Benefits & Services

We manage your covered benefits by:

  • Working with your doctor to decide what care is needed
  • Deciding what care is covered

Your doctor or provider must give most care. You’ll have your own personal doctor to call on.

We contract with a select network of providers for your care. We check our doctors and hospitals often to make sure you get the care you need. There may be times when no network provider can give you the care you need. If this happens, you may go out of the network for the care. We must approve this first.

A full list of covered benefits and services can be found in the handbook.

 

Our preferred lab vendor is LabCorp. You can search for locations and even make an appointment online.

Behavioral and mental health care is offered through Beacon Health Options (formerly PsychCare). Prior authorization or referral by a doctor is not required. Doctors in our network will see you outpatient within one (1) day for Urgent Care, within one (1) week for Routine Care, within one (1) month for Well Care or the doctor will provide care at hospitals listed in the directory.

We can provide you with the names of doctors and can help you make an appointment. Care from out-of-network providers who are not prior-approved are not covered. You may call Member Services to ask for authorization to use a provider that is not in our network. A list of the doctors in our network may be found in the Provider Directory.

If you are not happy with the doctor or case manager assigned to you, you can ask to see another one. You have the right to choose a different mental health case manager or provider if you are not happy with your current provider and as long as another provider is available. Call Member Services at 1-800-441-5501.

For emergencies and after-hours care in or out of the service area you may use any hospital or other setting, or call Beacon Health Options at 1-844-513-4954. You do not have to get approval or a referral from your doctor for emergency or post-stabilization services.

If you go to the hospital for an emergency, you need to make sure you get care after the emergency, called Post Stabilization services. This may help to keep you from having another emergency. Post-Stabilization services are covered services you get after emergency room care within or outside the network. These are services delivered to keep your condition stable after an emergency. Post-stabilization care services are provided and covered without asking for an okay.

The following feelings can indicate you need help:

  • Sadness that won’t go away
  • Feelings of hopelessness or helplessness
  • Feelings of guilt or worthlessness
  • Trouble sleeping
  • Poor appetite or weight loss
  • Loss of interest in things you enjoy
  • Trouble concentrating
  • Irritability
  • Headaches, stomach aches or backaches that won’t go away
  • If you need help, call your doctor. You can get help 24 hours a day. If your doctor is not available, we will find another doctor for you. If you are in danger of hurting yourself or someone else, call 911 or have someone take you to the closest emergency room.

Your doctor manages all of your health care needs. We will pay for your visits to doctors in our network. You can get unlimited visits to your PCP.

If you are homebound or cannot safely be taken to your PCP office, you can get one (1) more PCP home visit a month and one (1) more specialist home visit a month.

For emergencies, go to a hospital closest to you or call 911. Call your doctor and us if you go to the hospital. You do not have to get prior authorization from the plan for emergency or post-stabilization service.

If you have an emergency and you are outside of our service area, go to the closest hospital or call 911. Call your doctor and us as soon as you can.

Urgent care clinics are there for you and your family when you need to see a doctor and your doctor is not able to see you or the office is closed. Most urgent cares are open 24/7 and have short wait times. Health problems that can be treated in urgent cares include:

  • Common colds and flu symptoms
  • Ear pain
  • Minor cuts and scrapes
  • Sprains or strains
  • Sore throat
  • Minor burns

It’s good to know which urgent care clinic is close to you. You can find a list of urgent care clinics in our online Provider Search or you can speak with a nurse toll-free at 1-800-441-5501. If you have trouble hearing, dial 711. If you are having a medical emergency you should call 911. Do not try to drive yourself if you are having bad chest pain, bleeding that doesn’t stop, or if you feel like you might faint or if you cannot see well.

Please remember, you should call 911 or go to the emergency room if you have serious health issues like:

  • Chest pain, shortness of breath, and other symptoms of heart attack or stroke
  • Major broken bones
  • Uncontrollable bleeding
  • Deep wounds
  • Serious burns
  • High Fever (105 degrees F)
  • Major head injury
  • Thoughts of hurting yourself or others
  • Fainting

You can get Medicaid-approved eye exams, eyeglasses and medically necessary contact lenses. Adults 21 years of age and older can get one extra set of eyeglasses (frames and lenses) each year. To find a network provider call Member Services at 1-800-441-5501.

Diabetics get free diabetic retinal exams. These exams are very important to prevent blindness. This exam is in addition to other free eye services listed above.

You can get your hearing checked every two (2) years. You can get a hearing aid once every two (2) years and three (3) hearing aid repairs each year. For help finding a network hearing provider, just call Member Services at 1-800-441-5501.

You can go to Family Planning classes or get materials. Family Planning services include information, education, counseling, diagnostic procedures and contraceptive medication and supplies. Services are voluntary and you have full freedom of choice of methods for Family Planning to help you plan a family size or help you space the time between having children. You can go to any provider that participates with Medicaid for these services without a referral from your PCP. Family Planning services do not require prior authorization.

You can also get unlimited visits for prenatal and perinatal care.