2019 Provider Networks and Member Benefit Plans > Medicaid Managed Care and HARP Prepaid Benefit Package Definitions of Covered and Non-Covered Services (Appendix K - K.1, K.2, K.3)
Please see the Appendix K table for a listing of all covered services under Medicaid Managed Care Supplemental Security Income (SSI), non-SSI related, Fee-for-Service, and HARP. Family Health Plus and HIV Special Needs Plan members are not applicable.
Glossary terms found on this page:
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.
A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.