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HealthyHealthy PlusPCO**Adult Benefit Plan1/1/2015 -4/26/151/1/2015 -4/26/151/1/15- 8/31/15Effective 4/27/15Category 1: Ambulatory ServicesPrimary Care ProviderNo limitsNo limitsNo limitsNo limitsPhysician OfficeNo limitsNo limitsNo limitsNo limitsCertified Registered Nurse PractitionerNo limits No limitsNo limitsNo limitsFederally Qualified Health Center/Rural Health ClinicNo limits except for Dental Care Services as described belowNo limits except for Dental Care Services as described belowNo limits except for Dental Care Services as described belowNo limits except for Dental Care Services as described belowIndependent ClinicNo limitsNo limitsNo limitsNo limitsOutpatient Hospital ClinicNo limits No limitsNo limitsNo limitsPodiatrist ServicesNo limits No limitsNo limitsNo limitsChiropractor ServicesNo limits 10 visits per calendar year20 visits per yearNo limitsOptometrist Services2 visits (exams) per calendar year)1 visit per calendar year1 visit per two years2 visits (exams) per calendar year)Hospice CareThe only key limitation is related to respite care, which may not exceed a total of 5 days in a 60-day certification period.No limits, except for respite care, which may not exceed a total of 5 days in a 60-day certification period.No limits. Respite care is not provided.The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60-day certification period.Radiology (For example: X-Rays, MRIs, CTs)No limits No limitsNo limitsNo limitsDental Care ServicesDiagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation.Key Limitations:Dentures 1 per lifetime,Exams/prophylaxis 1 per 180 days,Crowns, Periodontics and Endodontics only via approved benefit limit exceptionDiagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation.Key Limitations:Dentures 1 per lifetime,Exams/prophylaxis 1 per 180 days,Crowns, Periodontics and Endodontics only via approved benefit limit exceptionNOT COVERED Diagnostic, preventive, restorative, and surgical dental procedures, prosthodontics and sedation.Key Limitations:Dentures 1 per lifetime,Exams/prophylaxis 1 per 180 days,Crowns, Periodontics and Endodontics only via approved benefit limit exceptionOutpatient Hospital Short Procedure Unit (SPU)No limits No limitsNo limitsNo limitsOutpatient Ambulatory Surgical Center (ASC)No limits No limitsNo limitsNo limitsNon-Emergency Medical TransportOnly to and from MA covered services.Only to and from MA covered services.NOT COVERED Only to and from MA covered services.Family Planning ClinicNo limitsNo limitsNo limitsNo limitsRenal DialysisInitial training for home dialysis is limited to 24 sessions per patient per calendar year.Backup visits to the facility limited to no more than 26 per calendar yearInitial training for home dialysis is limited to 24 sessions per patient per calendar year.Backup visits to the facility limited to no more than 75 per calendar yearNOT COVERED ?Initial training for home dialysis is limited to 24 sessions per patient per calendar year.?Backup visits to the facility limited to no more than 75 per calendar yearCategory 2: Emergency ServicesEmergency RoomNo LimitsNo limitsNo limits on emergency services.Non-emergency services are not covered.No limitsAmbulanceNo LimitsNo limitsNo limits on emergency ambulance services.Non-emergency ambulance services are not covered.No limitsCategory 3: HospitalizationInpatient Acute HospitalNo limits No limitsNo limitsNo limitsInpatient Rehab Hospital1 admit per calendar yearNo limitsNo limitsNo limitsInpatient Psychiatric Hospital30 days per calendar yearNo limitsNo limitsNo limitsInpatient Drug & AlcoholNo limitsNo limitsNo limitsNo limitsCategory 4: Maternity and NewbornMaternity – Physician, Certified Nurse Midwives, Birth CentersNo LimitsNo LimitsNo LimitsNo limitsCategory 5: Mental Health and Substance Abuse (Behavioral Health) *Outpatient Psychiatric ClinicFive hours or 10 one-half hour sessions of psychotherapy per recipient per 30 consecutive days No limitsNo limitsNo limitsMobile Mental Health