CHIP Member Benefits - bcbstx.com · Post-Partum Care Covered Services ... •Diagnosis-specific...

CHAPTER 4 CHIP MEMBER BENEFITS |51

CHIP Member Benefits

52|CHAPTER 4 CHIP MEMBER BENEFITS

APPENDIX A

CHIP COVERED SERVICESCovered Benefit CHIP Members and CHIP Perinate

Newborn Members Description CHIP Perinate Members (Unborn Child)

Behavioral Health Services - Inpatient

Behavioral health services, including services for serious behavioral illness, furnished in a free-standing psychiatric hospital, psychiatric units of general acute care hospitals and state-operated facilities, including, but not limited to: • Neuropsychological and psychological testing• When inpatient psychiatric services are ordered by a

court of competent jurisdiction under the provisionsof Chapters 573 and 574 of the Texas Health andSafety Code, relating to court ordered commitmentsto psychiatric facilities, the court order serves asbinding determination of medical necessity. Anymodification or termination of services must bepresented to the court with jurisdiction over the matter for determination.

• Does not require PCP referral

Not a covered benefit.

Behavioral Health Services - Outpatient

Behavioral health services, including services for serious behavioral/mental illness, provided on an outpatient basis, including, but not limited to: • Visits offered in a variety of community based settings

(including school and home-based) or in a state- operated facility

• Neuropsychological and psychological testing• Medication management• Rehabilitative day treatments• Residential treatment services• Sub-acute outpatient services partial hospitalization or

rehabilitative day treatment)• Skills training (psycho-educational skill development)• When outpatient psychiatric services are ordered by

a court of competent jurisdiction under the provisionsof Chapters 573 and 574 of the Texas Health andSafety Code, relating to court ordered commitmentsto psychiatric facilities, the court order serves asbinding determination of medical necessity. Anymodification or termination of services must bepresented to the court with jurisdiction over the matter for determination.



Covered Benefit CHIP Members and CHIP Perinate Newborn Members Description

CHIP Perinate Members (Unborn Child)

Behavioral Health Services - Outpatient (continued)

A Qualified Behavioral Health Provider – Community Services (QMHP-CS), is defined by the Texas Department of State Health Services (DSHS) in Title 25 T.A.C., Part I, Chapter 412, Subchapter G, Division 1, §412.303(48). QMHP-CSs shall be Providers working through a DSHS-contracted Local Behavioral/Mental Health Authority or a separate DSHS-contracted entity.

QMHP-CSs shall be supervised by a licensed behavioral health professional or physician and provide services in accordance with DSHS standards.

Those services include individual and group skills training (which can be components of interventions such as day treatment and in-home services), patient and family education, and crisis services.

Does not require PCP referral.

Case Management and Care Coordination Services

These services include outreach education, case management, care coordination and community referral.


Chiropractic Services

Services do not require physician prescription and are limited to spinal subluxation.


Delivery and Post-Partum Care

Covered Services include:

• Child’s benefit begins at birth and ends on last day of12-month continuous eligibility period.

• Birth-related services only for pregnantmember, and coverage ends on last day ofmonth in which they give birth.

Exception: Member receives two (2) postpartum visits even if it is beyond last day of birth month.


APPENDIX A



Durable Medical Equipment

$20,000, 12-month period limit for DME, prosthetics, devices and disposable medical supplies (diabetic supplies and equipment are not counted against this cap). Services include DME (equipment which can withstand repeated use and is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness, injury, or disability, and i s appropriate for use in the home), including devices and supplies that are medically necessary and necessary for one or more activities of daily living and appropriate to assist in the treatment of a medical condition, including: • Orthotic braces and orthotics• Dental devices• Prosthetic devices such as artificial eyes, limbs, braces,

and external breast prostheses• Prosthetic eyeglasses and contact lenses for the

management of severe ophthalmologic disease• Hearing aids• Diagnosis-specific disposable medical supplies,

including diagnosis-specific prescribed specialtyformula and dietary supplements

Advance Practice Registered Nurses (APRNs) and Physician Assistants (Pas) are prohibited from prescribing any durable medical equipment (including limited home health supplies) and outpatient schedule 11 controlled substance for Medicaid clients. This includes any product dispensed through the pharmacy.





Emergency Services, including Emergency Hospitals, Physicians and Ambulance Services

Authorization is not required as a condition for payment for emergency conditions or labor and delivery. Covered services include, but are not limited to, the following: • Emergency services based on prudent layperson

definition of emergency health condition• Hospital emergency department room and ancillary

services and physician services 24 hours a day/seven day a week, both by in-network andout-of-network providers

• Medical screening examination• Stabilization services• Access to DSHS designated Level I and Level II Trauma

Centers or hospitals meeting equivalent levels of carefor emergency services

• Emergency ground, air and water transportation• Emergency dental services, limited to fractured or

dislocated jaw, traumatic damage to teeth, removal ofcysts, and treatment relating to oral abscess of tooth or gum origin.

BCBSTX cannot require authorization as a condition for payment for emergency conditions related to labor with delivery. • Covered services are limited to those

emergency services that are directly related tothe delivery of the unborn child until birth

• Emergency services based on prudentlayp erson definition of emergency healthcondition

• Medical screening examination to determineemergency when directly related to the deliveryof the covered unborn child

• Stabilization services related to the labor with delivery of the covered unborn child

Emergency ground, air and water transportation for labor and threatened labor is a covered benefit.

Emergency ground, air and water transportation for an emergency associated with: a. Miscarriage orb. A non-viable pregnancy (molar pregnancy,

ectopic pregnancy, or a fetus that expired in utero) is a covered benefit.

Benefit limits: Post-delivery services or complications resulting in the need for emergency services for the mother of the CHIP Perinate are


APPENDIX A



Home and Community Health Services

Services that are provided in the home and community, including, but not limited to: • Home infusion• Respiratory therapy• Visits for private duty nursing (R.N., L.V.N.)• Skilled nursing visits as defined for home health

purposes (may include R.N. or L.V.N.).• Home health aide when included as part of a plan

of care during a period that skilled visits havebeen approved

• Speech, physical and occupational therapies• Services are not intended to replace the child’s

caretaker or to provide relief for the caretaker• Skilled nursing visits are provided on intermittent

level and not intended to provide 24-hour skilled nursing services

• Services are not intended to replace 24-hour inpatient or skilled nursing facility services


Hospice Care Services

Services include, but are not limited to: • Palliative care, including medical and support services,

for those children who have six months or less to live, to keep patients comfortable during the last weeks andmonths before death

• Treatment services, including treatment related to theterminal illness

• Up to a maximum of 120 days with a 6-month life expectancy

• Patients electing hospice services may cancel thiselection at anytime

• Services apply to the hospice diagnosis


CHAPTER 4 CHIP MEMBER BENEFITS | 57



Hospital Services – Inpatient

Inpatient General Acute and Inpatient Rehabilitation Hospital Service

Services include, but are not limited to: • Hospital-provided physician or provider services • Semi-private room and board (or private if medically

necessary as certified by attending) • General nursing care • Special duty nursing when medically necessary • ICU and services • Patient meals and special diets • Operating, recovery and other treatment rooms • Anesthesia and administration (facility

technical component) • Surgical dressings, trays, casts, splints

For CHIP Perinates in families with incomes at or below 186% of the Federal Poverty Level, the facility charges are not a covered benefit, however, professional services charges associated with labor with delivery are a covered benefit. Hospitals bill TMHP under the Emergency Medicaid Program.

