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Provider Manual

Coverage Specifics for Certain Services

Last Updated on August 28, 2018

Chiropractic Service Coverage

Chiropractic service means the covered health services provided by the Security Health Plan Medicare Advantage contracted chiropractors. Coverage is provided for medically necessary office visits, X-rays and manual manipulations of the spine to correct subluxation. It must be provided by a Security Health Plan Medicare Advantage contracted chiropractor. The services performed must be within the scope of the chiropractic license.

Security Health Plan will reimburse Medicare Advantage network providers at the Medicare allowable fee schedule for Medicare covered chiropractic services following a copayment by the member per manipulation. Claims will be adjudicated at the Medicare allowable rate in effect at the time of claim adjudication.

  • Security Health Plan contracts with Allied Health of Wisconsin, Inc. to manage its chiropractic network. Contracted chiropractors are listed in the Medicare Advantage Provider Directory.

Hearing Coverage

A hearing examination for purposes of the Medicare Advantage plan is defined as an examination to determine whether a hearing problem exists. Hearing examinations and hearing tests to determine whether a hearing problem exists are a covered benefit. The service should be coordinated with the member’s personal provider and be provided by a Security Health Plan ENT specialist (otolaryngologist) or audiologist. Diagnostic hearing exams are covered at 100 percent after the office visit copayment. Hearing aids and evaluation of the hearing aids are not a covered benefit.

Vision Coverage

A vision examination for purposes of the Medicare Advantage plan is defined as an examination to determine whether a vision problem exists. A vision examination to determine whether a vision problem exists is a covered benefit. This service should be coordinated with the member’s personal physician and be provided by a Security Health Plan ophthalmologist or optometrist. Refractions are also a covered benefit.

An annual routine vision exam is covered at 100 percent after the office visit copayment.

Preventive Care Coverage

Preventive care coverage includes, but is not limited to, one annual routine physical examination and vision examination, diagnostic hearing exams, mammogram, pap smear, pelvic exam, bone mass measurement test (for individuals at risk), colorectal screening exam, and prostate cancer screening exam. Diabetes self-management services and immunizations also are covered under the preventive care benefit (excluding insulin). Other services may or may not be considered preventive care under the Medicare Advantage plan; please call with any questions about coverage for specific services. Services are covered after the copayment per office visit.

Mental Health/Chemical Dependency Coverage

Outpatient mental health and chemical dependency services are a covered benefit. Outpatient mental health care is defined as outpatient visits or partial hospitalization sessions. Chemical dependency coverage is defined as diagnosis and medical treatment for the abuse of, or addiction to, alcohol and/or other drugs. Diagnostic services, including psychiatric, psychological, and medical laboratory testing are a covered benefit. Therapeutic services that are medically necessary for the treatment of the illness or addiction include services provided by psychiatrists, psychologists, clinical social workers, clinical nurse specialists and other health care professionals who meet Medicare criteria for coverage; and individual rehabilitative therapy and counseling. Family counseling and intervention may be covered only where the primary purpose of such counseling is the treatment of the patient’s condition. Services are covered when determined to be reasonable and medically necessary. Services are covered after the copayment per office visit. Contact Security Health Plan for verification of member benefits.

Inpatient mental health services are a covered benefit when determined to be medically necessary. There is a lifetime coverage limit of 190 days when an individual is hospitalized in a Medicare designated psychiatric hospital. This limit does not apply to care received on a psychiatric unit of a general hospital.

Skilled Nursing Facility

Part A: Skilled care in a skilled nursing facility (SNF) is covered at 100 percent of the Medicare approved charge (a copay may apply for certain services) for the first 100 days per incident of illness of skilled care. There is no coverage after the 100 days.

  • SNF care must occur at a Medicare certified Security Health Plan affiliated facility.
  • Admissions will be reviewed based on Medicare’s criteria for skilled care.
  • Skilled nursing facilities must notify Security Health Plan of an admission within 24 hours or the
    next business day of admissions.

Part B: Services in a SNF are covered consistent with the Medicare-approved charges. The services must be medically necessary. The SNF is requested to notify Security Health Plan of any admissions.

