|
Inpatient
General Acute and Inpatient Rehabilitation Hospital Services
|
- 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.
- 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, etc.)
- Oxygen services and
inhalation therapy
- Radiation and
chemotherapy
- Access to DSHS-designated
Level III perinatal centers or Hospitals meeting equivalent levels of
care
- 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
-
Surgical implants
|
|
Vary
based on plan and a family’s current cost-sharing level.
$0
- $100
|
|
Skilled Nursing Facilities
(Includes Rehabilitation Hospitals)
|
-
Semi-private room and board
-
Regular nursing services
-
Rehabilitation services
-
Medical supplies and use of appliances and equipment furnished by the facility
|
|
None
|
|
Outpatient
Hospital, Comprehensive Outpatient Rehabilitation Hospital, Clinic
(Including Health Center) and Ambulatory Health Care Center
|
-
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
-
Surgical implants.
|
|
Vary based on
plan and a family’s current cost-sharing level.
0 - $20 for
certain medications.
None for
preventive services.
|
|
|
-
American Academy of Pediatrics recommended well-child exams and preventive health
services (including but not limited to vision and hearing screening and
immunizations)
-
Physician office visits, in-patient and out-patient services
-
Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation
-
Medications, biologicals and materials administered in Physician’s office
-
Allergy testing, serum and injections
-
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 CRNA
-
Second surgical opinions
-
Same-day surgery performed in a Hospital without an over-night stay
-
Invasive diagnostic procedures such as endoscopic examinations
-
Hospital-based Physician services (including Physician-performed technical and
interpretive components)
-
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 medically necessary to support a dentist providing dental
services to a CHIP member such as general anesthesia or intravenous (IV)
sedation.
|
|
|
|
|
-
Orthotic braces and orthotics
-
Prosthetic devices such as artificial eyes, limbs, and braces
-
Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease
-
Hearing aids
-
Diagnosis-specific disposable medical supplies, including diagnosis-specific prescribed specialty formula and dietary supplements. (See complete list of covered DME in this section of the MHP
website)
|
|
|
|
|
-
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 have been approved.
-
Speech, physical and occupational therapies.
|
Services are
not intended to replace the child's caretaker or to provide relief for the
caretaker.
|
|
|
|
|
Services
include, but are not limited to:
-
Mental health services, including for serious mental 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.
-
Includes inpatient psychiatric services, up to 12-month period limit, ordered by a court of
competent jurisdiction under the provisions of Chapters 573 and 574 of the
Texas Health and Safety Code, relating to court ordered commitments to
psychiatric facilities. Court order serves as binding determination of
medical necessity. Any modification or termination of services must be
presented to the court with jurisdiction over the matter for
determination.
|
May require
prior authorization for
non-emergency services.
Does not
require PCP referral.
Inpatient
mental health services are limited to:
-
45 days 12-month inpatient
- 25 days of the inpatient benefit can be converted to residential treatment, therapeutic
foster care or other 24 hour therapeutically planned and structured
services or sub-acute outpatient (partial hospitalization or
rehabilitative day treatment) mental health services on the basis of
financial equivalence against the inpatient per diem cost
-
20 of the inpatient days must be held in reserve for inpatient use only
|
|
|
|
-
Mental health services, including for serious mental illness, provided on an outpatient basis.
-
Medication management visits do not count against the outpatient visit limit.
-
Includes outpatient psychiatric services, up to 12-month period limit, ordered by a
court of competent jurisdiction under the provisions of Chapters 573 and
574 of the Texas Health and Safety Code, relating to court ordered
commitments to psychiatric facilities. Court order serves as binding
determination of medical necessity. Any modification or termination of
services must be presented to the court with jurisdiction over the matter
for determination.
-
A Qualified Mental Health Professional (QMHP), as defined by and credentialed through Texas
Department of State Health Services (DSHS) standards (TAC Title 25, Part
II, Chapter 412), is a Local Mental Health Authorities provider. A QMHP
must be working under the authority of a DSHS entity and be supervised by
a licensed mental health professional or physician. QMHPs are acceptable
providers as long as the services would be within the scope of the
services that are typically provided by QMHPs. 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.
|
May require
prior authorization.
Does not
require PCP referral.
The visits
can be furnished in a variety of community-based settings (including
school and home-based) or in a state-operated facility.
Outpatient
limits include:
-
Up to 60 days; 12-month period limit for rehabilitative day treatment.
-
60 outpatient visits; 12-month period limit.
-
60 rehabilitative day treatment days can be converted to outpatient visits on the basis of
financial equivalence against the day treatment per diem cost.
