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Medical benefits

Services covered by First Choice and what to do:

  • Acute inpatient psychiatric services are free-standing psychiatric facilities that provide mental and behavioral health services. The current inpatient admission copay of $25 would apply for members over the age of 18 who are not part of a federally recognized Indian tribe and/or pregnant. (Effective July 1, 2019.)
    Have your First Choice network provider call First Choice for prior authorization.
  • Adult well visits are routine medical checkups to help make sure you are in good health.
    Make an appointment with your PCP.
  • Ambulance transportation is covered when medically necessary for your condition, and use of another method of transportation is not appropriate.
    Call 911 if there is an emergency.
  • Audiological services include testing, screening, preventive and/or corrective services for hearing disorders or determining if you have a hearing disorder. Services are free for members younger than age 21. Newborn hearing screenings are also covered by First Choice.
    Get a referral from your PCP or other Licensed Health Care Professional of the Healing Arts (LPHA) 
  • Autism Spectrum Disorder (ASD) services give mental health treatment to people with ASD. The member must be shown to have ASD before services can be received. A diagnosis must come from a complete psychological review. Services are available to members under 21 years of age. 
    Get a referral from your PCP or have your provider call First Choice for prior authorization.
  • BabyNet services are for children from birth up to 3 years who have developmental delays or conditions associated with developmental delays. They are provided in an outpatient setting. (Effective July 1, 2019.)
    Contact your First Choice provider for more details, including eligibility requirements.
  • Chiropractic care services are limited to 6 visits each year.
    Make an appointment with a First Choice chiropractor.
  • Communicable disease services help control and prevent diseases such as tuberculosis, sexually transmitted diseases and HIV/AIDS. Services include exams, assessments, diagnostic procedures, health education/counseling, treatment and contact tracing.
    Get care from any public health agency or make an appointment with your PCP.
  • Durable medical equipment includes medical products, surgical supplies and equipment when ordered by a physician as medically necessary.
    Call your PCP.
  • Family planning services include family planning exams, counseling services to help prevent or plan timing of pregnancy, birth control, family planning-related lab services and surgeries to prevent pregnancy.
    No referral or co-pay is required. Does not require prior approval, but some services may require forms for your doctor to complete and send to First Choice. Members are encouraged to use First Choice network providers, but you may see any provider who accepts Healthy Connections. You are free to choose the method of family planning you use without coercion or mental pressure.
  • Gastric bypass surgery is a surgery that helps you lose weight. The surgery changes how your stomach and small intestine handle the food you eat. To make sure First Choice members get the best results, we will only approve weight loss surgery at hospitals with Preferred Bariatric Surgery Center status. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) must approve these hospitals. Approved hospitals are listed on the American College of Surgeons website at www.facs.org. If you are thinking about having weight loss surgery, check the website to make sure the hospital you are using is approved.
    Have your First Choice network provider call First Choice for prior authorization.
  • Home health care are health care services at your home, including intermittent skilled nursing, home health aide, physical, occupational and speech therapy. Adult members age 21 years and older are limited to 50 visits per year. This does not include nursing homes and institutions.
    Get a referral from your PCP.
  • Hysterectomies, sterilizations and abortions are covered under certain circumstances. Hysterectomies are covered when they are non-elective and medically necessary. Hysterectomies are not covered if performed solely for rendering the member incapable of reproducing. Sterilizations are limited to members at least 21 years old, mentally competent and have voluntarily given consent. Abortions are covered if the pregnancy is a result of rape or incest, or if the member suffers from a physical disorder, injury or illness (including a life-endangering condition caused by or from the pregnancy) and this places the member in danger of death unless an abortion was performed.
    Call your PCP or First Choice for more details.
  • Immunizations are covered for adult members 19 years of age and older. Covered services include the vaccine and administration of the vaccine. Adult vaccinations include serogroup B meningococcal (MenB); measles, mumps, and rubella (MMR); varicella (VAR); and measles, mumps, rubella, and varicella (MMRV). Coverage for members under 19 years of age is provided through the Vaccine for Children (VFC) program.
    Call your PCP.
  • Inpatient services are items and medical and behavioral services provided under the direction of a doctor if you are admitted to a hospital when the stay is expected to last more than 24 hours. This includes room and board, miscellaneous hospital services, medical supplies and equipment.
    Get a referral from your PCP.
  • Lab and X-rays are services ordered by a doctor and provided by independent labs and X-ray facilities.
    Call your PCP.
  • Life-threatening emergencies are identified when medical care is needed right away because of a danger to your life, limb(s) or sight if not treated right away.
    Call 911 or go to the nearest emergency room.
  • Long-term care covers the first 90 calendar days of continuous confinement in a long-term care facility/nursing home. Additional days may be covered by the plan until your disenrollment or a maximum of 120 calendar days. After this time, payment for services are made by the Medicaid fee-for-service program. Includes skilled nursing care or rehabilitative services.
    Get a referral from your PCP.
  • Maternity services include prenatal (pre-birth), delivery, postpartum (after birth) services and nursery charges for a normal pregnancy or complications related to the pregnancy. Females between the ages of 12 and 55 years of age are eligible for CenteringPregnancy group prenatal care. CenteringPregnancy prenatal care is provided in a group setting, giving members more time with their provider up to 10 group visits before delivery.
    Call First Choice for a list of providers and more details.
