Benefits

Outpatient Services   |   Inpatient Services

Outpatient Services

Unless otherwise specified in this benefits handbook, the following benefits are provided on an outpatient basis when:

• Medically necessary;
• Provided or referred by your child’s primary care physician; and
• Preapproved by Keystone, where specified.

Allergy Testing and Treatment
Allergy tests, testing materials, and treatment

Ambulance Services (Preapproval, unless an emergency service and medical intervention and/or stabilization is medically necessary during transport)

Ambulance services on land, air or sea for medical intervention and/or stabilization of the member’s condition by a licensed medical professional during transit from the site where an emergency medical condition occurs to the facility of treatment. Other ambulance services will be covered only when ordered or referred by your child’s primary care physician and preapproved by Keystone. The vehicle used must be one that is specially designed and equipped for use only to transport sick or injured persons.

Anesthesia (Preapproval for outpatient epidural injection)
Anesthesia services performed in connection with covered services.

Autologous Blood Drawing/Storage/Transfusion
Services provided in conjunction with a planned episode of care that requires transfusion, including but not limited to, surgical procedures. Benefits are provided for storage of autologous blood until the date of scheduled care.

Cardiac Rehabilitation Therapy (Preapproval)

Chemotherapy (Preapproval for administration in a facility)

Dental Benefits (More information available)

Diabetic Self-Management and Education
Benefits are provided for self-management training and education relating to diet when prescribed by a primary care physician or referred specialist. Covered services may be provided by a participating provider who is a licensed health care professional approved by Keystone. Covered services may also be provided by a participating community-based program which is approved by Keystone in accordance with criteria based on the certification programs for diabetic self-management training and education programs developed by the American Diabetes Association and the Pennsylvania Department of Health, or at a participating hospital on an outpatient basis as follows:

	A.		Visits medically necessary upon the diagnosis of diabetes;
	B.		Visits under circumstances whereby your child’s primary care physician identifies or diagnoses a significant change in your child’s symptoms or conditions that necessitates changes in his/her self-management; and
	C.		Where a new medication or therapeutic process relating to your child’s treatment and/or management of diabetes has been identified as medically necessary by your child’s primary care physician.

Diabetic Supplies (Preapproval)
Benefits are provided for equipment and supplies when purchased through a participating durable medical equipment provider for use when your child is not an inpatient. Covered supplies include blood glucose monitors, monitor supplies, injection aids, syringes, insulin infusion devices, and pharmacological agents for controlling blood sugar.

Diagnostic Laboratory and X-Ray Services
X-ray and laboratory tests, procedures, and materials. Covered routine diagnostic outpatient services must be performed by your child’s primary care physician’s designated provider, except as follows. Diagnostic outpatient radiology services for children less than age 5 may be performed by any participating provider that is contracted by Keystone to perform radiology services.

Dialysis
Dialysis treatment when provided in the outpatient facility of a hospital, a free-standing renal dialysis facility or in the home. In the case of home dialysis, covered services will include equipment, training, and medical supplies. Private duty nursing is not covered as a portion of dialysis. The decision to provide benefits for the purchase or rental of necessary equipment for home dialysis will be made by Keystone. When your child becomes eligible for Medicare coverage of dialysis, Keystone dialysis benefits will be coordinated with such Medicare coverage.

Durable Medical Equipment (Preapproval, when required)
Benefits will be provided for the rental or, at the option of Keystone, the initial purchase per medical episode of standard durable medical equipment for therapeutic use.

Medical equipment is equipment used for medical purposes that has a long life and is not disposable (wheelchairs, commodes, crutches, etc.). Durable medical equipment must be purchased through a participating durable medical equipment company referred by your child’s primary care physician.

Genetic Testing and Counseling
Benefits are provided for genetic testing and counseling. Covered services are those testing and counseling services provided to members at risk by pedigree for a specific hereditary disease. The services must be for the purpose of diagnosis and where the results will be used to make a therapeutic decision.

Gynecological Care
Benefits are provided for female members for covered services provided by any Keystone participating obstetrical/gynecological specialist without a referral. Covered services include:

	A.		Routine maternity care;
	B.		Routine gynecological care including Papanicolaou (Pap) smears; and
	C.		Other gynecological care.

A referral is required for specialty care provided by a reproductive endocrinologist, infertility specialist, or gynecological oncologist.

Hearing Care
Benefits are provided for hearing screenings for diagnostic purposes and evaluation for hearing aid once every two years. Benefits are provided for 100% reimbursement for one hearing aid, per ear, every two calendar years. A reimbursement form may by obtained by calling 1-800-464-5437.

Home Health Care (Preapproval)
Care provided by a home health care provider in the member’s home, if within the service area.

Home Visits
Physician visits to your home, if within the service area.

Hospice Care (Preapproval)
Palliative and supportive services provided to a terminally ill member through a hospice program by a hospice provider given on an outpatient basis or in the member’s home in accordance with a plan of treatment preapproved by Keystone.

Immunizations (Shots)
Pediatric and adult immunizations (except those required for travel or work). Coverage will be provided for those child immunizations, including the immunizing agents, which, as determined by the Pennsylvania Department of Health, conform with the standards of the Advisory Committee on Immunization Practices of the Center for Disease Control, U.S. Department of Health and Human Services.

