www.unicare.com
In UniCare Health Plan of West Virginia, Inc., ® Registered mark of WellPoint, Inc. 0211 WVW3082 Rev:11/15/2012
Covered and Non-Covered Services
The matrix below lists the available benefits for adults enrolled in West Virginia Medicaid.
These benefits are identified by the three programs offered by the state of West Virginia: Basic,
Traditional and Enhanced. If you would like detailed information about the benefits, please see
our Provider Operations Manual, available on UniCare’s West Virginia Medicaid website.
Please note, an asterisk (*) denotes a value-added benefit that is provided by UniCare, that is not
covered by the state of West Virginia.
Benefits Matrix for Adults
Basic Program Enhanced Program Traditional Program
Ambulance Ambulance Ambulance
Behavioral Health Services – Inpatient
We cover:
• Diagnosis and treatment of mental illness, mental
retardation and substance abuse.
• Unlimited days based upon medical necessity.
Limitations
Prior authorization required. We do not cover:
• Services given at psychiatric residential treatment facilities (covered directly by the state through fee for services)
Behavioral Health Services – Inpatient
We cover:
• Diagnosis and treatment of mental illness, mental
retardation and substance abuse.
• Unlimited days based upon medical necessity.
Limitations
Prior authorization required. We do not cover:
• Services given at psychiatric residential treatment facilities (covered directly by the state through fee for services)
Behavioral Health Services – Inpatient
We cover:
• Diagnosis and treatment of mental illness, mental
retardation and substance abuse.
• Unlimited days based upon medical necessity.
Limitations
Prior authorization required. We do not cover:
• Services given at psychiatric residential treatment facilities (covered directly by the state through fee for services)
Behavioral Health Services – Outpatient
These types of service when provided in an outpatient or office setting.
We cover:
•
Diagnosis and treatment of mental illness, mentalretardation and substance abuse.
•
Unlimited visits based upon medical necessity.Limitations
Prior authorization required.
Behavioral Health Services – Outpatient
These types of service when provided in an outpatient or office setting.
We cover:
•
Diagnosis and treatment of mental illness, mentalretardation and substance abuse.
•
Unlimited visits based upon medical necessity.Limitations
Prior authorization required.
Behavioral Health Services – Outpatient
These types of service when provided in an outpatient or office setting.
We cover:
•
Diagnosis and treatment of mental illness, mentalretardation and substance abuse.
•
Unlimited visits based upon medical necessity.Limitations
Prior authorization required.
Chemical Dependency/Mental Health Services
These services are covered directly by the state’s fee-for-service Medicaid program.
Chemical Dependency/Mental Health Services
These services are covered directly by the state’s fee-for-service Medicaid program.
Chemical Dependency/Mental Health Services
Basic Program Enhanced Program Traditional Program
Chiropractic Services
Not covered.
Chiropractic Services
24 visits per calendar year. Coverage includes:
• Manipulation to correct subluxation
• Radiological examinations related to the service. Prior authorization required.
Chiropractic Services
24 visits per calendar year. Coverage includes:
• Manipulation to correct subluxation
• Radiological examinations related t othe service. Prior authorization required.
Dental Services
Coverage includes emergency services provided by a dentist or oral surgeon and is limited to the
treatment of fractures of mandible and maxilla, biopsy, removal of tumors and emergency extractions. Preventive dental services and orthodontia services are covered directly by the state for members up to age 21.
Limitations
Dental services do not include temporomandibular joint (TMJ) surgery and treatment.
Dental Services
Coverage includes emergency services provided by a dentist or oral surgeon and is limited to the
treatment of fractures of mandible and maxilla, biopsy, removal of tumors and emergency extractions. Preventive dental services and orthodontia services are covered directly by the state for members up to age 21.
Limitations
Dental services do not include temporomandibular joint (TMJ) surgery and treatment.
Dental Services
Coverage includes emergency services provided by a dentist or oral surgeon and is limited to the
treatment of fractures of mandible and maxilla, biopsy, removal of tumors and emergency extractions. Preventive dental services and orthodontia services are covered directly by the state for members up to age 21.
Limitations
Dental services do not include temporomandibular joint (TMJ) surgery and treatment.
Diabetes Care
Coverage includes:
• Diabetes education / nutrition counseling for members up to age 21
• Annual dilated retinal eye exam for diabetic members
Diabetes Care
Coverage includes:
• Diabetes education / nutrition counseling
• Annual dilated retinal eye exam for diabetic members
Diabetes Care
Coverage includes:
• Diabetes education / nutrition counseling
Basic Program Enhanced Program Traditional Program
Durable Medical Equipment (DME)
$1,000 per year. Requires prior authorization if exceeded. All custom DME also requires prior authorization.
•
Orthotics and Prosthetics• UniCare covers medical equipment and supplies,
including medical equipment for home use, when medically necessary and within the limits of Medicaid
• Enteral nutrition and total parental nutrition are covered only when the nutritional supplement is the only form of nutrition (except for enrollees under 21, where the supplement must be the main source of nutrition).