  • Medicines and pharmacies (prescriptions and over-the-counter) Some medicines need prior approval. Members may get an emergency supply of medicine that will cover them for 72 hours while a prior authorization request is pending. A member is permitted one temporary supply per prescription number. Inhalers, diabetic test strip and supplies, and creams or lotions are exceptions to the supply limit because of how they are packaged. For those medicines, the member may receive the smallest package size available. Generic medicine and supplies will be provided when available. Members may get a supply of certain medicines, that lasts 90 calendar days, to treat asthma, hypertension, diabetes, and high cholesterol. Call Member Services for complete information about covered medicines, the appeal process or a complete list of participating pharmacies.
    Get a prescription (including over-the-counter). Take it to a First Choice participating pharmacy. Present your First Choice and Healthy Connections ID cards. Call Member Services for a complete list of participating pharmacies.
  • Mental health, emotional health, and drug and alcohol services including those received through the Department of Alcohol and Other Drug Abuse Services (DAODAS) may need prior authorization. Your provider must call First Choice for prior authorization, when required, before rendering services.
    Get a referral from your PCP or have your provider call First Choice for prior authorization.
  • Obesity-management treatment is available for eligible adults over 21 years of age. Services include an initial screening, five additional face-to-face behavioral counseling visits, an initial dietitian visit for nutritional counseling and five follow up visits. Treatment for members up to age 21 is covered under the Well Child or Early Periodic Screening and Testing (EPSDT) benefit.
    Contact your PCP or First Choice for more detail including eligibility requirements.
  • Occupational, speech and physical therapy may require authorization in any setting.Your provider must call First Choice to see if authorization is required. Private rehabilitative therapy is covered only for members under 21 years of age and limited to 105 combined hours of service per fiscal year (July 1 to June 30th). Therapy provided in a hospital-affiliated outpatient setting is covered for all members if medical necessity and required criteria are met, authorization is obtained when necessary, and is limited to 105 combined hours per fiscal year.
    Get a referral from your PCP.
  • Opioid treatment programs (OTPs) are for members with opioid use disorder who need medication-assisted treatment. Services include an assessment, counseling, and medications. They are provided in an outpatient setting. Medical necessity must be confirmed at the time of admission by either a physician or an advanced practice registered nurse (APRN) who is employed or contracted by the OTP. Members should use providers who are in the First Choice network. (Effective July 1, 2019.)
    For more information, or if you need help finding a First Choice network OTP, please call Member Services at 1-888-276-2020.
  • Outpatient Pediatric AIDS Clinic services (OPAC) include specialty care, consultation and counseling services for Human Immunodeficiency Virus (HIV)-infected Medicaid-eligible children and their families. Care may be provided by OPAC or a First Choice network provider.
    Call your PCP or First Choice for more details.
  • Outpatient services are preventive diagnostic, therapeutic, rehabilitative, surgical and emergency services received for the treatment of a disease or injury at an outpatient/ambulatory care facility for a period of time under 24 hours.
    Get a referral from your PCP.
  • Primary care visits include visits to the personal doctor you chose from the First Choice Health Care Professional and Provider Directory.
    Make an appointment with your PCP.
  • Psychiatric assessment services are limited to a maximum of 1 assessment per member every 6 months.
    Contact your PCP or any provider who accepts Healthy Connections.
  • Psychiatric Residential Treatment Facility (PRTF) services are for people who need mental health care. They are provided in an inpatient facility. They are not provided in a hospital. Services include 24-hour supervision and specialized interventions. PRTF services are only for members under age 21. If a member is in the PRTF when he or she turns 21, services may continue until the member no longer needs them or when the member reaches age 22, whichever comes first. 
    Have your First Choice Network Provider call First Choice for prior authorization.
  • Rehabilitative behavioral health services are provided to reduce the effects of mental disabilities and improve the ability to function. For more information or if you need help from a First Choice Care Manager, please call Member Services at 1-888-276-2020.
    If prior authorization is needed, your First Choice Network Provider will handle the process for you.
  • Specialist visits are visits to a doctor who practices a certain area of medicine.
    You don't need a referral from your PCP. Make an appointment with the specialist.
  • Transplant services must have approval before being performed. Depending on the service and transplant, coverage may be provided by First Choice or Healthy Connections. First Choice benefits cover all services for corneal transplants. First Choice only covers the services before and after a kidney transplant and other transplants.
    Get a referral from your PCP or call your First Choice case manager.
  • Vision care for children under 21 includes 1 comprehensive eye exam each year, eye glass lenses, frames and fitting. Also covers a second pair of replacement eyeglasses with no co-pay if the first pair is lost or damaged. Medical vision exams are covered for members 21 years of age and older with certain medical conditions such as diabetes.
    Providers NOT in the First Choice network require prior authorization. Vision care for children under 21 years of age does not require prior authorization when using a First Choice provider. Services for members 21 years and older requires prior authorization. Call Member Services for a list of First Choice providers and additional information about covered benefits and prior authorization requirements.
  • Well-child visits (EPSDT visits) are regular medical checkups from birth through the month of the 21st birthday; visits may include immunizations (shots). See page 18 of your member handbook for recommended schedule of visits.
    Make an appointment with your PCP. 
  • Well-woman visits are regular medical checkups for women. They include a pelvic exam, breast exam, yearly sexually transmitted infections (STI) screening and, as recommended, a Pap test. It is also a chance to talk with your doctor about your health and reproductive health care needs.
    Make an appointment with your PCP or a First Choice gynecologist.

Please contact Member Services at 1-888-276-2020 for a complete list of services provided by either First Choice or Healthy Connections. Services not covered by First Choice or Healthy Connections are non-covered services. For additional information about non-covered services, please call Member Services.