TreatmentSame as OP Psychiatric ClinicNo limitsNOT COVERED No limitsOutpatient Drug and Alcohol TreatmentOpiate Detox: 42 visits per 365 days Chemotherapy/Drug-free visits: 3 visits per 30 daysNo limitsNo limitsNo limitsResidential Treatment Facility(Non-Hospital Residential Drug & Alcohol)NOT COVEREDNo limitsNo limitsNot addressed on Adult Benefit Plan gridMethadone MaintenanceOne visit per day / 7 visits per weekNo limitsNo limitsNo limitsClozapineLimited to persons with Schizophrenia1 per week (no 1 per week)No limitsNo limitsNo limitsPsychiatric Partial Hospital540 hours per calendar yearNo limitsNo limitsNo limitsPeer Support4 hours per day / 900 hours per yearNo limitsNOT COVERED No limitsCrisisNo limitsNo limitsNo limitsNo limitsTargeted Case Management – other than Behavioral HealthLimited to individuals identified in the target group No limits Limited to individuals identified in the target group (No limits)NOT COVERED Limited to individuals identified in the target group (No limits)Targeted Case Management – Behavioral Health OnlyLimited to individuals with SMI only No limits Limited to individuals with SMI only (No limits)NOT COVERED Limited to individuals with SMI only (No limits)Category 6: Prescription DrugsPrescription Drugs6 Script Limit Applies (Aetna Better Health does not apply limit)No LimitsNo limits No limitsNutritional SupplementsNo LimitsNo LimitsNOT COVERED No limitsCategory 7: Rehabilitation and Habilitation Services and DevicesSkilled Nursing Facility365 days per calendar year (30 consecutive days MCO responsibility and then transfer to FFS)365 days per calendar year (30 consecutive days MCO responsibility and then transfer to FFS)120 days per calendar year365 days per calendar year (30 consecutive days MCO responsibility and then transfer to FFS)Home Health Care Unlimited for first 28 days; limited to 15 days every month thereafter (60 visits per calendar year)Unlimited for first 28 days; limited to 15 days every month thereafter60 visits per yearUnlimited for first 28 days; limited to 15 days every month thereafterICF/IID and ICF/ORCRequires an institutional level of care No limits (Not covered)Requires an institutional level of care (No limits)NOT COVERED Requires an institutional level of care (No limits)Durable Medical EquipmentNo limitsNo limitsNo limitsNo limitsEyeglass LensesLimited to individuals with aphakia4 lenses per calendar yearLimited to individuals with aphakia4 lenses per calendar yearNOT COVERED Limited to individuals with aphakia4 lenses per calendar yearEyeglass FramesLimited to individuals with aphakia2 frames per calendar yearLimited to individuals with aphakia2 frames per calendar yearNOT COVERED Limited to individuals with aphakia2 frames per calendar yearContact LensesLimited to individuals with aphakia4 lenses per calendar yearLimited to individuals with aphakia4 lenses per calendar yearNOT COVERED Limited to individuals with aphakia4 lenses per calendar yearMedical SuppliesNo limits $2500 per calendar yearDiabetic supplies provided by pharmacies are not limitedNOT COVERED (Except diabetic supplies provided by pharmacies, which are not limited)No limitsTherapy (Physical, Occupational, Speech)- Rehabilitative and HabilitativeOnly when provided in a hospital, independent clinic or office, skilled nursing facility or home health setting30 visits per calendar year combined for Physical and Occupational Therapy30 visits per calendar year for Speech Therapy30 visits per calendar year combined for Physical and Occupational Therapy30 visits per calendar year for Speech TherapyOnly when provided in a hospital, independent clinic or office, skilled nursing facility or home health settingCategory 8: Laboratory ServicesLaboratoryNo limitsNo LimitsNo limitsNo limitsCategory 9: Preventative/Wellness Services and Chronic CareTobacco Cessation70 visits per calendar year 70 visits per calendar year As recommended by the US Preventive Services Task Force (not covered) 70 visits per calendar year ................
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