PCHP-HCH_Covered_Services_Update_09012024.pdf

PCHP/HCH Covered Services

PCHP/HCH Covered Services (Effective 9/1/2024) Page 1

The Pinellas County Health Program and Health Care for the Homeless Program has identified the following services with information on whether the service is covered by the program, what the description of the service is and it’s limitations, if any, and where and how a patient would obtain the service. Changes to service types or coverage are reviewed annually by the Human Services Health Care Administration program in partnership with the Florida Department of Health clinical team.

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

PRIMARY & PREVENTIVE

CARE1:

General primary medical care services are comprehensive and address prevention as well as acute and chronic conditions.

At a minimum, these services include assessment, diagnosis, screening, education and treatment;

referrals; and follow- up of such services.

Primary care, wellness and prevention to include clinical visits, annual physicals, basic laboratory services and tests, adult immunizations, electrocardiography (EKG) and/or spirometry, wellness screenings and prevention, healthy behavior education and nutrition services.

Yes Medical Home No

ABORTIONS No Coverage No N/A N/A

1 HCH Required Scope of Service

PCHP/HCH Covered Services (Effective 9/1/2024) Page 2

CANCER

Cancer treatment is covered for primary site only.

Limitations:

• Cancer treatment regimen including number of treatments must be pre-approved before starting cancer therapy.

• For secondary site or recurrence, referrals for other charity care providers may be offered.

• If metastasis is diagnosed, clients are referred to case manager for enrollment in Medicaid.

Once Medicaid is active, care is transitioned to Medicaid provider.

Medications:

All cancer medications must be pre-authorized. The initial chemotherapy dose may be approved and subsequent chemo/follow up shall be provided by the Prescription Assistance Program (PAP). The PAP will be used for chemotherapy agents, for other medications used to treat cancer cells, and for medications to counteract the side effects of chemotherapy, such as damage to bone marrow/blood cells, digestive and reproductive tract lining and hair follicles, nausea and vomiting.

The PCHP Formulary does not include these medications and the PCHP will not reimburse unless the medication is not available from the PAP.

PCHP will reimburse for injectable items such as normal saline, heparin sodium, diphenhydramine HCL, mannitol and selected supporting and generic medications.

Limited By Referral Yes

PCHP/HCH Covered Services (Effective 9/1/2024) Page 3

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

CARDIOLOGY Cardiology deals with the disorders of the heart as well as some parts of the circulatory system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology.

The medical homes provide onsite EKG. Other testing must be pre-authorized.

Yes By Referral Yes

CARPAL OR TARSAL TUNNEL

SYNDROME

No Coverage No N/A N/A

CASE MANAGEMENT Case management services are the coordination of support and enabling services to meet the ongoing needs of a patient.

At a minimum, these services include an assessment of factors affecting health (e.g., medical, social, housing, or educational), counseling and referrals to address identified needs and periodic follow-up of services.

Yes Medical Home No

CIRCUMCISIONS Medically Necessary Only. Must be pre-authorized. Yes By Referral Yes

COMMUNICABLE DISEASES –

HIV, HEPATITIS A, B & C

Communicable disease screenings at a minimum must include, but are not limited to, testing for tuberculosis, HIV, Hepatitis A, B and C, and other sexually transmitted diseases/infections based on a patient’s identified risk factors. See Screenings.

Limited Medical Home & By Referral Yes

PCHP/HCH Covered Services (Effective 9/1/2024) Page 4

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

Treatment for sexually transmitted infections is provided by the medical home. HIV and Hepatitis treatment is provided by Referral.

COMPLEMENTARY AND

ALTERNATIVE MEDICINE

Complementary and alternative medicine services are the assessment, diagnosis and non-conventional treatment of disorders/conditions used together with or in place of conventional medicine to support health and well-being of the mind and body (e.g., chiropractic care, acupuncture, meditation, and massage therapy).

No N/A N/A

COSMETIC SURGERY The procedures, techniques, and principles of cosmetic surgery are entirely focused on enhancing a patient’s appearance. Cosmetic surgery includes but is not limited to implants, augmentation, reduction, scar revision, hair transplants, lifts/stretches/injections, weight loss or reconstructive surgery.

No N/A

COVERAGE FOR EMERGENCIES

DURING AND AFTER HOURS

During the program’s regularly scheduled hours, the medical home has clearly defined processes and arrangements to respond to patients presenting with emergencies and to transfer patients to a more appropriate setting for additional health care services when appropriate.

Emergency Room services are not covered.

After regularly scheduled hours, after hours coverage includes the provision of telephone access through a

Yes N/A N/A

PCHP/HCH Covered Services (Effective 9/1/2024) Page 5

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

contracted provider, who can assess the patient's need for emergency medical care and if appropriate, who can then refer patients to a covering provider.

DENTAL – Preventive/Basic Services

Preventive dental services prevent diseases of the oral cavity and related structures.

At a minimum, these services include all of the following:

• basic dental screenings and recommendations for preventive intervention;

• oral hygiene instruction and related oral health education (e.g., prevention of oral trauma and oral cancer);

• oral prophylaxis, as necessary; and

• topical application of fluorides (e.g., fluoride varnishes) and the prescription of fluorides for systemic use when not available in the water supply.

Services may include application of sealants, and diagnostic screening for caries and periodontal disease through the use of dental x-rays.

Additional dental services are basic services at a general practice level to diagnose and treat disease, injury, or impairment in teeth and associated

PCHP/HCH Covered Services (Effective 9/1/2024) Page 6

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

structures of the oral cavity and include any diagnostic x-rays or imaging.

These services include fillings, extractions, and dentures.

DENTAL – Complex Dental Services

Complex dental services (e.g., oral surgery, surgical endodontics, orthodontics) are considered specialty services.

Medically necessary oral surgery procedures must be pre-authorized. There is no coverage for endodontics or orthodontics.

Limited By Referral Yes

DIALYSIS If End-Stage Renal Disease is diagnosed, clients are referred to case manager for enrollment in Medicaid.

Dialysis will be covered until Medicaid is active. Once Medicaid is active, care is transitioned to Medicaid provider.

Limited By Referral Medical Director Approval

DURABLE MEDICAL

EQUIPMENT

Durable medical equipment is equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a person in the absence of an illness or injury and is appropriate for use in the home.

Limited By Referral

Yes;

additional Medical Director approval required if over $500

EATING DISORDERS Eating disorders are serious conditions related to persistent eating behaviors that negatively impact your

No N/A N/A

PCHP/HCH Covered Services (Effective 9/1/2024) Page 7

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

health, your emotions and your ability to function in important areas of life. The most common eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder.

ELIGIBILITY ASSISTANCE Eligibility assistance services are support to health center patients to establish eligibility for and gain access to appropriate federal, state and local programs that provide or financially support the provision of medical, social, educational, housing, or other related services (e.g., Medicaid, Veteran’s benefits, the Special Supplemental Nutrition Assistance Program, Legal Aid).

Yes Medical Home or By Referral

No

EXPERIMENTAL

DRUGS/THERAPY/

PROCEDURES

An investigational drug can also be called an experimental drug and is being studied to see if your disease or medical condition improves while taking it.

No N/A N/A

FERTILITY/INFERTILITY See Gynecological Care No N/A N/A

GENETIC COUNSELING AND

TESTING

Genetic counseling involves collecting personal and family health history to determine how likely it is that a person has a genetic condition.

Genetic testing looks for changes, sometimes called mutations or variants, in your DNA.

Limitations:

• Medically necessary laboratory testing only.

Limited Medical Home Medical Director Approval

PCHP/HCH Covered Services (Effective 9/1/2024) Page 8

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

GENDER DYSPHORIA Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics. Reassignment surgery and medication therapy is not covered.

No N/A N/A

GYNECOLOGY – Preventive and Basic Services

Gynecological care services are the regular preventive assessment and appropriate treatment of conditions or disorders of the female reproductive system (with the exception of obstetrical services).

At a minimum, these services must include pelvic and breast exams, cervical cancer screening, and the review of menstrual and reproductive history and gynecological symptoms. Basic gynecological ultrasounds are included in this category and require a referral.

Yes Medical Home & By Referral

Yes for services requiring a referral

GYNECOLOGY – Advanced Services

Advanced gynecological services are considered specialty services (e.g., gynecologic oncology, urogynecology, reproductive endocrinology and infertility). Services offered by referral include gynecological procedures (e.g., colposcopy, hysterectomy, fibroid removal).

Limited By Referral Yes

HEALTH EDUCATION Health education services are a variety of learning experiences designed to help individuals improve their health. At a minimum, these services include education

PCHP/HCH Covered Services (Effective 9/1/2024) Page 9

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

regarding the availability and appropriate use of health services.

Services may include primary prevention and/or targeted education on self-managed care and other health promoting behaviors for patients with identified risk factors or conditions (e.g., diabetes, hypertension, tobacco cessation). These services may also include education on injury prevention and unique needs and risks of special populations (e.g., education to prevent common exposures experienced by Homeless individuals).

HEARING CARE Routine hearing exams are NOT covered, but a referral to a community resource will be offered.

Referrals for medically necessary related hearing problems such as ear infections or injuries to Ear, Nose and Throat will be covered.