For CHIP Perinates in families with income above 186% to 201% of the Federal Poverty Level, benefits are limited to professional service charges and facility charges associated with labor with delivery until birth, and services related to miscarriage or non-viable pregnancy. Services include: • Operating, recovery and other treatment rooms • Anesthesia and administration (facility

technical component)


Inpatient General Acute and Inpatient Rehabilitation Hospital Services (continued)

Services include, but are not limited to: • Drugs, medications and biologicals • Blood or blood products that are not provided free-of-

charge to the patient and their administration • X-rays, imaging and other radiological tests (facility

technical component) • Laboratory and pathology services (facility

technical component) • Machine diagnostic tests (EEGs, EKGs and so on) • Oxygen services and inhalation therapy • Radiation and chemotherapy • Access to Department of State Health Services • (DSHS)-designated Level III perinatal centers or

hospitals meeting equivalent levels of care

Medically necessary surgical services are limited to services that directly relate to the delivery of the unborn child, and services related to (a) miscarriage or (b) non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).

Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) are a covered benefit

Inpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: • Dilation and curettage (D&C) procedures • Appropriate provider-administered medications • Ultrasounds • Histological examination of tissue samples

58 | CHAPTER 4 CHIP MEMBER BENEFITS

APPENDIX A





In-network or out-of-network facility and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

Hospital, physician and related medical services, such as anesthesia, associated with dental care.

Inpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero)

Inpatient services associated with miscarriage or non- viable pregnancy include, but are not limited to: • Dilation and curettage (D&C) procedures • Appropriate provider-administered medications • Ultrasounds • Histological examination of tissue samples • Surgical implants • Other artificial aids including surgical implants






Inpatient services for a mastectomy and breast reconstruction include: • All stages of reconstruction on the affected breast • External breast prosthesis for the breast(s) on which

medically necessary mastectomy procedure(s) have been performed

• Surgery and reconstruction on the other breast to produce symmetrical appearance; and

• Treatment of physical complications from the mastectomy and treatment of lymphedemas

Implantable devices are covered under inpatient and outpatient services and do not count towards the DME 12-month period limit.

Pre-surgical or post-surgical orthodontic services for anomalies requiring surgical intervention and delivered a s part of a proposed and clearly outlined treatment plan to treat: • Cleft lip and/or palate • Severe traumatic skeletal and/or congenital

craniofacial deviations • Severe facial asymmetry secondary to skeletal defects,

congenital syndromal conditions and/or tumor growth or its treatment


APPENDIX A



Hospital Services - Outpatient

Comprehensive Outpatient Rehabilitation Hospital, Clinic (Including Health Center), and Ambulatory Health Care Center

(continued)

Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: • X-ray, imaging and radiological tests

(technical component) • Laboratory and pathology services

(technical component) • Machine diagnostic tests • Ambulatory surgical facility services • Drugs, medications and biologicals • Casts, splints, dressings • Preventive health services • Physical, occupational and speech therapy • Renal dialysis • Respiratory services • Radiation and chemotherapy • Blood or blood products that are not provided free-

of-charge to the patient and the administration of these products

• Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility

Services include the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: • X-ray, imaging and radiological tests

(technical component) • Laboratory and pathology services

(technical component) • Machine diagnostic tests • Drugs, medications and biologicals that

are medically necessary prescription and injection drugs

• Outpatient services associated with (a) a miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero

• Outpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to:

• Dilation and curettage (D&C) procedures • Appropriate provider-administered medications • Ultrasounds • Histological examination of tissue samples






(continued)

Services include, but are not limited to, the following services provided in a hospital clinic or emergency room, a clinic or health center, hospital-based emergency department or an ambulatory health care setting: • Radiation and chemotherapy • Blood or blood products that are not provided free-

of-charge to the patient and the administration of these products

Outpatient services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero)

Outpatient services associated with miscarriage or non- viable pregnancy include, but are not limited to: • Dilation and curettage (D&C) procedures; • Appropriate provider-administered medications; • Ultrasounds, and • Histological examination of tissue samples. • Facility and related medical services, such as

anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility

• Surgical implants • Other artificial aids including surgical implants

Outpatient services associated with miscarriage or non-viable pregnancy include, but are not limited to: 1. Laboratory and radiological services that

directly relate to antepartum care and/or the delivery of the covered CHIP Perinate until birth.

2. Ultrasound of the pregnant uterus is a covered benefit when medically indicated. Ultrasound may be indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, gestational age confirmation or miscarriage or non-viable pregnancy.

3. Amniocentesis, cordocentesis, fetal intrauterine transfusion (FIUT) and ultrasonic guidance for cordocentesis, FIUT are covered benefits with an appropriate diagnosis.

4. Laboratory tests are limited to: non- stress testing, contraction, stress testing, hemoglobin or hematocrit repeated once a trimester and at 32-36 weeks of pregnancy; or complete blood count (CBC), urinalysis for protein and glucose every visit, blood type and RH antibody screen; repeat antibody screen for Rh negative women at 28 weeks followed by RHO immune globulin administration if indicated; rubella antibody titer, serology for syphilis, hepatitis B surface antigen, cervical cytology, pregnancy test, gonorrhea test, urine culture, sickle cell test, tuberculosis (TB) test, human immunodeficiency virus (HIV) antibody screen, chlamydia test, other laboratory tests not specified but deemed medically necessary, and multiple marker screens for neural tube defects (if the client initiates care between 16 and 20 weeks); screen for gestational diabetes at 24-28 weeks of pregnancy; other lab tests as indicated by medical condition of client.


APPENDIX A





(continued)

Outpatient services provided at an outpatient hospital and ambulatory health care center for a mastectomy and breast reconstruction as clinically appropriate, include: • All stages of reconstruction on the affected breast • External breast prosthesis for the breast(s) on which


• Surgery and reconstruction on the other breast to produce symmetrical appearance

• Treatment of physical complications from the mastectomy and treatment of lymphedemas

Implantable devices are covered under inpatient and outpatient services and do not count towards the DME 12-month period limit.

Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: • Cleft lip and/or palate • Severe traumatic skeletal and/or congenital

craniofacial deviations • Severe facial asymmetry secondary to skeletal defects,

congenital syndromal conditions and/or tumor growth or its treatment

5. Surgical services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero) are a covered benefit.




Physician/ Physician Extender Professional Services

Services include, but are not limited to: • American Academy of Pediatrics recommended

well-child exams and preventive health services(including, but not limited to, vision and hearingscreenings and immunizations), and screeningfor behavioral health problems and behavioralhealth disorders

• Physician office visits, inpatient and outpatient services• Laboratory, X-rays, imaging and pathology

services, including technical component and/or professional interpretation

• Medications, biologicals and materials administered inphysician’s office

• Allergy testing, serum and injections

Services include, but are not limited to the following: • Medically necessary physician services for

prenatal and postpartum care and/or thedelivery of the covered unborn child until birth

• Physician office visits, inpatient and outpatient services

• Laboratory, X-rays, imaging and pathologyservices including technical component and /or professional interpretation

• Medically necessary medications, biologicalsand materials administered in physician’s office

Physician/ Physician Extender Professional Services (continued)

Services include, but are not limited to (continued): • Professional component (in/outpatient) of surgical

services, including:– Surgeons and assistant surgeons for surgical

procedures including appropriate follow-up care– Administration of anesthesia by physician (other than

surgeon) or Certified Registered Nurse Anesthetist (CRNA)

– Second surgical opinions– Same-day surgery performed in a hospital without

an overnight stay– Invasive diagnostic procedures such as

endoscopic examinations– Hospital-based physician services, including

physician-performed technical and interpretivecomponents

Services include, but are not limited to the following: • Professional component (in/outpatient) of

surgical services, including:– Surgeons and assistant surgeons for surgical

procedures directly related to the laborwith delivery of the covered unborn child until birth.

– Administration of anesthesia by a physician (other than surgeon) or CRNA

– Invasive diagnostic procedures directlyrelated to the labor with delivery of theunborn child.


APPENDIX A




Physician and professional services for a mastectomy and breast reconstruction include: • All stages of reconstruction on the affected breast; • External breast prosthesis for the breast(s) on which


• Surgery and reconstruction on the other breast to produce symmetrical appearance; and

• Treatment of physical complications from the mastectomy and treatment of lymphedemas.

• In-network and out-of-network physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section.

• Physician services associated with (a) miscarriage or (b) a non-viable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero).

Professional component of inpatient/outpatient surgical services (continued): • Surgical services associated with (a)

miscarriage or (b) a nonviable pregnancy (molar pregnancy, ectopic pregnancy, or a fetus that expired in utero.)

• Hospital-based physician services (including Physician performed technical and interpretive components).

• Professional component of the ultrasound of the pregnant uterus when medically indicated for suspected genetic defects, high-risk pregnancy, fetal growth retardation, or gestational age confirmation.

• Professional component of amniocentesis, cordocentesis, Fetal Intrauterine Transfusion (FIUT) and ultrasonic guidance for amniocentesis, cordocentesis, and FIUT.





Physician services associated with miscarriage or non-viable pregnancy include, but are not limited to: • Dilation and curettage (D&C) procedures • Appropriate provider-administered medications • Ultrasounds • Histological examination of tissue samples • Physician services medically necessary to support

a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation.

• Pre-surgical or post-surgical orthodontic services for medically necessary treatment of craniofacial anomalies requiring surgical intervention and delivered as part of a proposed and clearly outlined treatment plan to treat: – Cleft lip and/or palate – Severe traumatic skeletal and/or congenital

craniofacial deviations – Severe facial asymmetry secondary to skeletal

defects, congenital syndromal conditions and/or tumor growth or its treatment.

Professional component associated with a. A miscarriage or b. A nonviable pregnancy (molar pregnancy,

ectopic pregnancy, or a fetus that expired in utero).

Professional services associated with miscarriage or non-viable pregnancy include, but are not limited to: • Dilation and curettage (D&C) procedures; • Appropriate provider-administered medications; • Ultrasounds, and • Histological examination of tissue samples.


APPENDIX A



Prenatal Care and Pre-Pregnancy Family Services and Supplies

Covered, unlimited prenatal care and medically necessary care related to diseases, illness, or abnormalities related to the reproductive system, and limitations and exclusions to these services are described under inpatient, outpatient and physician services.

Primary and preventive health benefits do not include pre-pregnancy family reproductive services and supplies, or prescription medications prescribed only for the purpose of primary and preventive reproductive health care.

Services are limited to an initial visit and subsequent prenatal (antepartum) care visits that include: • One visit every four weeks for the first 28

weeks of pregnancy;• One visit every two to three weeks from 28 to

36 weeks of pregnancy; and• One visit per week from 36 weeks to delivery.

More frequent visits are allowed as medically necessary. Benefits are limited to 20 prenatal visits and two postpartum visits (maximum within 60 days) without documentation of a complication of pregnancy.

More frequent visits may be necessary for high- risk pregnancies.

High-risk prenatal visits are not limited to 20 visits per pregnancy.

Documentation supporting medical necessity must be maintained in the physician’s files and is subject to retrospective review.




Prenatal Care and Pre- Pregnancy Family Services and Supplies

(continued)

Visits after the initial visit must include: • Interim history (problems, marital status,

fetal status); • Physical examination (weight, blood pressure,

fundal height, fetal position and size, fetal heart rate, extremities), and

• Laboratory tests (urinalysis for protein and glucose every visit; hematocrit or hemoglobin repeated once a trimester and at 32-36 weeks of pregnancy; multiple marker screen for fetal abnormalities offered at 16-20 weeks of pregnancy; repeat antibody screen for Rh negative

• Women at 28 weeks followed by Rho immune globulin administration if indicated; screen for gestational diabetes at 24-28 weeks of pregnancy; and other lab tests as indicated by medical condition of client)


APPENDIX A



Prescription DrugBenefits

CHIP members are eligible to receive an unlimited n u m b e r of prescriptions per month and may receive up to a 90-day supply of a drug. Services include, but are not limited to: • Outpatient drugs and biologicals; including pharmacy-

dispensed and provider-administered outpatient drugsand biologicals

• Drugs and biologicals provided in an inpatient setting

Copayments Effective 10/15/2013:

Prime Therapeutics offers e-prescribing administered through Prime Therapeutics, which allows providers to: • Submit prescriptions electronically,• Verify client eligibility,• Review medication history, and• Review formulary information.

For additional information visit the website www.txvendordrug.com.

The formulary is also available for mobile devices on www.epocrates.com.

Services include, but are not limited to, the following: • Outpatient drugs and biologicals; including

pharmacy-dispensed and provider-administered outpatient drugs and biologicals

• Drugs and biologicals provided in an inpatient setting

CHIP Perinate has no copayments for this benefit.

BCBSTX offers e-prescribing abilities through Prime Therapeutics for providers to: • Submit prescriptions electronically,• Verify client eligibility,• Review medication history, and• Review formulary information.

For additional information visit the website www.txvendordrug.com.

The formulary is also available for mobile devices on www.epocrates.com.

Federal Poverty Level (FPL)

Generic Brand

At or below 100% $0 $3

Up to and including 151% of FLP

$0 $5

Above 151% through 186%

$10 $35

Above 186% through 201%

$10 $35




Prescription Drug Benefits – Continued

Limited Home Health Supplies Limited home health supplies such as needles, syringes, test strips, monitors and aerosol holding chambers are covered under the pharmacy benefit. Claims for these supplies should be submitted as a pharmacy claim to Prime Therapeutics:

CHIP: 855-457-0403

Limited Home Health Supplies Limited home health supplies such as needles, syringes, test strips, monitors and aerosol holding chambers are covered under the pharmacy benefit. Claims for these supplies should be submitted as a pharmacy claim to Prime Therapeutics:

CHIP: 855-457-0403


APPENDIX A



Prescription Drugs (Outpatient Only)

Prime Therapeutics LLC administers the BCBSTX pharmacy benefit for CHIP Members. These benefits cover outpatient prescription drugs obtained through any in-network pharmacy based on medical necessity. Members may obtain medication from any network pharmacy.

The formulary is used to administer pharmacy benefits for BCBSTX CHIP members. The goal of the formulary is to ensure that members receive therapeutically appropriate and cost-effective drug therapy. Since the formulary promotes rational, scientific care based on consideration of published clinical studies, Food and Drug Administration (FDA) data, community standards, and cost-benefit evaluations, the formulary serves as a primary reference in the selection of medications for CHIP members. The formulary is reviewed and, as necessary, updated once per quarter. Providers should always refer to the website for accurate formulary lists.

Please refer to the formulary for a list of covered drugs. To view the formulary and for additional information, go to www.txvendordrug.com. The formulary is also available for mobile devices on www.epocrates.com.

BCBSTX offers e-prescribing abilities through Prime Therapeutics for Providers to: • Verify client eligibility, • Review medication history, and • Review formulary and PDL information. • Above 100% through 151% FPL: Generic $0; Brand $5 • Above 151% through 186% FPL: Generic $10, Brand $35 • Above 186% through 201% FPL: Generic $10; Brand $35 • Prior authorization is required for certain drugs • Over the counter medications are not covered in the CHIP prescription benefit • We do not cover diet aids, cosmetic or hair-growth drugs, erectile dysfunction drugs, or drugs for infertility • We do not reimburse claims for nutritional products (enteral or parenteral), medical supplies or equipment

under the pharmacy benefit • We offer free prescription delivery from those Texas VDP approved delivery pharmacies in our Pharmacy

Provider Service Area network.

Quantity Supply: All medications will be limited to a one-month supply with a maximum 34-day supply at all retail pharmacies. If a medical condition warrants a greater quantity supply than the defined one-month supply of medication, then prior authorization (PA) is available.




Prior Authorization

Prior authorization (PA) is required for all non-formulary medications that appear on the Texas Medicaid Formulary. PA is not available for drugs that are not covered or not included in this benefit. PA may be obtained by phone or by fax.

Prime Therapeutics

BIN 011552

PCN; TXCAID

TX CHIP Pharmacy Help Desk: 855-457-0403

TX STAR Pharmacy Help Desk: 855-457-0405

Specialty Medications

Specialty medications are high-cost injectable drugs that generally require close supervision and monitoring of the patient’s drug therapy. These drugs often require special handling such as temperature-controlled packaging and overnight delivery and are often unavailable at retail pharmacy stores.

Self-injectable medications will be covered under the pharmacy benefit program, limited up to a 34-day supply per fill.

Office-based injectables are covered under the medical benefit.


APPENDIX A



Emergency Prescription Supply

A 72-hour emergency supply of a prescribed drug must be provided when a medication is needed without delay and prior authorization (PA) is not available. This applies to all drugs requiring a prior authorization (PA), such as those that are subject to clinical edits.

The 72-hour emergency supply should be dispensed any time a PA cannot be resolved within 24 hours for a medication on the Vendor Drug Program formulary that is appropriate for the member’s medical condition. If the prescribing Provider cannot be reached or is unable to request a PA, the pharmacy should submit an emergency 72-hour prescription.

A pharmacy can dispense a product that is packaged in a dosage form that is fixed and unbreakable, e.g., an albuterol inhaler, as a 72-hour emergency supply. The 72-hour emergency supply is not applicable if the three-prescription limit has been reached.

Rehabilitation Services

Services include, but are not limited to: • Habilitation (the process of supplying a child with

the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services including, but not limited to physical, occupational and speech therapy.

• Developmental assessment.


Skilled Nursing Facilities (SNFs) (includes rehabilitation hospitals)

Services include, but are not limited to: • Semi-private room and board • Regular nursing services • Rehabilitation services • Medical supplies and use of appliances and equipment

furnished by the facility





Substance Abuse - Inpatient Substance Abuse Treatment Services

Services include, but are not limited to:

Inpatient and residential substance abuse treatment services including detoxification, crisis stabilization, and 24-hour residential rehabilitation programs.

Does not require PCP referral.

Services provided by:

Magellan: 800-327-7390

TTY: 800-735-2988

www.magellanprovider.com


Substance Abuse - Outpatient Substance Abuse Treatment Services (continued)

Services include, but are not limited to: • Prevention and intervention services provided by

physician and non-physician providers, such asscreening, assessment and referral for chemicaldependency disorders.

• Intensive outpatient services• Partial hospitalization• Intensive outpatient services is defined as an organized

non-residential service providing structured group andindividual therapy, educational services, and life skillstraining which consists of at least 10 hours per weekf o r 4 to 12 weeks, but less than 24 hours per day.

• Outpatient treatment service is defined as consistingof at least one to two hours per week providingstructured group and individual therapy, educationalservices, and life skills training

• Does not require PCP referral


Tobacco Cessation Program

Covered up to $100 for a 12-month limit for a plan-approved program. May be subject to formulary requirements.


Transplants Services include, but are not limited to, the following:

Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplants and all forms of non- experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses.



APPENDIX A



Transportation: Value-Added Service

Members can arrange for transportation from us by calling Customer Service:

888-657-6061

TTY 711

Members can arrange for transportation from us by calling Customer Service:

888-657-6061

TTY 711

Vision Benefit

(through Davis Vision)

Annual routine eye health examination inclusive of refraction and dilation (when professionally indicated) at no cost.

