RIte Care – General Benefits

Behavioral Health - Inpatient:

• Covers up to 365 days of medically necessary inpatient care.
• Day, evening, partial, and residential treatment when medically necessary.
• Court-ordered treatment from network providers when medically necessary.
• Residential treatment includes therapeutic services; room and board covered in Joint Commission on Accreditation of Health Care Organizations (JCAHO) accredited facilities only.
• Medically necessary out of area emergency.
• Prior authorization is required for inpatient and partial hospitalization or residential treatment.

Behavioral Health - Outpatient:

• Self-referral for the first 12 outpatient visits per member per calendar year.
• Short and long term treatment covered based on medical necessity.
• Court-ordered services from network providers when medically necessary.
• Methadone maintenance and outpatient Methadone detoxification and collateral visits.
• Medically necessary out of area emergency care.
• Prior authorization required for more than 12 outpatient visits per member per calendar year.

Gynecological (GYN) and Family Planning Services:

• Medically necessary benefit for all comprehensive “annual exams” and up to four GYN/family planning visits per year from a network provider.
• No referral required.
• Sterilization covered in many cases. Must meet state and federal guidelines and have RI Medical Assistance consent form signed at least 30 days prior.
• Abortion not covered (except in cases of rape or incest or to save the life of the mother).

Medical Inpatient (hospital, rehabilitation center, skilled nursing facility (SNF)):

• Medically necessary benefit for up to 365 days per year.
• Prior authorization required.

Obstetric/Maternity Care Services:

• Physician services for prenatal, delivery and postpartum care.
• In-Patient for hospitalization.
• Childbirth Education and Parenting classes. No prior authorization required.
• Lactation services covered.
• Home visit for early maternity discharge covered. Covers one home visit and up to four hours each day for four days of Home Health Assistance (HHA) for members discharged within 48 hours of vaginal delivery and 96 hours of caesarean delivery.
• Prior authorization required.
• Sterilization covered in many cases. Must meet state and federal guidelines and have RI Medical Assistance consent form signed at least 30 days prior.

Prescription and Over-the-Counter Drugs:

• Generic substitution for prescribed drugs required unless specified by provider.
• Many over-the-counter drugs and durable medical equipment (example: wheelchair or crutches) and medical supplies covered.
• Limit of 30 days supply for generic, brand name and non-formulary drugs.
• Select drugs may require prior authorization.

Preventive, Well Care:

• Office visits.
• Immunizations and vaccines (Please note: immunizations for travel are not covered).
• Services rendered at contracted school-based clinics.

Specialty Physician Visits:

• Specialty physician office visits covered based on medical necessity.
• Medically necessary in-patient and ambulatory surgery.
• Cosmetic limited to medically necessary surgery needed to treat illness or injury to restore or provide function.
• Covers breast reconstruction following a mastectomy.
• Oral surgery covered only for diseases of the mouth and jaw and accidental injury.
• Prior authorization may be required.
• Second surgical opinion covered.