When delivered by an in-network provider
- Care Coordination Services
- Comfort Care and Hospice Services
- Diagnostic Services (e.g., lab tests, imaging)
- Durable Medical Equipment
- Prior approval required for costs over $500 or rental over 3 months
- EPSDT (Early & Periodic Screening, Diagnosis, and Treatment)
- Screenings and care for members under age 21
- Elective Surgeries/Procedures (prior approval needed)
- Emergency Services and Medical Transportation
- Family Planning Services (e.g., annual exams, birth control)
- Out-of-network providers allowed
- Sterilization requires consent forms
- Gender-Affirming Care
- Hearing Services
- One hearing aid every 5 years for qualifying adults
- Two hearing aids every 3 years for children
- Home Health Services
- Immunizations and Travel Vaccines
- Interpreter Services
- Lab Services, X-rays, and MRIs
- Some require prior approval
- Maternity Services (prenatal and postpartum care)
- Hospital Services (e.g., chemotherapy, pain management)
- Palliative Care (referral required)
- Prescription Medications
- Contraceptives: up to 90-day supply
- Other medications: up to 34-day supply
- Some drugs require prior approval
- Mental health drugs covered by OHP (not IHN-CCO)
- PT/OT/Speech Therapy
- Limit: 30 visits per year (per service)
- No limit for year after spinal, brain, or stroke injuries
- Preventive Services
- Includes physical exams, screenings, immunizations
- Routine physicals limited to once per year
- Primary Care Visits (e.g., checkups, screenings, non-urgent care)
- Non-Emergent Medical Transportation (NEMT)
- Free rides to care
- Help with bus passes or mileage
- Preapproval required from Ride Line
- Sexual Abuse Exams
- Specialist Services (e.g., cardiology)
- Abortion Services (covered by OHP, not by IHN-CCO)
- Surgical Procedures
- Prior approval required for planned surgeries
- No prior approval for:
- Colonoscopies
- GI Endoscopies
- ENT Endoscopies
- Telehealth Services (e.g., virtual, phone, or email visits)
- Traditional Health Worker (THW) Services (e.g., peer support)
- Urgent Care (covered anywhere in the U.S.)
- Women’s Health Services (e.g., Pap tests, breast exams, well-woman visits)
- Vision Services
- Non-pregnant adults (21+): Routine exams every 24 months, medical eye exams when needed
- Members under 21, pregnant adults, and postpartum adults: Eye exams and lenses when needed
- Preapproval required for contact lenses
Note: Some services may require referrals or prior approval. Always confirm coverage with your provider or care coordinator.
