| Ambulance services |
An OK from us is not needed for emergency ambulance transport |
- A licensed ambulance company
- An emergency
|
| Audiology services |
No |
The Texas Health Steps program gives audiology services and hearing aids for ages 0 through 20 |
| Chiropractic services |
You do not need an OK from us to see a chiropractor in your network |
Covers services that help keep the spine and other body structures straight |
| Yes |
For those members who qualify for these services. The state provides an array of services to members who would otherwise qualify for care in a nursing facility, an ICF/IDD, or an institution for mental diseases (IMD).
- Personal Care Services - CFC - All qualified members may receive medically and functionally necessary Personal Assistance Services under CFC.
- Acquisition, maintenance and enhancement of skills - All qualified members may receive this service to enable the member to accomplish ADLs, IADLs and health-related tasks.
- Emergency Response Services - CFC - (Emergency call button) - All qualified members may receive necessary emergency response services under CFC.
- Support Management - All qualified members may receive voluntary training on how to select, manage and dismiss attendants.
|
| Diagnostic and therapeutic radiology |
Some radiology services need an OK from us before you get the service. These include CT, MRI, MRA, PET and SPECT |
Testing and X-rays that are:
- not invasive
- done to find out what is wrong
- ordered and done by (or under the guidance of) your provider
|
| Doctor services |
No |
- Visits to doctors, specialists or other providers
- Well exams
|
| Durable Medical Equipment(DME) and disposable supplies |
Yes |
- Medical equipment given for use in the home
- Medically necessary
- Within the limits of what is covered by Medicaid
|
| Emergency services |
No |
- Emergency room
- Ambulance services
|
| Family planning |
No |
- Medical visits for birth control
- Marriage and family planning, education and counseling services
- Birth control medications, including long acting reproductive contraception (LARC)
|
| Home health services |
Yes |
- Nursing services
- Personal care services
|
| Inpatient hospital services |
Yes |
- Hospital room with two or more beds
- Nursing care
- Operating room
- Surgery
- Anesthesia
|
| Lab services |
Yes |
All authorized lab services |
| Medically Dependent Children Program (MDCP) STAR Kids |
Yes |
The following is a list of covered services for members who qualify for MDCP STAR Kids services. BCBSTX must provide medically and functionally necessary services to members who meet the functional and financial eligibility for MDCPSTAR Kids.
- Respite Care;
- Supported Employment;
- Financial Management Services;
- Adaptive Aids;
- Employment Assistance;
- Flexible Family Support Services;
- Minor home modifications; and
- Transition Assistance Services.
|
| OB/GYN services |
No |
- Care that has to do with pregnancy
- Care for any female medical condition
- One well-woman checkup per year
|
| Orthotics and prosthetics |
Sometimes needs an OK from us |
Parts needed such as man-made arms or legs and the parts needed to attach them
- Orthotic braces, splints or ankle and foot supports
- Covered when medically necessary
|
| Outpatient hospital services |
Yes |
- Dialysis
- Giving you someone else’s blood
|
| Physical, Occupational and Speech Therapy |
Sometimes needs an OK from us |
These services are covered when ordered by a doctor and are part of a written plan of care |
| Podiatry |
No |
Covered services include:
- Medical problems of the feet
- Medical or surgical treatment of disease, injury or defects of the foot
|
| Pregnancy and maternity care |
No |
- Pregnancy
- After-delivery care when medically necessary
- Newborn exams
|
| Prescription Drugs |
Some drugs including brand name drugs need an OK from BCBSTX |
- BCBSTX uses Medicaid/CHIP Vendor Drug Program's (VDP) preferred drug list
- Most generic and over-the-counter drugs are covered
|
| Therapies |
Sometimes needs an OK from us |
- Developmental assessments
- Physical, occupational or speech therapy
|
| Texas Health Steps Medical Checkups |
No |
- Routine shots
- Lab tests
- Comprehensive Care Program services for members 20 years and under
- DME
- Home health and other medically necessary services
|
| Transplant |
Yes |
- Human organ and tissue transplants that are not still being tested
- All corneal, bone marrow and peripheral stem cell transplants that are not still being tested
|
| Vision Services |
No |
An eye exam every 12 months |
