Benefits Grid

We provide superior Nebraska Medicaid benefits available to all our members. In the benefits grid below, you will find the services available and if prior authorization is required through Nebraska Total Care.

Heritage Health - Nebraska Total Care

Nebraska Total Care covers many medical services for your healthcare needs. Some services must be prescribed by your doctor. Some services must also be approved by Nebraska Total Care before you get the service. You can check if services were approved in the Member Portal.

There are some Medicaid members who have a copay for some brand name prescriptions. You can see more information about copays on the Pharmacy page.

You do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, OB/GYN care, or mental health/counseling services.

Benefits Grid (updated March 1, 2023)
Service	Description and limits	Prior authorization required
Allergy care	Allergy care	Yes, for some services
Ambulance - emergency	Includes ground and emergency helicopter	No
Ambulance - non-emergency	Ambulance transportation from one healthcare facility to another is only covered when it is medically necessary. Arranged for and approved by an in-network provider.	Yes
Behavioral Health	Age limitations may apply. Services include crisis stabilization, inpatient psychiatric hospitalization, outpatient assessment and treatment services, peer support, residential treatment facilities, and rehabilitation services.	Yes, for some services
Breast pumps	One electronic breast pump and kit per member, per delivery every two years. For multiples (twins, triplets, etc.) only one pump will be provided. Your doctor will need to write a prescription for a breast pump.	No
Chiropractic services	Coverage is limited to manual treatment of the spine and one set of spinal x-rays per year.	No
Continuous Glucose Monitor	One per member, with repair and replacement as considered medically necessary.	Yes
Durable Medical Equipment (DME)	Items that are not medically necessary and are not ordered by a provider are not covered.	Yes, in some situations
Drugs: prescription/pharmacy	Use a pharmacy in our network. This can include mail-order pharmacies. Prescription drugs and OTC items approved by the U.S. Food and Drug Administration (FDA).	Yes, for some medications
Drugs: over the counter (OTC)	Over the counter medications require a doctor's prescription.	No
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)/Well-child exam	Services are for members age 20 and younger. Sports and school physicals annually.	No
Eye care services and eye glasses	Under age 21, eye exam annually and one pair of frames and lenses every 2 years. Age 21 and older, eye exam and one pair of frames and lenses every 2 years.	No
Family planning	Family planning services can be from any Medicaid doctor. This includes well-women exams, screening, and pregnancy testing.	No
Foot care	House calls are only covered if visiting a provider would cause you harm. Foot care visits may be limited. Orthotics are covered for some conditions.	Yes, in some situations
Hearing aids and services	Hearing aids and services.	Yes, for cochlear implants
High-risk prenatal and infant services	Care management provides special support for members at risk or with special health needs.	Notify plan
Home health care	Care must be prescribed by your doctor. And, not able to be received at the hospital or provider's office. Other conditions apply.	Yes
Hospice Services	Other than an inpatient facility.	Yes
Immunizations for children	Available to members age 21 and younger.	No
Inpatient and outpatient hospital care	Items that are not medically necessary are not covered.	Yes, including observation services
Lab services and testing	Paternity testing and infertility treatment tests are not covered.	Yes
Lactation Consultation	Five sessions per child, up to 90 minutes	No
Maternity care	See your provider as soon as you know you are pregnant. Send us the Notice of Pregnancy form at first visit. Prenatal through postpartum services are covered.	Yes, for more than two OB ultrasounds.
Nurse midwife services	Covered with all in network providers.	Yes, for non-participating providers.
OB ultrasounds	Two are allowed per pregnancy unless ordered by perionatologist.	Yes, if more than two.
Office visits	Covered with all in network providers.	Yes, for non-participating providers
Orthotics/Prosthetics	Orthotics/Prosthetics	Yes
Pain management	Not applicable for post-operative pain management.	Yes
Physician services	One routine physical exam every 12 months performed by your PCP. Health visits as needed.	No
Private duty nurse services	Overnight nursing services and respite care hours are limited.	Yes
Psychiatric hospital services	Psychiatric hospital services	Yes
Psychiatric services	Psychiatric services	Yes, for some services
Psychological services	Psychological services	Yes, for some services
Radiology and x-rays	Must be ordered by a provider.	Yes, for high-tech radiology, including CT, MRI, MRA
Reconstructive surgery	Surgery that is performed to make you look better and is determined to be cosmetic is not covered.	Yes
Rehabilitation services	Rehabilitation services	Yes
Skilled Nursing Facility care	Items that are not medically necessary are not covered. This includes private rooms or convenience/comfort items.	Yes
Sterilization services	Sterilizations require informed consent forms 30 days prior to the date of procedures. Hysterectomies are covered on a limited basis.	No
Therapy (occupational, physical, speech) services	There is a combined limit of 60 therapy sessions per year for members 21 and over. This includes physical therapy, occupational therapy, and speech therapy services.	Yes, after the first 12 sessions
Stop smoking/ tobacco cessation	Certain medications, patches, or gum to help you stop smoking are covered. Call 1-800-QUIT-NOW (784-8669) for more information.	No
Surgery	Surgery	Yes, except in an emergency
Transplant services	Transplant services	Yes
Urgent care	Urgent care	No