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.
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.
| 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 | Manual treatment of the spine, one set of spinal x-rays per year, traction, electrical stimulation, ultrasound, and other evaluation and therapy procedures. | No, if provided by a Chiropractor |
| Continuous Glucose Monitor | One per member, with repair and replacement as considered medically necessary. | Yes |
| Dental care, preventive | Two visits every year for members age one and older. Members covered under 599 CHIP are excluded. | No |
| Dental care, treatment | Treatment that is medically necessary and ordered by a dental provider. | Yes, in some situations |
| 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 18 and younger at doctor's office. | 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 (1-800-784-8669) for more information. | No |
| Surgery | Surgery | Yes, except in an emergency |
| Transplant services | Transplant services | Yes |
| Urgent care | Urgent care | No |