RIte Care – Ancillary Benefits

Diagnostic Procedures and Tests:

• Covered benefit for lab, x-ray and other diagnostic services, including urine drug and lead screening.
• Audiology services may require prior authorization. Screening is usually done by a PCP.

Durable Medical Equipment and Hearing Aids:

• Covers medically necessary surgical appliances, prosthetic devices, orthotic devices, medical supplies, hearing aids, ear molds, and molded shoes.
• TED stockings, ostomy supplies, wrist splints, glucose meters, test strips and cervical collars.
• Breast pump covered.
• Prior authorization may be required.

Home Health Services:

• Covers private duty nursing and homemaking/personal care services when medically necessary.
• Prior authorization required.
• Respite care, relief care and day care are not covered.

Medical, Ostomy, and Enteral Supplies:

• Covers medically necessary supplies (for example: disposable supplies, ostomy, diabetic and enteral supplies).
• Diapers for members three years or older, and caloric supplements like Duocal and Pediasure.
• Prior authorization required.
• Hygiene items are not covered.

Outpatient Rehab Therapy (physical, occupational, speech, language, hearing, respiratory):

• Medically necessary therapy covered.
• Prior authorization required.
• Early Intervention Program Rehabilitation Therapy as part of IFSP covered. No authorization required (from birth to three years old and limited to physical therapy, occupational therapy and speech therapy).

Abortion:

• Not covered (except in cases of rape or incest or to save the life of the mother).
• Prior authorization required.

Blood Products:

• Covers administrative fees and supplies for blood administration and autologous donations in a hospital or outpatient clinic.
• Covers Factors VIII and IX for treatment of hemophilia.

Cardiac Rehab:

• Covers up to 12 weeks following hospital discharge and up to 26 weeks for risk reduction, illness adjustment and therapeutic services.
• Prior authorization required.

Chemotherapy:

• Covered.
• Prior authorization required.

Chiropractic Services:

• Not covered.

Court-Ordered Services:

• Covers medically necessary court ordered services by network providers.

Dental Care:

• Coverage limited to emergency care following an accidental injury, uncontrolled pain or bleeding; extractions for bony impacted or infected teeth.
• Prior authorization required.

Diabetes:

• Covers education, visits and supplies (for example: glucose meters, test strips, lancets, insulin injection aids, syringes, molded shoes).

Dialysis:

• Covered in-patient, outpatient, and home dialysis in full.

Education Classes - Group sessions (for example: prepared childbirth, parenting, smoking, nutrition, diabetes, asthma, etc.):

• Covered for approved programs.
• No prior authorization for approved classes.

Emergency Room:

• Covered for emergency services.
• Out of area covered for emergencies.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services:

• Covered for all children and young adults up to age 21.
• Includes initial, preventive and follow-up visits.
• Includes medically indicated interperiodic screens.
• Includes multi-disciplinary evaluation and treatment for children with significant development disabilities and delays.

Hospice Services:

• Covered benefit up to 210 days lifetime maximum for palliative treatment only.
• Prior authorization required.

Interpreter Services:

• Covered as necessary to access care (requires 72 hour notice).

Newborn Services:

• Newborn immediately eligible for services.
• Circumcisions performed on newborn sons are covered.
• Prior authorization required; see Obstetrical Care.

Nutrition Services:

• Covered as delivered by a licensed dietitian for certain medical conditions as outlined in Rite Care and as referred by a health plan physician. Covers nutritional supplements under pharmacy. 
• Prior authorization required.

Optometry Services:

• For members 21 and older, benefits include routine vision exams, including refraction, and provision of frames and lenses, if needed, limited to once every two years.
• Includes other medically necessary visits for illness or injury to the eye.
• For children under 21, covered as medically necessary with no other limits.

Out-of-Network Services:

• By exception only, when medically necessary.
• Requires authorization by health plan.

Podiatry:

• Covered for routine care for diabetics and as medically necessary for management of specific conditions.

Psychological Testing:

• Covered in determining differential diagnosis.
• Prior authorization required.
• Testing for IQ determination or learning disorders not covered.

Second and Tertiary (third) Opinions:

• Covers second opinion. Member can request tertiary opinion.
• In-network should be accessed. Out-of-network requires prior authorization.
• Prior authorization required.

Smoking Cessation:

• Covers classes and medication.
• No co-payment or authorization for formulary drugs.

Transplant Services:

• Covered when ordered by a health plan physician.
• Prior authorization required.

Transportation Services, Emergency

• Covered for emergency services or when authorized by a health plan provider; or in order to assess whether a condition warrants treatment as an emergency service.
• Medically necessary transportation including air ambulance if indicated.
• Prior authorization required.

Transportation Services, Non-Emergency:

• Covered for non-emergency transportation including bus passes.
• Includes para-transit services when authorized/arranged by the health plan through RIPTA and RIDE. Call Member Services at 1-800-963-1001 to arrange.
• Prior authorization required.