The following DME is not covered:
•
Equipment used for exercise•
Equipment or supplies used only for making the room or home comfortable, such as air conditioning, air filters, air purifiers, spas, swimming pools, elevators and supplies for hygiene or appearance•
Experimental or research equipment•
More than one piece of equipment that serves the same functionDurable Medical Equipment (DME)
Prior authorization required. All custom DME also requires prior authorization.
•
Orthotics and Prosthetics• UniCare covers medical equipment and supplies,
including medical equipment for home use, when medically necessary and within the limits of Medicaid
• Enteral nutrition and total parental nutrition are covered only when the nutritional supplement is the only form of nutrition (except for enrollees under 21, where the supplement must be the main source of nutrition).
The following DME is not covered:
•
Equipment used for exercise•
Equipment or supplies used only for making the room or home comfortable, such as air conditioning, air filters, air purifiers, spas, swimming pools, elevators and supplies for hygiene or appearance•
Experimental or research equipment•
More than one piece of equipment that serves the same functionDurable Medical Equipment (DME)
Prior authorization required. All custom DME also requires prior authorization.
•
Orthotics and Prosthetics• UniCare covers medical equipment and supplies,
including medical equipment for home use, when medically necessary and within the limits of Medicaid
• Enteral nutrition and total parental nutrition are covered only when the nutritional supplement is the only form of nutrition (except for enrollees under 21, where the supplement must be the main source of nutrition).
The following DME is not covered:
•
Equipment used for exercise•
Equipment or supplies used only for making the room or home comfortable, such as air conditioning, air filters, air purifiers, spas, swimming pools, elevators and supplies for hygiene or appearance•
Experimental or research equipmentBasic Program Enhanced Program Traditional Program
Family Planning
Coverage includes:
•
Family planning clinics•
Private physicians•
Services•
Supplies•
Family planning, education and counseling•
Medical visits for birth control•
Annual cervical cancer screenings•
Human papillomavirus (HPV) testing for women 18 years of age and older•
Pregnancy tests•
Lab tests•
Tests for sexually transmitted infections (STIs)•
Screening, testing, counseling and referral for treatment for members at risk for HIV•
SterilizationThe following items are not covered:
•
Treatment for members who cannot get pregnant•
Sterilization for recipients in institutions, or for those who are mentally incompetent•
Hysterectomies, unless medically necessary•
Pregnancy terminations Family Planning Coverage includes:•
Family planning clinics•
Private physicians•
Services•
Supplies•
Family planning, education and counseling•
Medical visits for birth control•
Annual cervical cancer screenings•
Human papillomavirus (HPV) testing for women 18 years of age and older•
Pregnancy tests•
Lab tests•
Tests for sexually transmitted infections (STIs)•
Screening, testing, counseling and referral for treatment for members at risk for HIV•
SterilizationThe following items are not covered:
•
Treatment for members who cannot get pregnant•
Sterilization for recipients in institutions, or for those who are mentally incompetent•
Hysterectomies, unless medically necessary•
Pregnancy terminations Family Planning Coverage includes:•
Family planning clinics•
Private physicians•
Services•
Supplies•
Family planning, education and counseling•
Medical visits for birth control•
Annual cervical cancer screenings•
Human papillomavirus (HPV) testing for women 18 years of age and older•
Pregnancy tests•
Lab tests•
Tests for sexually transmitted infections (STIs)•
Screening, testing, counseling and referral for treatment for members at risk for HIV•
SterilizationThe following items are not covered:
•
Treatment for members who cannot get pregnant•
Sterilization for recipients in institutions, or for those who are mentally incompetent•
Hysterectomies, unless medically necessary•
Pregnancy terminationsHome Health
60 units per year, prior authorization required.
Provided at the recipients’ place of residence on orders of a physician. Residence does not include:
•
Hospital nursing facility•
Intermediate care facility/mental retardation•
State institutionHome Health
60 units per year, prior authorization required.
Provided at the recipients’ place of residence on orders of a physician. Residence does not include:
•
Hospital nursing facility•
Intermediate care facility/mental retardation•
State institutionHome Health
60 units per year, prior authorization required.
Provided at the recipients’ place of residence on orders of a physician. Residence does not include:
•
Hospital nursing facility•
Intermediate care facility/mental retardationBasic Program Enhanced Program Traditional Program
Hospice
Services include:
•
Nursing care•
Physician services•
Medical social services•
Short-term inpatient care•
Durable medical equipment•
Drugs•
Biologicals•
Home health aide and homemakerMust have physician certification that recipient has a life expectancy of six months or less.
Recipient waives right to other Medicaid services related to the terminal illness.
Hospice
Services include:
•
Nursing care•
Physician services•
Medical social services•
Short-term inpatient care•
Durable medical equipment•
Drugs•
Biologicals•
Home health aide and homemakerMust have physician certification that recipient has a life expectancy of six months or less.
Recipient waives right to other Medicaid services related to the terminal illness.
Hospice
Services include:
•
Nursing care•
Physician services•
Medical social services•
Short-term inpatient care•
Durable medical equipment•
Drugs•
Biologicals•
Home health aide and homemakerMust have physician certification that recipient has a life expectancy of six months or less.