For purposes of the Medicare Advantage plan, skilled care services are defined as skilled nursing or skilled rehabilitation services provided according to a physician’s order and:

  • require the skills of qualified technical and professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists, or audiologists; and
  • must be provided by or under the supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

Physician professional services for the evaluation and management of a member admitted to the SNF are reimbursable separately to physicians.

Comprehensive Medication Review (CMR): For purposes of the Medicare Advantage plan, Security Health Plan must offer Medication Therapy Management Program (MTMP) to all members receiving care in a long-term care setting (LTC).  This is required per the HPMS memo dated 4/10/12.  In order to actively engage Advocare members, skilled nursing facilities must notify Security Health Plan of Admission of an Medicare Advantage member within 24 hours or the next business day of admission regardless of coverage, Part A, Part B, custodial, etc.  Notification is required EVEN IF Security Health Plan is not paying for the Medicare Advantage member’s stay.

Home Health Care Services

Home health care agencies must notify Security Health Plan within two business days of the initial assessment. Medicare payment criteria will be used for home health services.

The treatment must be reasonable and necessary for the treatment of a specific illness, injury, or disability, and must be consistent with the nature and severity of the member’s condition, particular medical need, and accepted standards of medical practice.

Home health care services must be provided by a Medicare certified affiliated Security Health Plan home health care provider.

Home health services shall consist of one or more of the following:

  • Part-time or intermittent home nursing care by or under the supervision of a registered nurse
  • Part-time or intermittent home health aide services that are part of the home care plan. Services must be provided under the supervision of a registered nurse.
  • Physical, occupational or speech therapy.
  • Medical supplies prescribed by a physician. These are covered to the same extent they would have been covered under the policy if the member was hospital-confined.
  • Medical social services as part of the home care plan. This may include counseling or help in finding resources in the community.
  • Laboratory services by or for a hospital.
  • Medically necessary portable X-rays and EKGs.
  • Nutrition counseling provided by or under the supervision of a registered or certified dietitian where such services are part of the home care plan.
  • Medically necessary durable medical equipment provided by the agency and as ordered by a physician.

In order to be eligible to receive home health services, the patient must be:

  • confined to the home or in an institution that is neither a hospital nor primarily engaged in providing skilled nursing or rehabilitation services;
  • under the care of a physician and under a plan of treatment reviewed and approved by a physician; and
  • in need of intermittent or part-time skilled nursing care or physical, occupational or speech language
    therapy.

Transportation

Transportation required to take a homebound individual to a hospital, SNF, rehabilitation center, clinics, or other place, to receive services that cannot be provided in the home is not a benefit. Ambulance transportation for emergent services is covered.

Medical Supplies and Equipment

Medical supplies and durable medical equipment (DME) are a covered benefit as defined by CMS, state regulatory agencies, and Security Health Plan rules.

Coverage for DME for Advocare members will be provided in accordance with Medicare’s guidelines. Advocare pays 100 percent of Medicare mandated benefits.

DME must be obtained from a Security Health Plan contracted DME vendor. DME covered under Medicare may include, but is not limited to, the following:

  • Wheelchairs, hospital beds, crutches, or walkers used at home
  • Nebulizers or oxygen equipment used at home
  • Medical supplies such as ostomy bags, catheters and catheter supplies, surgical dressings and splints
  • Breast prosthesis after surgery
  • Artificial limbs and eyes

DME must be prescribed by the attending physician or personal provider and is reviewed by Security Health Plan to determine if Medicare criteria for coverage are met. DME may also be approved if coverage is in the best interest of the member as determined by the Security Health Plan case management team and is reviewed on a case-by-case basis.

The DME vendor is responsible for assisting Advocare members in obtaining prior authorization of any durable medical equipment. Prior authorization requests should be directed to Security Health Plan.

All prospective request determinations will be communicated to the providers within two calendar days, unless additional information is needed to support the medical necessity. In that situation, the determination will be made within 14 calendar days of receiving all necessary documentation.

Questions regarding coverage of DME should be directed to Security Health Plan. Requests for coverage of all DME must be prior authorized by Security Health Plan Health Services Department at 1-800-991-8109.

Personal Care

Nonspecialized, unskilled personal care, services of housekeepers, services of food service arrangements such as Meals on Wheels Programs and full-time nursing care at home are not covered.

Renal Dialysis Services

Renal dialysis services received while the member is temporarily outside of the service area are covered services. A copayment applies to office visits.