BlueCaid Coverage Chart - e-Referral - BCBSM.com

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BlueCaid coverage chartBlueCaid benefit(continued)EPSDT/Well ChildCare ProgramSee also: Leadtesting (blood)Description of BlueCaid coverage BlueCaid provides outreach and encourages participation based on notification from thestate of Michigan of members due or overdue for EPSDT/Well Child exams. Upon receipt ofthe names of those members eligible for the EPSDT/Well Child Care Program, BlueCaidsends each family a postcard advising the members to seek the appropriate services. Theprogram coverage specifics and reporting requirements include:o Vision: Diagnosis and treatment of refractive errors or abnormal visiono Oral health screening and flouride varnish: At age 1 (12 months), BlueCaid providers(pediatricians, family practitioners and nurse practitioners) will provide an oral healthscreen and flouride varnish treatment. Referral to a dentist will be made if dental care isneeded.Note: Medical providers must complete online certification in order to provide flouridevarnish treatments. Providers can access infant oral health training and certificationmaterials at michigan.gov/medicaidproviders > Billing and Reimbursement > ProviderSpecific Information > Dental.o Hearing services must include at least the diagnosis of and treatment for hearing defects,including hearing aids, as appropriate. A conventional hearing aid, monaural or binaural,when medically necessary, is covered in full every third benefit year.o Providers may refer to a community mental health provider.o Hearing, vision and dental assessments: Medical record must show inspection of mouthand teeth.o Interpretative conference and appropriate counseling, for parents and guardians: Medicalrecord should show anticipatory guidance intended to help the parent or guardian andchild understand what to expect regarding growth and development. This includesinformation about healthy lifestyles and practices and the prevention of accidents anddiseases. Provider also provides the following services:o Objective testing for developmental behavior, hearing and vision must be performed inaccordance with the current American Academy of Pediatrics Recommendations forPreventive Pediatric Health Care, which can be found at http://brightfutures.aap.org >Clinical Practice > Recommendations for Preventive Pediatric Health Care.o State law requires that health professionals comply with specified reporting requirementsfor communicable disease and other health indicators, as referenced atmichigan.gov/mdch/providers > Communicable and Chronic Diseases > InfectiousDiseases – Reporting and Tracking.o Providers must make appropriate referrals for a diagnostic or treatment servicedetermined to be necessary.o Oral screening should be part of a physical exam. Each child must have a direct referral toa dentist such that a dental exam can be completed by age 3. Note: Referral to a dentistat age 1 is recommended but is not required.o Children should also be referred to a hearing and speech clinic, optometrist orophthalmologist or other appropriate provider for objective hearing and vision services, asnecessary.o Referral to community mental health services also may be appropriate.(continued on next page)4Updated January 2012
BlueCaid coverage chartBlueCaid benefit(continued)EPSDT/Well ChildCare ProgramSee also: Leadtesting (blood)Emergencyservices andpoststabilizationcareFamily planningservicesDescription of BlueCaid coverage Laboratory services for:o Tuberculin testing: Medical records should show evidence of a TB test performed. This isrecommended at 12 months, 4 to 6 years and 14 to 16 years.o Hematocrit and hemoglobin testing: Medical records should show evidence of ahemoglobin or hematocrit lab test being performed. This is recommended between 6 and12 months, 15 months and 4 years, 5 and 12 years and 14 and 18 years.o Urinalysis: Medical records must show evidence of a urine test performed; this test isrecommended between 1 and 12 months, 15 months and 4 years, 5 and 12 years and 14and 18 years.o Other needed testing, as determined by the physician Vision services must include at least the diagnosis of and treatment for refractive errors orabnormal vision. This includes glasses, if appropriate. Dental services must include at least relief of pain and infections, restoration of teeth andmaintenance of dental health. (The BlueCaid provider is responsible for screening / referralonly. Other dental services are provided through the state, not through BlueCaid.) Also included are other health care, diagnostic services, treatment or services covered underthe state’s Medicaid Plan that are necessary to correct or ameliorate defects, physical ormental illnesses and conditions discovered during a screening. A medically necessaryservice may be available under the EPSDT/Well Child Care Program if listed in a federalstatute as a potentially covered service, even if Michigan’s Medicaid program does not coverthe service under its state’s Plan for Medical Assistance Program.Emergency services must be available 24 hours per day, seven days per week. BlueCaidcovers emergency services and medical screening and stabilization exams without a referral orprior authorization. Members may go to any emergency facility.Emergency services are medically necessary services provided to a member to address thesudden onset of a medical condition that manifests itself in acute symptoms, including severepain, of sufficient severity that the absence of immediate medical attention could reasonably beexpected to result in: Serious jeopardy to the health of the member or, in the case of a pregnant woman, to thehealth of the woman or that of her unborn child Serious impairment of bodily functions Serious dysfunction of any body organ or partEmergency services also include covered inpatient and outpatient services that are furnishedby a provider that is qualified to furnish these services and needed to evaluate or stabilize anemergency medical condition.Poststabilization care includes services related to an emergency medical condition that areprovided after a member is stabilized, in order to maintain the member’s stabilized condition orto improve or resolve the member’s condition.Emergency services can be accessed anywhere in the world. BlueCaid members are asked tocontact their primary care physician within 24 hours of seeking emergency care to arrange forfollow-up. A BlueCaid member who receives emergency care from a non-BlueCaid-affiliatedhospital or facility may be transferred to a BlueCaid network hospital when it is safe to do so.BlueCaid is responsible for covering most family planning services through the member’sprimary care physician or obstetrician-gynecologist. The MDCH places special value on access to family planning services for BlueCaidmembers. BlueCaid members may obtain family planning services from any provider theywish (for example, in network or out of network, and without referral). BlueCaid membersmay self-refer to family planning providers for family planning services.(continued on next page)5Updated January 2012
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