-
60 outpatient visits can be converted to skills training (psycho educational skills
development) or rehabilitative day treatment on the basis of financial
equivalence against the outpatient visit cost.
-
Inpatient days converted to sub-acute outpatient services are in addition to the
outpatient limits and do not count towards those limits.
|
|
|
|
|
Services include, but are
not limited to:
-
Inpatient and residential
substance abuse treatment services including detoxification and crisis
stabilization, and 24-hour residential rehabilitation programs.
|
May require
prior authorization for
non-emergency services
Does not
require PCP referral.
Limits
include:
-
Medically necessary detoxification and stabilization services, limited to 14 days per
12-month period.
-
24-hour residential rehabilitation programs, or the equivalent, up to 60 days per 12-month
period.
-
30 days may be converted to partial hospitalization or intensive outpatient rehabilitation, on the
basis of financial equivalence against the inpatient per diem cost.
-
30 days must be held in reserve for inpatient use only.
|
|
|
|
|
Services
include, but are not limited to:
-
Prevention and intervention services that are provided by physician and non-physician
providers, such as screening, assessment and referral for chemical
dependency disorders.
-
Intensive outpatient services is defined as an organized non-residential service
providing structured group and individual therapy, educational services,
and life skills training which consists of at least 10 hours per week for
four to 12 weeks, but less than 24 hours per day.
-
Outpatient treatment service is defined as consisting of at least one to two hours
per week providing structured group and individual therapy, educational
services, and life skills training.
|
May require
prior authorization.
Does not
require PCP referral.
-
Intensive outpatient program (up to 12 weeks per 12-month period).
-
Outpatient services (up to six-months per 12-month period).
|
|
|
Rehabilitation
Services
|
|
Habilitation (the process of supplying a child with the means to reach age-appropriate
developmental milestones through therapy or treatment) and rehabilitation
services include, but are not limited to the following:
-
Physical, occupational and speech therapy
-
Developmental assessment
|
|
None
|
|
Hospice
Care Services
|
-
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
and months before death
-
Treatment for unrelated conditions is unaffected
Patients
electing hospice services waive their rights to treatment related to their
terminal illnesses; however, they may cancel this election at anytime.
|
Requires
authorization and physician prescription
Services
apply to the hospice diagnosis
|
None
|
|
Emergency Services, including Emergency Hospitals, Physicians, and
Ambulance Services
|
-
Emergency services based on prudent lay person definition of
emergency health condition
-
Hospital emergency department room and ancillary services and
physician services 24 hours a day, 7 days a week, both by in-network and
out-of-network providers
-
Medical screening examination
-
Stabilization services
-
Access to DSHS designated Level 1 and Level II trauma centers
or hospitals meeting equivalent levels of care for emergency services
-
Emergency ground, air and water transportation
-
Emergency dental services, limited to fractured or dislocated jaw, traumatic
damage to teeth, and removal of cysts.
|
MHP does not
require authorization as a condition for payment for emergency conditions
or labor and delivery.
|
Vary based on
plan and a family’s current cost-sharing level.
$0 - $50 per
visit.
|
|
|
-
Using up-to-date FDA
guidelines, all non-experimental human organ and tissue transplants and
all types of non-experimental corneal, bone marrow and peripheral stem
cell transplants, including donor medical expenses.
|
|
None
|
|
Vision
Benefit
|
-
One examination of the eyes
to determine the need for and prescription for corrective lenses per
12-month period, without authorization
-
One pair of
non-prosthetic eyewear per 12-month period
|
-
health plan may
reasonably limit the cost of the frames/lenses.
-
Does not require
authorization for protective and polycarbonate lenses when medically
necessary as part of a treatment plan for covered diseases of the eye.
|
Vary based on plan and a
family’s current cost-sharing level.
$0 - $10.00 per visit.
|
|
Chiropractic
Services
|
|
Services
do not require physician prescription and are limited to spinal
subluxation
|
Requires
authorization for twelve visits per 12-month period limit
(regardless of number of services or modalities provided in one
visit)
|
Vary based on
plan and a family’s current cost-sharing level.
$0 - $10 per
visit
|
|
Tobacco
Cessation Program
|
|
Covered
up to $100 for a 12- month period limit for a plan‑approved program
Requires
authorization. Mercy Health Plans defines plan-approved program.
May
be subject to formulary requirements.
|
None
|
|
|
|
Medically
necessary case management services above and beyond those normally
provided to all members are covered.
These covered services include outreach, informing intensive case
management, care coordination and community referral.
|
|