How to Use Your Benefits
What Is Covered
CoventryCares covers all medically necessary services that Medicaid covers.
Medically necessary means that the treatment will do 1 of these 3 things:
- It will stop you from getting sick or disabled.
- If you get sick, hurt or disabled, it will help make your condition better or it will stop it.
- It will help you do daily activities. We compare how well you are able to do these activities with how well other people your age are able to do them.
A service or benefit is medically necessary if it is covered under Medicaid and meets one of the following standards:
- The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.
- The service or benefit will, or is reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.
- The service or benefit will assist the member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the member and those functional capacities that are appropriate for the Members of the same age.
Below are some services CoventryCares covers. Unless you have copay, and your benefit plan covers these services, you do not have to pay for them. Be sure to show your CoventryCares ID card and your ACCESS ID card to get these services. Please call Member Services if you have any questions.
Some benefits have limits or copays.
The benefits with limits are marked with a star *. Check the Copay Sheet that came with this handbook. It will tell you if your benefits have limits or copays.
- PCP office visits – routine, urgent and emergency care.
- Medical care during pregnancy.
- Hospital services when you are not a patient overnight.*
- Overnight hospital stays including a semi-private room, medical services, surgery, anesthesia, and drugs.*
- Basic vision care and eyeglasses or contact lenses.*
- Basic hearing care.*
- Basic dental care.*
- Family planning (birth control).
- Chiropractic care.*
- X-rays and lab tests.*
- Immunizations (shots).*
- Prescription drugs.*
- Home health services – such as home health aides.*
- Durable medical equipment (DME) and supplies – such as wheelchairs or crutches.*
- Hospice care (end of life care).
- Disease screenings and treatment for things like tuberculosis, HIV, AIDS, HPV, and diseases passed on by having sex.
- Ambulance transportation for emergencies and when medically necessary.
- Specialty care.*
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT) – health checkups, screening, and immunizations for children up to age 21.
- Rehabilitation care like physical, occupation and speech therapy.*
- Short-term care in a nursing home.*
What Is Not Covered (Exclusions)
CoventryCares does not cover some services. They are:
- Care for mental health and drug or alcohol abuse problems. (These are covered by the county or your behavioral health plan.)
- Hearing aids for anyone 21 and older.
- For most members 21 and older, fixing crooked teeth and teeth not in the right place (orthodontia)
- Services, medicines, and equipment that are not medically necessary.
- Cosmetic surgeries and medicines.
- Long-term care in a nursing home.
- Experimental procedures or drug treatments.
- Hysterectomy (surgery to remove the female organs), if preformed for hygiene only or so that you cannot have a baby.
- Treatments to help you get pregnant or to find out why you cannot have a baby (infertility treatment).
- Surgery of the mouth that is cosmetic.
- Paternity testing (test to determine the father of a baby).
- Personal care items such as hairbrushes, shampoo, toothpaste, feminine hygiene products.
- Personal items or services while you are in the hospital, such as television and telephone.
- Changes to your home – such as a chair lift.
- Reversing (changing back) surgeries like having your tubes tied or vasectomy.
- Surgery to make mentally ill patients or persons in a hospital unable to have a baby.
- Services not covered by Medicaid.
- Prescription drugs for members 21 and older who are not eligible for Medical Assistance drug benefits.
- EPSDT, private duty nursing, hearing aids, and immunizations other than flu shots for members 21 and older.
- Clinical trials.
Most Limits Do Not Apply to Members under Age 21
There may be other services CoventryCares does not cover. Check the copay sheet that came with your Member Handbook. You may have to pay for services that CoventryCares does not cover. You also may have to pay for services if you do not use a network provider. Call Member Services:
- If you are not sure if CoventryCares covers a service.
- If you need a list of network providers.
CoventryCares must approve requests for services that we do not cover and Medicaid does not cover. Your provider should call us for approval. This does not include family planning and emergencies.
You may get some services without seeing your PCP first. These services are called self-referral services. These services are called self-referral services. You should make sure you get these services from CoventryCares participating providers. Call Member Services to find a participating provider.
Here is a list of services you may get without seeing your PCP:
- Chiropractic care.
- Cancer treatment (radiation and chemotherapy)
- Dental care.
- Diabetes eye test and diabetes education.
- EPSDT, if covered in your plan.
- Family planning (birth control). You can see any provider, even one not in the network.
- Maternity care.
- Childbirth classes.
- Immunizations (shots).
- Routine women’s care (GYN – gynecology).
- Breast cancer screening (mammogram).
- Pap smears (cervical cancer screening).
- Basic vision care.
- Sexually transmitted diseases (STDs).
- Stop-smoking classes.
- Treatment when your kidneys do not work (dialysis), if covered in your plan.
- Emergency services and emergency ambulance transportation.
- Speciality care. Make sure you have a specialist who is signed up with CoventryCares. If you do not, you may have to pay for the service. It is a good idea to call and check with Member Services to make sure the specialist is in our network.
You have the right to get a second opinion about your medical care. If you want one, tell your primary care provider (PCP). He or she will send you to another CoventryCares specialist. CoventryCares covers the cost of the visit. Always check with your PCP before going to another specialist for a second opinion.
Sometimes Specialists Can Be Primary Care Providers (PCPs)
Members with special needs can request that a specialist be PCP. To do this, the specialist must agree to serve as your PCP. CoventryCares must approve this request. Call Member Services to make this request.
Continued Care with a Non-Network Specialist
If a specialist leaves our network while he or she is taking care of you, you have the right to see him or her for some time. This way your care can continue without a break. Call Member Services. They will help you.
Services That Need Prior Authorization
CoventryCares must okay some services before you can get them. This is called prior authorization. Your PCP or specialist will do this for you.
If CoventryCares does not approve your provider’s prior authorization request, we will tell you. We will also tell you how to follow the grievance process and about your right to a fair hearing.
CoventryCares must approve the following services if they are covered under your benefit plan before you can get them:
- Services from providers not in the CoventryCares network. This does not include family planning, obstetrical care and emergency care, services or rental durable medical equipment (DME).
- Ambuance transportation when it is not an emergency.
- Staying in a hospital, nursing home, skilled nursing home or rehabilitation hospital when it is not an emergency.
- Surgeries in a hospital or surgery center. Some surgeries in a doctor’s office.
- Rehabilitation services. Examples are heart (cardiac) and lung (pulmonary) therapy, outpatient and home care physical, occupational and speech therapy.
- Home health services like IV drug therapy, skilled nursing visits and home health aide visits, medical social worker and dietician visits.
- Buying DME, like wheelchairs.
- Corrective appliances and prosthetics, like artificial limbs and orthopedic shoes.
- Any service or product not covered by Medical Assistance.
- Some outpatient tests and procedures, like MRI, MRA, MRS, CT/ and CAT, PET, CTA, SPECT and bone density scans, infusions, plasmapheresis and hyperbaric oxygen therapy.
- Radiation therapy, chemotherapy, pain management and hospice (end of life) services.
- Some prescription drugs, injectables and specialty drugs, some over-the-counter (nonprescription) drugs, and some DME supplies like diapers, ostomy supplies and tube feeding and nutritional supplements.
- All organ transplant tests and appointments.
- Genetic testing.
- Experimental treatments and investigational procedures, services and drugs.
- Specialty dental services, including anesthesia and surgical procedures.
- Chiropractic care after the first visit.