Benefits Grid

Service Description and limits Prior authorization required
Allergy care   Yes, for some services
Ambulance - emergency Includes ground and emergency helicopter No
Ambulance - non-emergency   Yes
Behavioral Health Age limitations may apply. Services include crisis stabilization, inpatient psychiatric hospitalization, outpatient assessment and treatment services, residential treatment facilities, and rehabilitation services.  Yes, for some services
Breast pumps   Yes
Chiropractic services Coverage is limited to manual treatment of the spine and one set of spinal x-rays per year. Ages 20 and younger can have 18 visits per year. Adults 21 and older can have 12 visits per year. 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   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 harmu. Foot care visits may be limited. Orthotics are covered for some conditions.  Yes, in some situations
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
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. 
Lab services and testing Paternity testing and infertility treatment tests are not covered.  Yes
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
Orthodics/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   Yes
Psychiatric services   Yes, for some 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   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
Stop smoking/ tobacco cessation Certain medications, patches, or gum to help you stop smoking are covered. Smoking cessation is covered through Tobacco-Free-Nebraska. Call 1-800-QUIT-NOW (784-8669) for more information. No
Surgery   Yes, except in an emergency
Transplant services   Yes
Urgent care   No