 |
|
|
Basic Health Frequently Asked Questions
|
Is there a co-payment for a Well / Routine care?
What services require a co-payment?
Is there a co-payment for allergy shots?
Is there co-insurance or a deductible?
Is Speech Therapy covered?
Is Physical Therapy, Occupational Therapy, or Chiropractic Care
covered?
Is DME covered?
Is Alternative care a covered benefit?
Is a referral required for a Diabetes consultation?
What services require prior authorization?
May a Basic Health member self-refer to a specialist?
Must the member’s PCP submit ongoing referrals or referrals for ancillary services to CUP? Or, may the Specialist submit the referral request?
Are the limited Prior Authorization requirements for Basic
Health Subsidized members the same for CUP members who are assigned to The Vancouver
Clinic?
Do all children on Basic Health qualify for the Basic Health
Plus Program?
Are Maternity Services a covered benefit under Basic Health?
Is there a co-payment for a Well / Routine care? [Back to Top]
No. There is no co-payment for preventive care. Preventive care includes routine
physicals, immunizations, PAP tests, mammograms, and other screening and testing
when provided as part of the preventive care visit.
What services require a co-payment? [Back to Top]
There is a $15 co-payment for an Urgent Care or office visit (excluding preventive
care, laboratory, radiology services, radiation, and chemotherapy for which there
is $0 co-payment). There is a $100 co-payment for an Emergency Room visit. Pharmacy
co-payments include a $10 co-payment for Tier 1 (generic formulary drug) and 50%
of the drug cost for Tier 2 (brand name formulary drug).
Is there a co-payment for allergy shots? [Back to Top]
The Health Care Authority has clarified
there is a $15 co-payment for each visit for allergy shots.
Is there co-insurance or a deductible? [Back to Top]
Yes. The patient is responsible for a 20% co-insurance for many benefits, including
hospital outpatient and inpatient stays, inpatient mental health and chemical dependency,
radiology (except for outpatient x-ray and ultrasound), chiropractic/physical therapy
services, and other professional services. Once the patient has met the $150 deductible,
all co-insurance payments will be applied toward the $1,500 annual out-of-pocket
maximum. Deductibles and out-of pocket maximums are per person, per year.
Is Speech Therapy covered? [Back to Top]
No.
Is Physical Therapy, Occupational Therapy, or Chiropractic Care covered? [Back to Top]
Physical Therapy, Occupational Therapy, or Chiropractic Care are covered up to a
combined maximum of 12 visits per year. (Of those, no more than six can be for chiropractic care.) Visits qualify only when used as post-operative treatment following reconstructive
joint surgery. Visits must be within one year of surgery.
Is DME covered? [Back to Top]
Medical equipment and supplies not specifically listed in this “Schedule
of Benefits” except while the member is hospitalized (including, but not limited
to, hospital beds, wheelchairs, and walk aids).
Is Alternative care a covered benefit? [Back to Top]
No.
Is a referral required for a Diabetes consultation? [Back to Top]
A referral is not required for a Diabetes consult with an in-network Endocrinologist.
Members diagnosed with Diabetes may also self-refer for Diabetic/Education consultations
at the SWMC Diabetes program. However, other types of
consultations are not covered, such as nutritional counseling.
What services require prior authorization? [Back to Top]
Please login to our website
for more information about services that require a prior authorization.
May a Basic Health member self-refer to a specialist? [Back to Top]
Yes, members may self-refer to an in-network specialist for consultations. But
treatment following a consultation does require prior authorization.
Must the member’s PCP submit ongoing referrals or referrals for ancillary services
to CUP? Or, may the Specialist submit the referral request? [Back to Top]
Basic Health members may self-refer for consultations with Specialists. However,
ongoing care after the consult must be authorized by the member’s PCP and by CUP.
Are the limited Prior Authorization requirements for Basic Health Subsidized
members the same for CUP members who are assigned to The Vancouver Clinic? [Back to Top]
No, CUP has fewer prior authorization requirements for the Basic Health Subsidized
membership. The Vancouver Clinic still requires prior authorization for most services
for Healthy Options and Basic Health members assigned to their group.
Do all children on Basic Health qualify for the Basic Health Plus Program? [Back to Top]
No. Basic Health Plus is a Medicaid program for children under 19 in low-income
households who are Basic Health members and meet the eligibility guidelines for
Medicaid. The Dept. of Social and Health Services (DSHS) determines eligibility
for Basic Health Plus. The Plus program covers the same benefits as Healthy Options.
Are Maternity Services a covered benefit under Basic Health? [Back to Top]
Yes, but maternity care is limited to 30 days following diagnosis. Pregnant members
must apply for the Maternity Benefits Program for additional maternity benefits.
The Maternity Benefits Program is a Medicaid program for pregnant women who are
Basic Health members and meet the eligibility guidelines for Medicaid. Members should
contact Basic Health at (800) 660-9840 for an application. DSHS determines eligibility.
|