Sterilization
- Radiation
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Covered: Diagnostic and treatment services
Diabetes education services with a valid referral
|
$0 copay for facility
$3 copay for professional services
|
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Pharmacy
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Covered: Mental Health Prescriptions covered under the FFS benefit using the MIHEALTH for diabetic drugs or supplies
Not covered: Injectables used in clinics or physician offices.
|
$1 copay. No copays for diabetic drugs or supplies
|
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Physician
Nurse Practitioner (NP)
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 TB, 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.
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$3 copay for professional services
|
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Podiatrist
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Limited servcies
- 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.
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$3 copay
|
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Prosthetics/Orthotics
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Not covered
|
N/A
|
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Private Duty Nursing
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Not covered
|
N/A
|
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Substance Abuse
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Covered through local Mental Health/Substance Abuse programs.
|
N/A
|
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Therapies
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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
|
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Transportation (non ambulance)
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Not covered
|
N/A
|
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Urgent Care Clinic
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Professional services provided in a freestanding facility are covered.
|
$3 copay
|