Recipient waives right to other Medicaid services related to the terminal illness.
Inpatient Services
Prior authorization required.
•
Inpatient Hospital Care•
Inpatient Psychiatric Services (Psychiatric residential treatment centers covered directly by the state)•
Inpatient Rehabilitation (up to age 21)Inpatient Services
Prior authorization required.
•
Inpatient Hospital Care•
Inpatient Psychiatric Services (Psychiatric residential treatment centers covered directly by the state)•
Inpatient Rehabilitation (up to age 21)Inpatient Services
Prior authorization required. Unlimited, medically necessary days based on diagnosis-related groups.
•
Inpatient Hospital Care•
Inpatient Psychiatric Services (Psychiatric residential treatment centers covered directly by the state)•
Inpatient Rehabilitation (up to age 21)Limitations
Excludes adults in institutions for mental diseases.
Non-Emergency Medical Transportation
Five trips per year, covered directly by the state’s fee-for-service Medicaid program.
Non-Emergency Medical Transportation
Covered directly by the state’s fee-for-service Medicaid program.
Non-Emergency Medical Transportation
Covered directly by the state’s fee-for-service Medicaid program.
Nursing Home Services
These services are covered directly by the state through their fee-for-service program.
Nursing Home Services
These services are covered directly by the state through their fee-for-service program.
Nursing Home Services
These services are covered directly by the state through their fee-for-service program.
Nutritional Education
With physician’s orders, enrollment in Weight Watchers program.*
Nutritional Education
With physician’s orders, enrollment in Weight Watchers program.*
Nutritional Education
Basic Program Enhanced Program Traditional Program
Outpatient Services
Coverage includes:
•
Diagnostic X-ray, lab services and testing. CTs, MRIs, PET MRAs and SPECTs require prior authorization.•
Occupational, speech and physical therapies, priorauthorization required when in a home setting.
•
Prostate-specific antigen for men if medically necessary (member is symptomatic); ordered by a provider acting within the scope of his license based on American Cancer Society guidelines.Outpatient Services
Coverage includes:
•
Cardiac rehabilitation outpatient services, prior authorization required•
Diagnostic X-ray, lab services and testing. CTs, MRIs, PET MRAs and SPECTs require prior authorization.•
Occupational, speech and physical therapies, prior authorization required.•
Prostate-specific antigen for men if medically necessary (member is symptomatic); ordered by a provider acting within the scope of his license based on American Cancer Society guidelines.•
Pulmonary Rehabilitation, prior authorization required•
Weight managementOutpatient Services
Coverage includes:
•
Cardiac rehabilitation outpatient services, prior authorization required•
Diagnostic X-ray, lab services and testing. CTs, MRIs, PET MRAs and SPECTs require prior authorization.•
Occupational, speech and physical therapies, prior authorization required.•
Prostate-specific antigen for men if medically necessary (member is symptomatic); ordered by a provider acting within the scope of his license based on American Cancer Society guidelines.•
Pulmonary Rehabilitation, prior authorization required•
Health education on weight managementPhysicians, Nurse Practitioners, Midwifes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
•
Primary care office visits•
Physician office visits, specialty care•
Podiatry services, up to age 21, or if PCP cannot perform services: Treatment for acute conditions (infections, inflammations, ulcers, bursitis)
Surgeries for bunions, ingrown toe nails
Reduction of fractures, dislocation and treatment of sprains
Orthotics
Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered.
Physicians, Nurse Practitioners, Midwifes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
•
Primary care office visits•
Physician office visits, specialty care•
Podiatry services: Treatment for acute conditions (infections, inflammations, ulcers, bursitis)
Surgeries for bunions, ingrown toe nails
Reduction of fractures, dislocation and treatment of sprains
Orthotics
Routine foot care treatment for flat foot, nail trimming and subluxations of the foot are not covered.
Physicians, Nurse Practitioners, Midwifes, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
•
Primary care office visits•
Physician office visits, specialty care•
Podiatry services: Treatment for acute conditions (infections, inflammations, ulcers, bursitis)
Surgeries for bunions, ingrown toe nails
Reduction of fractures, dislocation and treatment of sprains
Orthotics
Basic Program Enhanced Program Traditional Program
Prescriptions
Four per month, covered directly by the state’s fee-for-service Medicaid program.
Prescriptions
Covered directly by the state’s fee-for-service Medicaid program.
Prescriptions
Covered directly by the state’s fee-for-service Medicaid program.
Private Duty/Skilled Nursing
Covered up to age 21
Private Duty/Skilled Nursing
Covered up to age 21
Private Duty/Skilled Nursing
Covered up to age 21
Tobacco Cessation
Access to Quit Line.
Tobacco Cessation
Information on smoking and tobacco cessation through UniCare’s Health Education program.
Access to Quit Line.
Tobacco Cessation*
Information on smoking and tobacco cessation through UniCare’s Health Education program.
Access to Quit Line.
Vision Services
Covers medical services only.
Vision Services
Covers medical services only:
•
Refractions•
Eyeglasses•
Preventive eye exams. Vision care excludes prescription sunglasses and designer frames.Vision Services
Covers medical services only:
