Plans

Ambulance
Per trip - $0

Dental care - $0

Inpatient hospital
Per day - $0
Maximum with limits - $0

Medical centers
Ambulatory surgical center - $0
Federal Qualified Health Center or Regional Health Center - $0
Independent medical/surgical center - $0
Short procedure unit - $0

Medical equipment
Purchase - $0
Rental - $0

Medical visits
Certified nurse practitioner - $0
Chiropractor - $0
Doctor - $0
Optometrist - $0
Podiatrist - $0

Outpatient hospital
Per visit – outpatient surgical, except maternity - $0
Per visit – non-surgical or diagnostic - $0

Prescriptions
Generic - $0
Brand name - $3

X-rays
Per service - $0

• Beyond Medicaid coverage, participants can request an oral hygiene kit

• Beyond Medicaid covered vision services, $100 yearly for glasses or contacts for Nursing Facility Clinically Eligible (NFCE) participants

• After hospital stay: 14 days of home delivered meals
• After hospital stay: 14 days of respite care
• Smart Start for Baby
• Health library
• Community Connect community resource
• 90-day prescription refill for those not on Medicare

• My Health Pays™ card for health items at authorized retailers. Learn more at My Health Pays™.
• Support services for members waiting for LTSS eligibility determination
• Up to $5000 allowance to move from nursing facility to the community
• Personal support services for participants waiting for LTSS eligibility decision

* There are no co-pays for persons living in a nursing, personal care or domiciliary home. Pregnant women, new mothers and terminally ill participants getting hospice care have no co-pays. Some services, items and drugs have no co-pays. For co-pay updates, go to ow.ly/WGQM30hern9.