Prescription eyewear (if applicable) as follows: • Spectacle lenses every year (clear plastic single vision,

bifocal or trifocal lenses, any prescription, at no cost)• A large assortment of frames are available every year

(see benefit guide for more information) at no cost• Free one year breakage warrantee on Davis Vision

supplied material• Medically necessary contacts paid in full with

prior approval


Covered services must meet the CHIP definition of medically necessary covered services. There is no lifetime maximum on benefits; however, 12-month period or lifetime limitations apply to certain services, as specified in the benefit matrix, above. There is no spell-of-illness limitation for CHIP and C HIP Perinate Newborn Members.

VALUE-ADDED SERVICES – CHIP AND CHIP PERINATE

Non-Emergency Transportation Services BCBSTX will offer non-emergency transportation services to access covered services and health education classes when other transportation is not readily available or feasible for a member to use. This benefit will assist members in keeping medical appointments and help improve health outcomes.

The following member information must be provided to the intake operator at the time of the call: • CHIP ID number• Name, address, and telephone number• Name, address, and telephone number

of the health care provider• Purpose of the trip

• Affirmation that no other means oftransportation are available

• Special needs, wheelchair lift, or attendant need


Services and benefits available include: • Transportation to and from appointment• Lodging assistance• Meal assistance

All lodging and meals expenses will require prior approval. They will only be approved for prior approved medical appointments that are over 75 miles from the member’s home. There is a daily limit of $120 per night for lodging and $50 per day for meals with a total maximum amount of $1000 within a 12-month period. These expenses will be reimbursed once the member turns in receipts for their approved travel costs.

Limitations: BCBSTX transportation is available for CHIP and CHIP Perinate members for approved rides in the service area when the distance is less than 75 miles. Prior authorization is required. If the distance is over 75 miles, lodging and food allowances are included for CHIP members and one parent, guardian or authorized caregiver only. This does not apply to CHIP Perinate members. All lodging and meal expenses for CHIP members will require three days prior approval. Approval for BCBSTX transportation overnight lodging and transport may be approved in less than three days on a case by case basis. They will only be approved for prior approved medical appointments greater than 75 miles from the member’s home. There is a daily limit of $120 per night for lodging and $50 per day for meals with a total maximum amount of $1,000 per 12-month period.

24 Hour Nurse Advice Line Help is available to CHIP and CHIP Perinate members through the 24-hour, seven-day-a-week, toll-free Nurse Advice Line. Nurses deliver relevant information on health issues and community health services. Teens can call and speak confidentially to a nurse about adolescent health issues. The 24-Hour Nurse Advice Line also features an audiotape library with more than 300 health-related topics. The Nurse Advice Line uses interpreter services to accommodate the needs of members who are non-English speaking.

To contact the Nurse Advice Line call: 844-971-8906; TTY: 800-368-4424

Limitations: There are no limitations for this benefit. Members may access the Nurse Advice Line at any time.

Enhanced Eyewear for Children Through Davis Vision, BCBSTX offers an enhanced eyewear benefit that exceeds state requirements and provides our child and adolescent members with an upgrade on stylish frames. All enrolled CHIP children ages 0-18 years of age are eligible to receive the enhanced eyewear benefit. Children are eligible for one enhanced pair per year for a maximum value of $175.

Limitations: Benefit will be limited to one pair of stylish frames every year after completion of an eye exam. The maximum value of the frames will not exceed $175. Enhanced frames are restricted to CHIP members and do not apply to CHIP Perinate members.


APPENDIX A

Free Infant Car Safety Seat Program The BCBSTX Free Infant Car Safety Seat Program encourages expectant CHIP members to receive early and ongoing prenatal care and promote infant safety. Pregnant members will be eligible for a free car seat by completing the following activities: • Visiting their doctor in first trimester or within the first month of enrollment• Completing an appropriate number of prenatal visits based on length of pregnancy at the time of enrollment. The

number of prenatal visits is defined using the Healthcare Effectiveness Data and Information Sets (HEDIS) definition ofappropriate number of prenatal visits based on length of enrollment in BCBSTX until time of delivery.

• Enrolling in the Special Beginnings® program

All expectant CHIP members are eligible for this benefit. For more information about Special Beginnings or the free infant car safety seat, call the Customer Service at 877-560-8055.

Limitations: Members must be pregnant and must complete the above listed activities to receive a free infant care safety seat.

Sports and Camp Physicals BCBSTX will cover Sports and Camp Physicals performed by primary care providers once a year to encourage children’s participation in sports and physical fitness programs. The goal of this program is to prevent childhood obesity by encouraging participation in physical activities. This benefit is available for all CHIP members aged 18 and under.

Limitations: Sports and Camp physicals will be available as provided by CHIP providers. Sports and Camp Physicals are limited to CHIP kids ages 18 and under, and do not apply to CHIP Perinate.

Pregnancy/Delivery and Newborn Care Classes BCBSTX offers a comprehensive series of pregnancy, delivery and newborn care classes to encourage expectant members to receive early and ongoing prenatal care to promote healthy births. Pregnant members will be eligible for three classes, one per trimester, or they may attend our one-day overview class.

First trimester topics: Second trimester topics: Third trimester topics: Stages and phases of labor

When to go and what to bring to the hospital

Lamaze coaching

Techniques of breathing and relaxation

Pain relief options

Variations in labor

Early recovery expectations

Cesarean section experience Include a brief labor rehearsal

Newborn behaviors and appearance

Newborn genital care

Diapering, dressing and umbilical cord care

Newborn health and safety basics

Breast feeding basics

Classes will be offered at various community-based locations. All members are eligible for these classes no matter where they plan to deliver.


BCBSTX members who need transportation to classes are encouraged to utilize the BCBSTX transportation Value Added Service as described above. Spanish-speaking classes are available. Members may request to attend a class taught in Spanish when registering for the class.

Limitations: CHIP and CHIP Perinate members must be pregnant. Classes will be offered at various community-based locations, based on available space.

Breast Feeding Coaching BCBSTX will offer breast feeding coaching to interested expectant CHIP members to provide practical information that prepares moms for breastfeeding.

Coaching topics will include: • Benefits of breast feeding to mother and baby• How milk is made• Infant feeding cues• Mother and baby positioning

• Tips for success• How to tell if infant is getting enough milk• Problem prevention (sore nipples, engorgement)• Options for feeding during separation from infant

Breast feeding coaching can be requested by calling Customer Service or a Customer Advocate. The Customer Advocates coordinate service by contacting the home health agency to schedule a breast feeding coaching visit by the In-home Wellness Nurse.

Limitations: All newly enrolled pregnant or newly enrolled CHIP/CHIP Perinate women who are interested in breast feeding their newly delivered infant are eligible. The member must have delivered while on the Plan.

Free Breast Pumps for Completing Breast Feeding Coaching BCBSTX offers free breast pumps to new moms who have completed breast feeding coaching. These services are related to a delivery while on BCBSTX plan. The free breast pump is provided to all moms who complete the breast-feeding coaching by the In-home Wellness Nurse. The pump will be given to the mom at the time of the coaching.