RIte Care – Ancillary Benefits

Diagnostic Procedures and Tests:
• Covered benefit for lab, x-ray and other diagnostic services, including urine drug and lead screening.
• Audiology services may require prior authorization. Screening is usually done by a PCP.

Durable Medical Equipment and Hearing Aids:
• Covers medically necessary surgical appliances, prosthetic devices, orthotic devices, medical supplies, hearing aids, ear molds, and molded shoes.
• TED stockings, ostomy supplies, wrist splints, glucose meters, test strips and cervical collars.
• Breast pump covered.
• Prior authorization may be required.

Home Health Services:
• Covers private duty nursing and homemaking/personal care services when medically necessary.
• Prior authorization required.
• Respite care, relief care and day care are not covered.

Medical, Ostomy, and Enteral Supplies:
• Covers medically necessary supplies (for example: disposable supplies, ostomy, diabetic and enteral supplies).
• Diapers for members three years or older, and caloric supplements like Duocal and Pediasure.
• Prior authorization required.
• Hygiene items are not covered.

Outpatient Rehab Therapy (physical, occupational, speech, language, hearing, respiratory):
• Medically necessary therapy covered.
• Prior authorization required.
• Early Intervention Program Rehabilitation Therapy as part of IFSP covered. No authorization required (from birth to three years old and limited to physical therapy, occupational therapy and speech therapy).

Abortion:
• Not covered (except in cases of rape or incest or to save the life of the mother).
• Prior authorization required.

Blood Products:
• Covers administrative fees and supplies for blood administration and autologous donations in a hospital or outpatient clinic.
• Covers Factors VIII and IX for treatment of hemophilia.

Cardiac Rehab:
• Covers up to 12 weeks following hospital discharge and up to 26 weeks for risk reduction, illness adjustment and therapeutic services.
• Prior authorization required.

Chemotherapy:
• Covered.
• Prior authorization required.

Chiropractic Services:
• Not covered.

Court-Ordered Services:
• Covers medically necessary court ordered services by network providers.

Dental Care:
• Coverage limited to emergency care following an accidental injury, uncontrolled pain or bleeding; extractions for bony impacted or infected teeth.
• Prior authorization required.

Diabetes:
• Covers education, visits and supplies (for example: glucose meters, test strips, lancets, insulin injection aids, syringes, molded shoes).

Dialysis:
• Covered in-patient, outpatient, and home dialysis in full.

Education Classes - Group sessions (for example: prepared childbirth, parenting, smoking, nutrition, diabetes, asthma, etc.):
• Covered for approved programs.
• No prior authorization for approved classes.

Emergency Room:
• Covered for emergency services.
• Out of area covered for emergencies.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services:
• Covered for all children and young adults up to age 21.
• Includes initial, preventive and follow-up visits.
• Includes medically indicated interperiodic screens.
• Includes multi-disciplinary evaluation and treatment for children with significant development disabilities and delays.

Hospice Services:
• Covered benefit up to 210 days lifetime maximum for palliative treatment only.
• Prior authorization required.

Interpreter Services:
• Covered as necessary to access care (requires 72 hour notice).

Newborn Services:
• Newborn immediately eligible for services.
• Circumcisions performed on newborn sons are covered.
• Prior authorization required; see Obstetrical Care.

Nutrition Services:
• Covered as delivered by a licensed dietitian for certain medical conditions as outlined in Rite Care and as referred by a health plan physician. Covers nutritional supplements under pharmacy.
• Prior authorization required.

Optometry Services:
• For members 21 and older, benefits include routine vision exams, including refraction, and provision of frames and lenses, if needed, limited to once every two years.
• Includes other medically necessary visits for illness or injury to the eye.
• For children under 21, covered as medically necessary with no other limits.

Out-of-Network Services:
• By exception only, when medically necessary.
• Requires authorization by health plan.

Podiatry:
• Covered for routine care for diabetics and as medically necessary for management of specific conditions.

Psychological Testing:
• Covered in determining differential diagnosis.
• Prior authorization required.
• Testing for IQ determination or learning disorders not covered.

Second and Tertiary (third) Opinions:
• Covers second opinion. Member can request tertiary opinion.
• In-network should be accessed. Out-of-network requires prior authorization.
• Prior authorization required.

Smoking Cessation:
• Covers classes and medication.
• No co-payment or authorization for formulary drugs.

Transplant Services:
• Covered when ordered by a health plan physician.
• Prior authorization required.

Transportation Services, Emergency

• Covered for emergency services or when authorized by a health plan provider; or in order to assess whether a condition warrants treatment as an emergency service.
• Medically necessary transportation including air ambulance if indicated.
• Prior authorization required.

Transportation Services, Non-Emergency:
• Covered for non-emergency transportation including bus passes.
• Includes para-transit services when authorized/arranged by the health plan through RIPTA and RIDE. Call Member Services at 1-800-963-1001 to arrange.
• Prior authorization required.

• Covered for non-emergency transportation including bus passes.
• Includes para-transit services when authorized/arranged by the health plan through RIPTA and RIDE. Call Member Services at 1-800-963-1001 to arrange.
• Prior authorization required.