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Benefit Package

As a result of recently enacted legislation, many of the HUSKY B program co-payments will be changing beginning on July 1, 2010. Public Act 10-3 (budget deficit mitigation legislation) requires that cost sharing in the HUSKY B program be the same as cost sharing for state employee health plans. The law does not change the types or amount of services your child may receive. Some co-pays are a set dollar amount (co-pays) and some of the new amounts are a percentage of the charge for the service. (co-insurance). Please see the attached notice for more information and details on these changes.

Current HUSKY Benefit Package (as of July 1)
Benefits that may require prior authorization
Limited Benefits
Exclusions and Limitations

While cost-sharing varies by family income, the total annual cost-sharing for any family may not exceed 5% of total income in a year. Please follow the links below to see specific annual cost-sharing amounts by income and family size.

HUSKY B - Band 1 Annual Cost Share Limit (income is 185% - 235% of the federal poverty level)

HUSKY B - Band 2 Annual Cost Share Limit (income is 235% - 300% of the federal poverty level)

HUSKY consists of two programs; HUSKY A and B. HUSKY A (Medicaid) is for children, parents and other caregivers with incomes under 185% of the federal poverty level. It also covers pregnant women with incomes under 250% of the federal poverty level. HUSKY B is only for children with family incomes over 185% of poverty. There is no income limit for HUSKY B, so any child can qualify.

HUSKY A and B have similar benefit packages; however, HUSKY A has no co-pays or premiums.

Below is the HUSKY B benefit package.

Outpatient Physician Visits	$10 co-pay
Preventive Care Periodicity schedule and reporting based on the American Academy of Pediatrics as amended from time to time.	No co-pay Periodic and well child visits, immunizations, WIC evaluations as applicable, and prenatal care covered in full with $10 co-pay on other visits.
	Age Category Birth to Age 1 Ages 1-5 Ages 6-10 Ages 11-19	Number of Exams 6 exams 6 exams 1 exam every 2 years 1 exam every year
Immunization Schedule Per the Advisory Committee on Immunization Practices as amended from time to time	Age Category Birth	Recommended Immunizations Hepatitis B (Hep B) - 1st dose Hep B - 2nd dose
	1-4 months	Diphtheria, Tetanus, Pertussis (DPT) - 1st dose; Haemophilus
	2 months	Influenza Type B (Hib) - 1st dose; Polio (OPV) - 1st dose
	4 months	DPT - 2nd dose; Hib - 2nd dose; OPV – 2nd dose
	6 months	DPT - 3rd dose; Hib - 3rd dose
	6-12 months	Hep B - 3rd dose; OPV - 3rd dose
	12-15 months	Hib -3rd dose; Measles, Mumps, Rubella (MMR)-1st dose
	12-18 months	Chicken Pox (Var)-single dose; DPT - 4th dose
	4-6 years	DPT - 5th dose; MMR - 2nd dose; OPV - 4th dose
	11-12 years	Tetanus Diphtheria
	11-12 years	Influenza: Every year beginning at 6 months for children who have serious long-term health problems such as heart disease, lung disease, kidney disease, metabolic disease, diabetes, asthma, anemia, and/or are on long term aspirin treatment Pneumococcal: Vaccinate children 2 years and older who are at risk of pneumococcal disease or its complications.
Eye Exam	$15 co-pay
Hearing Exam	$15 co-pay
Nurse Midwives	$10 co-pay (except for preventative services)
Nurse Practitioners	$10 co-pay (except for preventative services)
Podiatrists	$10 co-pay
Chiropractors	$10 co-pay
Naturopaths	$10 co-pay
Preventative Family Planning Services	100%
Inpatient Physician	100%
Emergency Care	100% if determined to be an emergency in accordance with state law.
Family Planning	100%

MCOs may require prior authorization for the following:

Inpatient Hospital	100%
Outpatient Surgical Facility	100%
Ambulance	100% if determined to be an emergency in accordance with state law
Pre-Admission/Continued Stay	Arranged through provider
Short Term Rehabilitation	100% For conditions where significant improvement is expected within 60 days including: physical therapy; speech therapy; occupational therapy; and skilled nursing care (excludes private duty nursing)
Home Health Care	100% Includes disposable medical supplies for homebound members Excludes custodial care, homemaker care or care that may be provided in a medical office, hospital or skilled nursing facility and offered to the member is such setting.
Hospice	100% Provided to members who are diagnosed as having a terminal illness with a life expectancy of six months or less. Covered care includes: nursing care; physical therapy, speech therapy, and occupational therapy; medical social services; home health aides and homemakers; medical supplies; drugs; appliances; DME; physician services; short-term inpatient care, including respite care and care for pain control and acute and chronic symptom management; services of volunteers and other benefits when ordered by a physician. Limitations on short-term therapies do not apply.
Lab and X-Ray	100%
Pre-Admission Testing	100%
Durable Medical Equipment (DME)	DME means equipment that is furnished by a supplier or home health agency that: 1. can withstand repeated use; 2. is primarily and customarily used to serve a medical purpose; 3. is generally not useful to an individual in the absence of an illness or injury; and 4. is appropriate for use in the home 100 % covered except DME does not include: • Power wheelchairs for members who are eligible for HUSKY Plus Physical; • Devices not medical in natures such as: • whirlpools, • saunas, • elevators, • vans, • van lifts, • home convenience items (e.g., air cleaners, filtration units and related apparatus, exercise bicycles and other types of exercise equipment), • insulin injectors, • non-rigid appliances and supplies, such as, sheets, self-help devices, experimental or investigational research equipment, and • items for personal comfort and or usefulness to the member’s household. Supplemental coverage available under HUSKY Plus Physical for medically eligible children.
Hearing Aids	Hearing aids for children twelve years of age or younger, limited to $1,000.00 within a 24-month period. Supplemental coverage available under HUSKY Plus Physical for medically eligible children.
Prosthetics	100% for devices whether worn anatomically or surgically implanted, which replace all or part of a body organ or structure and which correct, strengthen or provide necessary support to the body will be covered when medically necessary. Excludes: orthopedic shoes, foot orthotics, wigs or hairpieces. Supplemental coverage available under HUSKY Plus Physical for medically eligible children.
Dental	100% Dental services include: Exams, 1 every 6 months; X-rays, Fluoride Treatments