Limitations: New moms are encouraged to have completed breast feeding coaching to receive the breast pump. Breast pumps will be hand delivered to all members who request an In-home Wellness Visit, at no charge to the member.

In-Home Wellness Visits for Newborns and Moms BCBSTX will provide discharged newborns and moms an In-home Wellness Visit upon request from the member or from their PCP or OBY/GYN. All members who have delivered on the Plan are eligible for the In-home Wellness Visit. These services are also beneficial to all members with a high-risk pregnancy and/or who have been followed by Case Management.

Home visits will be conducted by a registered nurse within five days of discharge in an effort to reduce morbidity associated with common conditions that present in the postnatal period, but they can be requested at any time. The goal is to improve overall quality of care for newborns and their moms and reduce hospital-based services.


APPENDIX A

If the home visiting nurse identifies issues that require referral of mom or baby to their OB/GYN or the newborn’s PCP, the member will be referred to BCBSTX Case Management to ensure follow-up on any identified issues.

Limitations: CHIP and CHIP Perinate members must have delivered a live baby while on the Plan.

BCBSTX Offers Farmers Market Vouchers for Pregnant Moms BCBSTX is making it easier for pregnant members to maintain a healthy diet consisting of at least five servings of fruits and vegetables each day. Pregnant members will receive 10 vouchers, worth $2 each; toward the purchase of fresh produce from one of four selected Farmers Markets in Travis County. Expecting members can request vouchers by contacting the BCBSTX Customer Advocate. Members are eligible for 10 vouchers up to two times per pregnancy. That adds up to $40 in fruit and vegetable purchases.

Limitations: Vouchers are redeemable for fresh fruits and vegetables at the market locations listed below: • SFC East Market, 51st Street and 183 (YMCA)• SFC Downtown, 4th and Guadalupe• SFC Triangle, 46th and Lamar• SFC Sunset Valley, 3200 Jones Road (Tony Burger Center)

No cash is provided if the member does not use the full value of the voucher. Member must provide their own transportation to the market. Vouchers are for pregnant moms for 10 vouchers, up to two times per pregnancy. Vouchers will be mailed to the member within five days of request and validation of membership. Members may request vouchers on four separate occasions with a minimum of two weeks between requests.

Dental Services for Adult Pregnant Women BCBSTX will offer the following dental services to CHIP Perinate members over 19 years of age:

• Oral Exam• Cleanings

• Sealants• Extractions

• X-rays• Fillings

• Scaling and planning

Members must see a participating dental provider within the Liberty Dental Network and may only receive benefits up to a maximum of $250 annually.

Limitations: BCBSTX will provide dental care for pregnant women not covered by the CHIP dental program. Adult pregnant women defined as CHIP Perinate women over age 19. Members must see a participating dental provider in the network; benefits for treatment services per scheduled treatment up to a maximum of $500. Dental services are limited to CHIP Perinate women over 19 years of age. They do not apply to CHIP members.

Safety Booster Seats for Kids BCBSTX offers free children’s safety booster seats for children between the ages of 2 to 12 who have out grown their baby car seat, and weigh between 30 and 100 pounds. To get the booster seat, the child must have a Well Child checkup or Texas Health Steps checkup within 90 days of signing up with BCBSTX, or a yearly Well Child checkup or Texas Health Steps checkup.


Limitations: Booster seats are for children ages 2 - 12 who have out grown their infant car seat and meet the height and weight requirements for the booster seat. The booster seat is for children 30 to 100 pounds and a maximum height of 57”. Parents or guardians are responsible for ensuring that their child meets the height/weight criteria to safely use the booster seat.

Safety Helmets for Kids BCBSTX offers free safety helmets to help children stay safe while riding bikes, skate boards or doing other outdoor activities. Members ages 3 to 18 can receive a free safety helmet every two years. To get the safety helmet, the child must have a Well Child checkup or Texas Health Steps checkup within 90 days of signing up with BCBSTX, or a yearly Well Child checkup or Texas Health Steps checkup.

Limitations: Members are limited to one new safety helmet every other year. Members will be required to complete and submit the appropriate paperwork to demonstrate that they meet the criteria to receive a helmet.

Free Diaper Bag with New Baby Items BCBSTX will provide pregnant or newly delivered members who have attended our pregnancy classes with a free diaper bag that includes new baby items.

Limitations: Members must be on the Plan to be eligible. Members also need to have attended one BCBSTX approved prenatal education class to be eligible to request the gift.

Hands Free Breast Pump Bra BCBSTX will provide for mothers who are breastfeeding, and delivered on our plan a hands-free breast feeding bra. The bra will be provided during the In-home Wellness Visit.

Limitations: Members must be on the Plan to be eligible. Members must have also delivered their new baby on the Plan and be willing to meet with the In-home Wellness Nurse to have the bra delivered.

Breast Feeding Support Kit Gift Pregnant CHIP members who are breast feeding will be eligible for a breast-feeding support kit gift. This gift will be delivered by the In-home Wellness Nurse. The kit includes breast milk disposable bags, soothing breast pads, breast soothing cream, a breast milk storage tracking refrigerator magnet, nipple protectors and a case. These items are provided to members who can benefit from use after working with the In-home Wellness Nurse.

Limitations: Members must have delivered while on our Plan and notify BCBSTX upon delivery. Members have up to 30 days post-delivery to contact the Plan and request the support kit. Breast feeding members must be willing to have an In-home Wellness Visit to receive the breast-feeding support kit, which will be delivered during the visit. Breast nipple protectors are handed out to members by the In-home Wellness Nurse as needed.

Free Breast Pump for CHIP Perinate CHIP Perinate members are eligible for a free breast pump as part of their Value-Added Services.


APPENDIX A

Timely Well Child Checkups Incentive Child members within the age ranges below are eligible to request a $50 gift card when they complete the required well child checks:

• 15 Months old: six checkups by 15 months of age• 3-6 Years old: one checkup by the end of the calendar year• 12-20 Years old: one checkup by the end of the calendar year

Limitations: Parents or guardians of child members must ensure their enrolled children complete well child checks in the specified time frames. Members or a parent or guardian of under-aged members have to complete the documentation and send it in to request the gift card. Members must be active on the Plan to receive the gift card.

ADDITIONAL BENEFITS

Care Van Program BCBSTX provides greater outreach to children enrolled in the CHIP program by expanding Care Van Program operations for Care Van immunization clinics. All enrolled CHIP members are eligible to receive immunizations at Care Van clinics. The Care Van Program conducts 50 outreach immunization clinics in the Travis service area each year.

Text4baby BCBSTX offers this free mobile information program to all pregnant CHIP members. The program gives pregnant women and new moms’ tips to help care for their health and give their babies the best start in life they can have. Members who sign up for this service get free SMS text messages each week, timed to their due date or the baby’s first birthday. Members can sign up for the service by texting BABY to 511411 (or BEBE for Spanish messages). Members can use this service from the time they find out they are pregnant through the baby’s first birthday. To sign up for this service, go to the link below and follow the directions. text4baby.org. Data fees/charges may apply.


