Allergy Testing | Allergy extract and extract injection | N/A (not applicable) |
Ambulance | Limited to emergency ground ambulance transport to the hospital Emergency room | N/A |
Case Management | Not covered | N/A |
Chiropractor | Not covered | N/A |
Dental | Routine dental services non-covered except for services of oral surgeons. | N/A |
Dermatology | Covered if ordered by an MD, DO or NP | $0 copay |
Emergency Services | Covered | $0 copay |
Eyeglasses | Not covered | N/A |
| Family Planning - Infertility screening
- Contraceptive devices
| Covered. Services may be provided Family Planning Program. | N/A |
Heaing Aids | Not covered | N/A |
Home Health | Not covered | N/A |
Home Help (personal care) | Not covered | N/A |
Hospice | Not covered | N/A |
Immunizations | Covered per ACIP guidelines. Travel immunizations are not covered. | N/A |
Inpatient Hospital | Not covered effective March 1, 2005 | N/A |
| Lab & X-Ray - Diagnostic and therapeutic EKG, x-ray, radium isotope and radiation therapy
- CAT, MRI, MRA and PET
- Chelation therapy for certain diagnoses
| Covered if ordered by an MD, DO or NP for diagnostic and treatment purposes. | N/A |
Medical Supplies/Durable Medical Equipment (DME) | Limited coverage. Medical supplies are covered except for the following: - Gradient surgical garments, formulas and feeding supplies, and supplies related to any noncovered DME item.
- DME items are not covered except for glucose monitors
| No copays for diabetic supplies |
Mental Health Services | Covered. Services must be provided through the local community mental health center. | N/A |
Nursing Facility | Not covered | N/A |
Optometrist | Not covered | N/A |
| Outpatient Hospital (Not emergency services) - Surgery
- Dialysis
- Chemotherapy
- Sterilization
- Radiation
| Covered. Diagnostic and treatment services and diabetes education services. | $0 copay |
Pharmacy | Covered: Mental health prescriptions covered under the FFS benefit using the MIHEALTH card Not covered: Injectables used in clinics or physician offices. | $1 copay. No copays for diabetic drugs or supplies |
| Physician Nurse Practitioner 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.
| $0 Copay |
Podiatrist | Limited services - When referred by a primary care physician for foot care related to diabetes. Diagnosis codes 250.00-250.93 with procedure codes 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.
| $0 Copay |
Prosthetics/Orthotics | Not covered | N/A |
Private Duty Nursing | Not covered | N/A |
Substance Abuse | Covered through local Mental Health/Substance Abuse programs. | N/A |
Therapies | 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 |
Transportation (non ambulance) | Not covered | N/A |
Urgent Care Clinic | Professional services provided in a freestanding facility are covered. | $3 copay |