Coverage Listing

Service Coverage Benefit Limitation Comments
Abortion Carved Out n/a Fee-for-Service MO HealthNet
Allergy Services Covered No limits or age restrictions  
Ambulatory Surgery Center Covered    
Anesthesia Services Covered    
Behavioral Health Services Covered Includes Community Based, Inpatient and Outpatient Services. Services administered by Cenpatico.
Chiropractic Services Not Covered    
Circumcisions (Routine/Elective) Covered (added benefit) For infants up to six weeks after birth  
Dental Services Covered Limited to children under 21 and certain pregnant women.

 

  • 1 Cleaning every 6 months
  • Extractions and fillings
  • 1 set of x-rays per 24 month period
  • Other dental services are available
  • Orthodontic braces are only covered if medically necessary

Adult coverage is limited to treatment of trauma to the mouth, jaw, teeth, or other contiguous sites as a result of injury, and dental services when the absence of dental treatment would adversely affect a pre-existing medical condition.

 
Dialysis Covered    
Durable Medical Equipment (DME) Covered    
Early Periodic Screening Diagnosis and Treatment Covered For members less than 21 years old  
Emergency Room Services Covered    
Enteral & Parenteral Nutrition for Home Use Covered    
Environmental Lead Assessment Covered Limited to children under 21 Limited to 1 initial assessment per year  
Family Planning Covered    
FQHC & RHC Services Covered    
Hearing Aids and Related Services Covered Limited to children under 21 and some pregnant women.   
Home Births Carved Out   FFS MO HealthNet
Home Health Care Services Covered Children under age 21 Limited to 2 skilled nurse visit, occupational therapy, speech therapy and physical therapy evaluation Adults 21 and over: Limited to 100 visits per year
 
Hospice Care Covered Hospice services for children (ages 0‐20) may be concurrent with the care related to curative treatment of the condition for which a diagnosis of a terminal illness has been made.  
Hospital Services: Inpatient Covered    
Hospital Services: Outpatient Covered    
Hysterectomy Covered Not covered if preformed for the following reasons:

 

  • The hysterectomy was performed solely for the purpose of rendering an individual permanently incapable of reproducing; or
  • if there was more than one purpose to the procedure, it would not have been performed except for the purpose of rendering the individual permanently incapable of reproducing
Consent Form Required
Laboratory Services Covered    
Maternity Care Services Covered Includes:

 

  • Nurse mid-wife services
  • Pregnancy related services
  • Services for conditions that might complicate pregnancy
 
Orthotics & Prosthetics Covered    
Physician, and Nurse Practitioner Services Covered    
Podiatrist Services Covered 21 and Older Excludes: trimming of nondystrophic nails, any number; debridement of nail(s) by any method(s), one (1) to five (5); debridement of nail(s) by any method(s), six (6) or more; excision of nail and nail matrix, partial or complete; and strapping of ankle and/or foot  
Prescription Drugs Carved Out n/a FFS MO HealthNet
Radiology and x-rays Covered    
Sterilization Procedures Covered   Consent Form Required
Therapy (OT, PT, ST) Services (Outpatient) Covered Limited to children under 21.  
Transplant Service Covered Pre and Post Transplant Services Only  
Transportation Limited    
Vision Services and Eyewear Covered Under 21: 1 eye exam per year 1 pair of glasses per year
21 and Older: 1 eye exam every 2 (two) years 1 pair of glasses every 24 months
 
Approved: May 11, 2012