PRIMARY CARE PROVIDERREQUIREMENTSFORBEHAVIORAL HEALTHThe PCP must have behavioral health screening and evaluation processes available for detection, treatment or referral of members. PCPs are responsible for documenting in medical records any referrals and any known self-referrals for behavioral health services.

PCPs are also encouraged to: • Maintain contact with behavioral health provider.• Document behavioral health assessments and treatments – medical record documentation and referral information

using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) multi-axial classifications.• Inform the provider of any condition the member may have that could affect the behavioral health service.• Communicate and coordinate services essential to ensuring quality and continuity of care. The PCP should assist with

behavioral health referrals and provide Magellan with supporting documentation.• Initiate a member referral for behavioral health services by contacting Magellan by phone at 800-327-7390

(TTY: 800-735-2988).• Obtain consent for disclosure of information.

Behavioral health providers are encouraged to contact a member’s PCP to discuss the patient’s general health. They must also contact members who have missed appointments within 24 hours to reschedule appointments per HHSC-mandated provisions. Training for PCPs is available on the BCBSTX website.

BEHAVIORAL HEALTH SERVICES

Member Access to Behavioral Health Services Behavioral health services are provided for the treatment of behavioral/mental health disorders, emotional disorders, and chemical dependency disorders. Behavioral health services do not require a PCP referral. Members may self-refer to any Medicaid-enrolled behavioral health provider for treatment.

A PCP may, in the course of treatment, refer a patient to a behavioral health provider for assessment or for treatment of an emotional, mental or chemical dependency disorder. A PCP may also provide behavioral health services within the scope of his practice.

Assessment Instruments for Behavioral Health Available for Use by Primary Care Providers

In addition to the screening tools provided in the Texas Medicaid Provider Procedures manual, additional tools are available by contacting Magellan Customer Service department at 800-327-7390 or visiting www.MagellanAssist.com and access the PCP Toolkit.


APPENDIX A

Targeted Case Management and Rehabilitation Covered services are provided to members with Severe and Persistent Behavioral/Mental Health Illness (SPMI) and Serious Emotional Disturbance (SED), when medically necessary, targeted case management and rehabilitation is a covered benefit under BCBSTX. Magellan contracts with local mental health authorities (LMHAs) to provide these services.

Coordination Between Behavioral Health and Physical Health Services BCBSTX requires that all physicians and professional providers have screening and evaluation procedures for the detection, treatment of, or referral for, any known or suspected behavioral health problems and disorders. Physicians and professional providers may provide any clinically appropriate behavioral health services within the scope of their practice.

BCBSTX requires that all behavioral health service providers refer members with known or suspected and untreated physical health problems or disorders to their PCP for examination and treatment, with the member’s or the member’s legal guardian’s consent. Behavioral health providers may only provide physical health care services if they are licensed to do so.

BCBSTX also requires that behavioral health providers send initial and regular summary reports of a member’s behavioral health status to the primary care provider (PCP) or professional provider, with the member’s or the member’s legal guardian’s consent.

Court-ordered Commitments Court-ordered commitment means a commitment of a member to a psychiatric facility for treatment that is ordered by a court of law pursuant to the Texas Health and Safety Code, Title VII, Subtitle C. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination.

Follow-up After Hospitalization for Behavioral Health Services BCBSTX requires that all members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/ or continuing treatment prior to discharge. The outpatient treatment must occur within seven days from the date of discharge. Providers must contact members who have missed appointments within 24 hours to reschedule appointments.

Focus Studies and Utilization Management Reporting Requirements Consistent with National Committee for Quality Assurance (NCQA) standards, Magellan analyzes relevant utilization data against established thresholds for each health plan to detect potential under- and over-utilization on at least a semi-annual basis.


If findings from these monitors fall outside the specified target ranges or threshold and indicate potential under- or over- utilization that may adversely affect members, further drill-down analyses will occur based upon the recommendation of the Magellan Utilization Management Committee (UMC). The drill-down analyses may include data from specific provider and practice sites, including but not limited to: • Case management services as needed for members receiving behavioral health services• Retrospective reviews of services provided without authorization• Investigation and resolution of member and provider complaints and appeals within established time frames• Coordination with the local mental health authorities• Focus studies• Claims payment for covered behavioral health services

Magellan’s Claims Address Magellan Health Services Attn: Claims P.O. Box 2154 Maryland Heights, MO 63043

Magellan established a comprehensive Quality Improvement program to help ensure that high quality behavioral health treatment and services are provided to CHIP members, including focused activities to monitor and evaluate access across the behavioral health continuum of care.

To help ensure continuity and coordination of care, Magellan takes specific actions to help CHIP members follow up with a behavioral health outpatient provider in a timely manner after discharge from an inpatient treatment facility.

Procedures for Follow-up on Missed Appointments Behavioral health providers are encouraged to contact a member’s PCP to discuss the patient’s general health and must contact members who have missed appointments within 24 hours to reschedule appointments, per HHSC-mandated provisions.

Cost Sharing CHIP members are responsible for the copayments listed on their ID card until they meet their cost sharing limit. Once the cost sharing limit is met, members should contact Maximus, the Administrative Services Contractor to obtain a new ID card. CHIP Perinate, CHIP Perinate Newborn members, and CHIP members who are Native Americans or Alaskan Natives do not have cost sharing. Additionally, for CHIP members there is no cost-sharing on benefits for well-baby and well-child services, preventive services or pregnancy-related assistance.


APPENDIX A

CHIP Cost Sharing Effective January 1, 2014*** Enrollment Fees (for 12-month enrollment period) At or below 151% of FPL* $0 Above 151% up to and including 186% of FPL $35 Above 186% up to and including 201% of FPL $50 Copayments (per visit) At or below 100% of FPL Charge Office Visit $3 Non-emergency ER $3 Generic Drug $0 Brand Drug $3 Cost-sharing Cap 5% of family’s income** Facility Copayment, Inpatient $15 Above 100% up to and including 151% of FPL Charge Office Visit $5 Non-emergency ER $5 Generic Drug $0 Brand Drug $5 Cost-sharing Cap 5% of family’s income** Facility Copayment, Inpatient (per admission) $35 Above 151% up to and including 186% of FPL Charge Office Visit $20 Non-emergency ER $75 Generic Drug $10 Brand Drug $35 Cost-sharing Cap 5% of family’s income** Facility Copayment, Inpatient (per admission) $75 Above 186% up to and including 201% of FPL Office Visit $25 Non-emergency ER $75 Generic Drug $10 Brand Drug $35 Cost-sharing Cap 5% of family’s income** Facility Copayment, Inpatient (per admission) $125

* The Federal Poverty Level (FPL) refers to income guidelines established annually by the federal government.** Per 12-month term of coverage. ***Subject to annual change by Texas Health and Human Services.