Limited Benefits

Eye Care	Eyeglass frames and lenses or contact lenses Once every two consecutive eligibility periods with an allowance of $100 toward the purchase of these goods. The optical hardware must be provided without charge under the following conditions: · One pair of contact lenses every two consecutive eligibility periods when such lenses are determined to be the primary and the best method for aiding the member vision and the lenses are not needed solely for the correction of vision; · Eyeglass frames and lenses and contact lenses that are determined to be medically necessary after eye surgery, the initial pair only; and · Contact lenses, as needed, for the treatment of Keratonconus.
Dental	Amalgam and composite restorations (fillings) - 20% of charge Crowns, inlays and onlays/prosthodontics - 33% of charge Bridges - 50% of charge Recetement bridges, crowns inlays and space maintainers - 20% of charge Full or partial denture - 50% of charge Repaid, relining and rebasing dentures - 20% Root canal treatment/endodontic surgery - 20% of charge Miscellaneous surgical procedure - 20% of charge Surgical extraction, including wisdom tooth - 33% of charge Periodontal Surgery - 50% of charge Simple extraction - 20% of charge Space maintainers - 33% of charge General anesthesia - 20% of charge Miscellaneous - 20% of charge Orthodontic treatment - Allowance of $725 per case, no co-pay
Nutritional Formulas	100% limited to medically necessary amino acid modified preparations and low protein modified food products for the treatment of inherited metabolic diseases when ordered by a participating physician
Contraceptives	Intrauterine Devices (IUD) and insertion of the IUD - $50 allowance per member; internally implantable time-release devices and their insertion - $50 allowance per member; and time-released contraceptive injections - $15 allowance per member per injection
Oral Contraceptives	$5 co-pay on generics $10 co-pay on brand-name formularies (included in prescription drugs)
Prescription Drug	$5 co-pay on generics $10 co-pay on brand-name formularies
Short and Long Term Rehabilitation	Covered services include home and community based rehabilitation services.
Home Health Care	100% Includes Medication administration Excludes: Custodial care, homemaker care or care that may be provided in a medical office, hospital or skilled nursing facility and offered to the member is such setting.

Exclusions and Limitations:

1. Services and/or procedures considered to be of an unproven, experimental, or research nature or cosmetic, social, habilitative, vocational, recreational, or educational.

2. Services in excess of those deemed medically necessary to treat the patient’s condition.

3. Services for a condition that is not medical in nature.

4. Devices required by third parties, such as school or employment physicals, physicals for summer camp, enrollment in health, athletic, or similar clubs, premarital blood work or physicals, or physicals required by insurance companies or court ordered alcohol or drug abuse course.

5. Cosmetic and reconstructive surgery is excluded, except when surgery is required for:
a) reconstructive surgery in connection with the treatment of malignant tumors or other destructive pathology that causes dysfunction;
b) reduction mammoplasty in females when medically necessary and breast surgery in males only in cases of suspected malignancy. Surgery must be necessary to achieve normal physical or bodily function.

6. Routine foot care rendered:
a) in the examination, treatment or removal of all or part of corns, callosities, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the foot.
b) in the cutting, trimming or other non-operative partial removal of toenails, except when medically necessary in the treatment of neuro-circulatory conditions.

7. Evaluation, treatment and procedures related to, and performance of, sex-change operations.

8. Surgical treatment or hospitalization for the treatment of morbid obesity except where prior authorized medically necessary.

9. Care, treatment, procedures, services or supplies that are primarily for dietary control including, but not limited to, any exercise weight reduction programs, whether formal or informal, and whether or not recommended by an in-network physician or out-of-network physician.

10. Acupuncture, biofeedback, or hypnosis.

11. Treatment at pain clinics unless determined to be medically necessary.

12. Ambulatory blood pressure monitoring.

13. Any court order for testing, diagnosis, care, or treatment deemed not medically necessary.

Content Last Modified on 6/14/2010 10:41:09 AM