Injections (Preapproval, when required)
Injectable medication for the immediate treatment of an injury or acute illness when administered in the physician’s office.

Mammogram Screening
Mammograms will be covered only when recommended by your child’s primary care physician or a referred specialist. Approval by your child’s primary care physician is not required for a referral received from an obstetrical/gynecological specialist or Keystone.

Maternity Care
Benefits are provided for female members for covered services provided by a primary care physician or participating obstetrician/gynecologist without a referral.

Medical Foods (Preapproval)
Benefits are provided for nutritional products which are specifically formulated for the therapeutic treatment of phenylketonuria, branch-chain ketonuria, galactosemia, and homocystinuria. These foods may be taken by mouth and may not be a person’s sole source of nutrition. This treatment must be ordered by your child’s primary care physician or referred specialist.

Mental Health Care (More information available)

Newborn Care
Care of a newborn child, born to a CHIP member, is covered for a period of 31 days following birth. Such care shall include routine nursery care, prematurity services, preventive health care services, as well as coverage for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. To ensure continuity of care for the newborn, the mother of the newborn should fill out a Medicaid application as soon as the baby is born. The social services department at the hospital or the Caring Foundation can assist the mother of the newborn with this process.

Obstetrical Care
Benefits are provided for female members for obstetrical care, including prenatal and postnatal care, complications of pregnancy and childbirth.

Covered services are provided by a primary care physician or participating obstetrician/gynecologist without a referral.

Office Visits
Covered services provided in the physician’s office.

Oral Surgery (Preapproval in a facility)
Limited oral surgical procedures in an outpatient setting and required in connection with the following:

	A.		The removal or exposure of teeth which are partially or totally covered by bone
	B.		Accidental injury to the jaw or structures contiguous to the jaw or injury related to sound natural teeth
	C.		The correction of a non-dental physiological condition which has resulted in a severe functional impairment
	D.		Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth

Orthotics (Preapproval)
Benefits are provided for:

	A.		The initial purchase and fitting (per medical episode) of orthotic devices, except foot orthotics, unless the covered child requires foot orthotics as a result of diabetes
	B.		The replacement of covered orthotics for a covered child when required due to natural growth

Foot orthotics ordered and covered as a result of diabetes, must be purchased through a participating durable medical equipment provider.

Podiatric Care
Covered services include: capsular or surgical treatment of bunions; ingrown toenail surgery; and other non-routine medically necessary foot care. In addition, for patients with peripheral vascular and/or peripheral neuropathic diseases, including but not limited to diabetes, routine foot care services are covered. All such care must be performed by your child’s primary care physician’s designated provider.

Prescription Drugs (More information available)

Primary and Preventive Care
Preventive health care, including, but not limited to, periodic health assessments, well-child care, and periodic gynecological examinations, according to schedules approved by Keystone, when provided by your child’s primary care physician or a participating gynecologist.

Prosthetic Devices (Preapproval)
Benefits will be provided for:

	A.		The initial purchase and fitting (per medical episode) of prosthetic devices and supplies (except dental prosthetics), which replace all or part of an absent body organ and its adjoining tissues or replace all or part of the function of a permanently useless or malfunctioning body organ
	B.		The replacement of external prostheses for a covered child when required due to a natural growth process

Pulmonary Rehabilitation Services (Preapproval)
Benefits are limited to treatment received within a 60 consecutive day period.

Radiation Therapy

Rehabilitation Therapy Services (Preapproval)
Covered services for all covered therapies other than speech therapy must be performed at your child’s primary care physician’s designated provider. Covered services for acute conditions are subject to the determination that significant improvement can be expected within 60 days. Covered therapies include:

• Occupational
• Physical
• Hand
• Speech

Covered services include:

	A.		All therapeutic exercise, testing and soft tissue mobilization
	B.		All physical modalities utilizing heat, cold, light, air, electricity, sound, all forms of water therapy, massage, mobilization and mechanical stimulation
	C.		Checking out the fitting of splints, braces, prostheses and other orthotic devices (orthotic devices are not covered unless stated otherwise)
	D.		Reconditioning, including work reconditioning

Respiratory Therapy (Preapproval)
Respiratory therapy services when provided by a licensed respiratory therapist.

Serious Mental Illness Health Care (More information available)

Specialist Services
Covered services provided by referred specialists. Referrals to non-participating specialists are approved by Keystone when no appropriate participating specialist is available within a reasonable geographic distance when the referral is judged to be medically necessary by Keystone. The referral is valid for an enrolled member for 90 days from the date of issue. Self-referrals are excluded, except for emergency and routine gynecological care. Additional covered services recommended by the referred specialist will require another written referral from your child’s primary care physician.

Spinal Manipulation Services (Preapproval)
Covered services may be provided by your child’s primary care physician or referred specialist licensed to perform such services. Covered spinal manipulation services are provided in order to treat an acute condition related to an acute medical episode and are subject to the determination that significant improvement can be expected.

Substance Abuse Treatment (More information available)

Surgery (Preapproval)
Surgical services required for treatment of disease or injury.

Termination of Pregnancy (Preapproval)
Covered only when necessary to prevent the death of the woman, or in the case of rape or incest. Elective abortions are not covered.

Vision Care (More information available)