EXCLUSIONS FROM COVERED SERVICES - CHIP• Certain Health Care Acquired Conditions (HCAC)• Inpatient and outpatient infertility treatments or

reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, orabnormalities related to the reproductive system

• Personal comfort items including but not limited topersonal care kits provided on inpatient admission, telephone, television, newborn infant photographs, mealsfor guests of patient, and other articles which are notrequired for the specific treatment of sickness or injury

• Experimental and/or investigational medical, surgicalor other health care procedures or services which arenot generally employed or recognized within themedical community

• Treatment or evaluations required by third partiesincluding, but not limited to, those for schools, employment, flight clearance, camps, insurance or court

• Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility.

• Mechanical organ replacement devices including, but not limited to artificial heart

• Hospital services and supplies when confinement issolely for diagnostic testing purposes, unless otherwisepre-authorized by BCBSTX

• Prostate and mammography screening• Elective surgery to correct vision• Gastric procedures for weight loss• Cosmetic surgery/services solely for cosmetic purposes• Dental devices solely for cosmetic purposes• Out-of-network services not authorized by BCBSTX

except for emergency care and physician services for amother and her newborn(s) for a minimum of 48 hoursfollowing an uncomplicated vaginal delivery and 96 hoursfollowing an uncomplicated delivery by caesarian section

• Services, supplies, meal replacements or supplementsprovided for weight control or the treatment of obesity, except for the services associated with the treatmentfor morbid obesity as part of a treatment plan approved by BCBSTX

• Acupuncture services, naturopathy and hypnotherapy• Immunizations solely for foreign travel• Routine foot care such as hygienic care• Diagnosis and treatment of weak, strained, or flat feet and

the cutting or removal of corns, calluses and toenails (thisdoes not apply to the removal of nail roots or surgicaltreatment of conditions underlying corns, calluses or ingrown toenails)

• Replacement or repair of prosthetic devices and durablemedical equipment due to misuse, abuse or loss when confirmed by the member or the vendor

• Corrective orthopedic shoes• Convenience items• Orthotics primarily used for athletic or

recreational purposes• Custodial care (care that assists a child with the activities

of daily living, such as assistance in walking, gettingin and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision thatis usually self-administered or provided by a parent. Thiscare does not require the continuing attention of trained medical or paramedical personnel.) This exclusion doesnot apply to hospice services.

• Housekeeping• Public facility services and care for conditions that

federal, state, or local law requires be provided in apublic facility or care provided while in the custody oflegal authorities

• Services or supplies received from a nurse, which do not require the skill and training of a nurse

• Vision training and vision therapy• Reimbursement for school-based physical therapy,

occupational therapy, or speech therapy services are notcovered except when ordered by a physician/PCP.

• Donor non-medical expenses• Charges incurred as a donor of an organ when the

recipient is not covered under this health plan


APPENDIX A

EXCLUSIONS FROM COVERED SERVICES – CHIP PERINATEFor CHIP Perinate members in families with incomes at or below 186% of the Federal Poverty Level, inpatient facility charges are not a covered benefit if associated with the initial Perinatal Newborn admission. ‘Initial Perinatal Newborn admission’ means the hospitalization associated with the birth.

• Inpatient and outpatient treatments other than prenatal care, labor with delivery, servicesrelated to (a) miscarriage and (b) a non-viablepregnancy, and postpartum care related tothe covered unborn child until birth

• Inpatient behavioral/mental health services• Outpatient behavioral/mental health services• Durable medical equipment or other

medically related remedial devices• Disposable medical supplies• Home and community-based health care services• Nursing care services• Dental services• Inpatient substance abuse treatment services and

residential substance abuse treatment services• Outpatient substance abuse treatment services• Physical therapy, occupational therapy, and services for

individuals with speech, hearing, and language disorders• Hospice care• Skilled nursing facility and rehabilitation hospital services• Emergency services other than those directly related

to the labor with delivery of the covered unborn child• Transplant services• Tobacco Cessation programs• Chiropractic services• Medical transportation not directly related to labor or

threatened labor, miscarriage or non-viable pregnancy, and/or delivery of the covered unborn child

• Personal comfort items including but not limited topersonal care kits provided on inpatient admission, telephone, television, newborn infant photographs,meals for guests of patient, and other articles whichare not required for the specific treatment relatedto labor with delivery or post-partum care

• Experimental and/or investigationalmedical, surgical or other health careprocedures or services which are notgenerally employed or recognized withinthe medical community

• Treatment or evaluations required bythird parties including, but not limited to,those for schools, employment, flightclearance, camps, insurance or court

• Private duty nursing services whenperformed on an inpatient basis or in askilled nursing facility

• Coverage while traveling outside of theUnited States and U.S. Territories(including Puerto Rico,

• U.S. Virgin Islands, Commonwealth ofNorthern Mariana Islands, Guam, andAmerican Samoa)

• Mechanical organ replacement devicesincluding, but not limited to artificialheart


• Hospital services and supplies whenconfinement is solely for diagnostic testingpurposesand not a part of labor with delivery

• Prostate and mammography screening• Elective surgery to correct vision• Gastric procedures for weight loss• Cosmetic surgery/services solely for cosmetic purposes• Out-of-network services not authorized by the health

plan except for emergency care related to the labor withdelivery of the covered unborn child

• Services, supplies, meal replacements or supplementsprovided for weight control or the treatment of obesity

• Acupuncture services, naturopathy and hypnotherapy• Immunizations solely for foreign travel• Routine foot care such as hygienic care• Diagnosis and treatment of weak, strained, or flat feet

and the cutting or removal of corns, calluses andtoenails (this does not apply to the removal of nail rootsor surgical treatment of conditions underlying corns,calluses or ingrown toenails)

• Corrective orthopedic shoes• Convenience items• Orthotics primarily used for athletic or recreational purposes• Custodial care: This is care that assists with the activities of daily

living, such as walking, getting in and out of bed, bathing,dressing, feeding, toileting, special diet preparation, andmedication supervision that is usually self-administered orprovided by a caregiver. This care does not require thecontinuing attention of trained medical or paramedicalpersonnel.

• Housekeeping• Public facility services and care for conditions that

federal, state, or local law requires be provided in apublic facility or care provided while in the custody oflegal authorities

• Services or supplies received from a nurse, which donot require the skill and training of a nurse

• Vision training, vision therapy, or vision services• Convenience items• Donor non-medical expenses• Charges incurred as a donor of an organ

CHIP Member Benefits - bcbstx.com · Post-Partum Care Covered Services ... •Diagnosis-specific...

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Transcript of CHIP Member Benefits - bcbstx.com · Post-Partum Care Covered Services ... •Diagnosis-specific...