PA Update

Prior Authorization Updates

Effective January 1, 2019
  • Acupuncture will continue to require prior authorization
  • Providers must be credentialed for acupuncture services
  • Does not apply to BadgerCare Plus, Senior Preferred and State (ETF) members   
Certificate Updates

Effective January 1, 2019


Accidental Dental Coverage for Sound Natural Teeth

Specific to Dental / Oral Surgery Providers
  • Coverage for replacement of sound, natural teeth when damaged due to accidental injury
  • Implants will not be covered

Osteotomy Exclusion

  • With the exception to the treatment of TMJ

Bariatric Surgery

  • One allowed per lifetime of the member regardless of insurer

Biofeedback Clarification

  • Visit limit of eight per lifetime for Pediatric Visits

Hearing Aid Benefits

  • List now updated every six months, rather than annually.
  • Model numbers not on the approved hearing aid list will be covered up to $1,500 per ear every three years
  • Specific criteria must be met
  • Hearing aids must be purchased from an in-network provider

Preventive Breast Cancer Screening

Effective January 1, 2019
  • Women ages 40 and older will be covered at $0 copay.
  • Cost sharing will be applied to women receiving a breast cancer screening under age 40

Specialty Lenses – All commercial plans

  • Specialty lenses are not covered – if billed, no part of the lens is paid for
Certificate Updates - MN Only

Minnesota Only

The Home Care section of the GHP-MN Certificate has been changed as follows:

Private Duty Nursing for Ventilator-Dependent Persons Covered with Prior Authorization.


PRIOR AUTHORIZATION REQUIRED.

  • Part-time or intermittent home skilled nursing care that is part of the home care plan – by or under the supervision of a registered nurse of medical social worker
  • Physical, respiratory, occupational, speech therapy or nutritional counseling
  • Home infusion therapy
  • Medical supplies, drugs and laboratory services covered to the same extent they would have been covered if the member was confined in a hospital.

As required by Minnesota Statute 62A.155 –

Coverage for up to 120 hours of services provided by a home care nurse or personal care assistant to a ventilator-dependent person during the time the ventilator-dependent person is in a hospital. The personal care assistant or home care nurse shall perform only the services of communicator or interpreter for the ventilator-dependent patient during a transition period of up to 120 hours to assure adequate training of the hospital staff to communicate with the patient and to understand the unique comfort, safety, and personal care needs of the patient.

Preventive Services Updates 

Preventive Services Updates for ACA-Compliant Plans

Effective October 1, 2018
  • Vision: Amblyopia screening for children aged six months to five years
Effective January 1, 2019
  • Preventive Prescription Drug Changes – increased $0 cost-sharing coverage
  • Fluoride Supplements (drops, chewable tablets) – For children with no fluoride in their water supply, fluoride supplements will be covered at $0 copay from age six months to five years.
  • Folic Acid 400mcg and 800mcg (OTC) – Beginning at age 12, folic acid will be covered at $0 copay
  • Colonoscopy Preps – Members within the age range of 50 to 75 years will have $0 copay for two prescriptions per year.
  • One annual screening for Urinary Incontinence added for all women
  • Diabetes (Type 2) Screening for Women with a history of Gestational Diabetes – Expanding coverage from within one year after birth to include one screening annually for a minimum of ten years after pregnancy.
Effective April 1, 2019
  • Behavioral Counseling to Prevent Skin Cancer – Age range of coverage is now six months to 24 years