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Diamond State Health Plan Benefits Package
Doctor Office Visits and Screenings
Routine and sick office visits
Specialist Office Visits
Well baby and child visits
Early Periodic Screening, Diagnostic and Treatment (EPSDT) services (Members under 21 years of age)
Periodic preventative health screenings
Necessary diagnostic and treatment services
Vaccines
Pediatric or family nurse practitioners’ services
Preventative Services
Mammogram
Colonoscopy
OB/GYN exam and annual Pap tests
Tests and Studies
Laboratory work
X-Rays
Radiology services, including invasive and non-invasive imaging (when medically necessary)
Maternity Care
Prenatal and postpartum care
Delivery
Birthing center admission
Newborn Care
Early discharge home visits for new mothers
Nurse-midwife services
Family Planning
Pharmacy
Care Management and care coordination services
Vision services (members under 21)
Routine eye exams – 1 every 12 months
Eyeglasses/Contacts – covered every 12 months
Vision services (members 21+)
Dental services
Ages 21 & Older
Annual Maximum: $1,000 in dental services per member per calendar year
Potential additional $1,500 per member per calendar year on an emergency basis
Ages 6 months to 5 years
Fluoride varnish one time every 6 month
Ages 20 and under:
Behavioral Health
Behavioral Health and substance disorder services
Covered for adults ages 18 and older
Children 17 & under limited to 30 outpatient visits per calendar year
Inpatient behavioral health in general hospital or psychiatric hospital
Covered for adults ages 18 and older
Services provided by Department of Services for Children, Youth, and Their Families (DSCYF) for members 17 and under
Behavioral services to treat autism spectrum disorder pursuant to EPSDT
Organ and tissue transplants
Chiropractor services when medically necessary
Ambulatory surgery center services
Physical, speech, occupational therapy when medically necessary
Hospice services
Skilled Nursing Facility Services
Limited to 30 days per calendar year
Hospital services
Inpatient services
Outpatient services
Federally Qualified Health Center
Podiatrist Services
Routine foot care only covered when member has diabetes, circulatory or vascular disorders
Lactation counseling services
Crisis intervention for adults
Transportation services
Emergency medical transportation only
Emergency hospital services
Home health services
Orthotic and prosthetic devices as well as other durable medical equipment and assistive technology services
Diamond State Health Plan Plus LTSS Benefits Package
Doctor Office Visits and Screenings
Routine and sick office visits
Specialist Office Visits
Well baby and child visits
Early Periodic Screening, Diagnostic and Treatment (EPSDT) services (Members under 21 years of age)
Periodic preventative health screenings
Necessary diagnostic and treatment services
Vaccines
Pediatric or family nurse practitioners’ services
Preventative Services
Mammogram
Colonoscopy
OB/GYN exam and annual Pap tests
Tests and Studies
Laboratory work
X-Rays
Radiology services, including invasive and non-invasive imaging (when medically necessary)
Maternity Care
Prenatal and postpartum care
Delivery
Birthing center admission
Newborn Care
Early discharge home visits for new mothers
Nurse-midwife services
Family Planning
Pharmacy
Care Management and care coordination services
Vision services (members under 21)
Routine eye exams – 1 every 12 months
Eyeglasses/Contacts – covered every 12 months
Vision services (members 21+)
Dental services
Ages 21 & Older
Annual Maximum: $1,000 in dental services per member per calendar year
Potential additional $1,500 per member per calendar year on an emergency basis
Ages 6 months to 5 years
Fluoride varnish one time every 6 month
Ages 20 and under:
Behavioral Health
Behavioral Health and substance disorder services
Covered for adults ages 18 and older
Children 17 & under limited to 30 outpatient visits per calendar year
Inpatient behavioral health in general hospital or psychiatric hospital
Covered for adults ages 18 and older
Services provided by Department of Services for Children, Youth, and Their Families (DSCYF) for members 17 and under
Behavioral services to treat autism spectrum disorder pursuant to EPSDT
Members under age 18
Limited to 30 units outpatient behavioral health benefits
Organ and tissue transplants
Chiropractor services when medically necessary
Ambulatory surgery center services
Physical, speech, occupational therapy when medically necessary
Hospice services
Skilled Nursing Facility Services
Hospital services
Inpatient services
Outpatient services
Federally Qualified Health Center
Podiatrist Services
Routine foot care only covered when member has diabetes, circulatory or vascular disorders
Lactation counseling services
Crisis intervention for adults
Transportation services
Emergency medical transportation only
Emergency hospital services
Home health services
Orthotic and prosthetic devices as well as other durable medical equipment and assistive technology services
Community-based residential alternatives that include assisted living facilities
Attendant Care Services
Include bathing, dressing, personal hygiene, transferring, toileting, skin care, eating and assisting with mobility
Respite Care
Both at home and in nursing and assisted living facilities
Limited to no more than 14 calendar days per year
Limit may be exceeded with prior authorization
Adult day services
Not available to members residing in assisted living and nursing facilities
Day habilitation
Not available to members residing in assisted living and nursing facilities
Cognitive services
Limited to 20 visits per year plus an assessment
Not available to members residing in assisted living and nursing facilities
Personal emergency response system (PERS) [electronic device that enables a member to secure help in an emergency]
Not available to members residing in assisted living and nursing facilities
Support for Self-Directed HCBS
Self-Directed Attendant Care for Children
Legally responsible family members are limited to providing 40 hours of service per week
Independent activities of daily living (Chore) services
Not available to members residing in assisted living and nursing facilities
Nutritional supports
Prior authorization required
Not available to members residing in assisted living and nursing facilities