Limited By Referral No

HOME HEALTH Home health care includes the following health care services given in home for an illness or injury. Services include:

• Skilled nursing

• Physical therapy

• Occupational therapy

• Speech therapy

• Home Health Aide visit

PCHP/HCH Covered Services (Effective 9/1/2024) Page 10

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

• MSW visit

• Infusion therapy services

• Wound Care

Limitations:

Any service requiring home visits will be restricted to two (2) weeks of treatment, up to a maximum of six (6) visits, pending reauthorization by DOH.

Ambulatory wound care clients must be evaluated in DOH medical home for requested reauthorization.

Infusion Therapy: Not to exceed one hundred eighty

(180) patient days per ninety (90) calendar days.

IMMUNIZATIONS Immunization services are the provision of age-appropriate preventive vaccines (i.e flu, pneumonia, Tdap).

These services may also include any immunizations recommended by Federal, state or local authorities to address an outbreak.

Yes Medical Home No

LABORATORY - Basic Laboratory services are screening and diagnostic tests ordered by health center providers to provide information for the assessment of health center patients.

PCHP/HCH Covered Services (Effective 9/1/2024) Page 11

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

At a minimum, these services include the specimen collection, processing and interpretation of the result, and must include access to a combination of: a) Clinical Laboratory Improvement Amendments (CLIA) waived tests; and b) moderate complexity laboratory tests, which are appropriate for the treatment and management of common conditions of the patient population.

LABORATORY – Specialty Services may also include access to high complexity laboratory tests in the support of basic health services, ordinarily provided by a certified reference laboratory.

There is limited coverage for these laboratory services.

Exceptions may be approved on a case-by-case basis and must be pre-authorized.

Limited By Referral Medical Director Approval

MENTAL HEALTH

SERVICES/PSYCHIATRY

Mental health services are the prevention, assessment, diagnosis, treatment/intervention, and follow-up of mental health conditions and disorders (e.g., depression, anxiety, attention deficit and disruptive behavior disorders) including care of patients with severe mental illness who have been stabilized.

These services may include treatment and counseling for health center patients such as individual or group counseling/psychotherapy, cognitive-behavioral

Limited Medical Home and By Referral No

PCHP/HCH Covered Services (Effective 9/1/2024) Page 12

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

therapy or problem-solving therapy, 24-hour crisis services, and case management services.

Psychiatry is considered a specialty service.

Limitations:

Mental health Services are not covered for clients with a documented history of Severe and Persistent Mental Illness (SPMI). Clients with SPMI will be provided community based resources for these services.

NURSING HOME No Coverage No N/A N/A

NUTRITION Nutrition services prevent and treat diseases and conditions through nutritional assessment, diagnosis and treatment.

These services may include medical nutrition therapy, nutrition education and counseling, and other interventions to enhance knowledge and impact behaviors related to healthy eating, nutrition and health.

These services may include the nutrition services of a WIC program, if the WIC program is within the scope of project.

Yes Medical Home and By Referral No

PCHP/HCH Covered Services (Effective 9/1/2024) Page 13

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

OBSTETRICAL – Prenatal Care, Intrapartum Care (Labor & Delivery), and Postpartum Care

Obstetrical care services are the clinical assessment, management/treatment and coordination of services and referrals for the mother and fetus to maximize the outcome of the pregnancy. Such services extend from the mother's diagnosis of pregnancy thru the approximately six-week period following the delivery and can be divided into three components: 1) Prenatal;

2) Intrapartum (labor & delivery); and 3) Postpartum.

Services include progressive risk assessments of mother, fetus and the newborn, and must be consistent with the individual health center provider's licensure, credentials, and privileging.

Yes By Referral No

OCCUPATIONAL, PHYSICAL

AND SPEECH THERAPY

(OUTPATIENT)

Occupational therapy services provide assessment and treatment services to assist patients in their ability to perform activities of daily living.

Physical therapy services provide assessment and treatment services to assist patients to maintain, restore, and improve physical activity and functioning while ensuring safety.

Speech-language pathology/therapy services provide assessment and treatment services to assist patients to improve and optimize their ability to communicate and swallow.

PCHP/HCH Covered Services (Effective 9/1/2024) Page 14

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

• Outpatient physical therapy, occupational therapy, and speech therapy have a combined limit of thirty (30) treatments in a twelve (12) month period.

OPTOMETRY (EYE CARE) Optometry services assess the health of the eyes and related structures.

These services include conducting routine eye exams, prescribing glasses/contacts, identifying related systemic conditions affecting the eye, and treating injuries and disorders of the visual system.

Ophthalmology and surgical procedures of the eye (e.g., laser surgery) are considered specialty services.

Limitations:

• Diabetic members may be authorized for annual eye exams.

• All other eye care services shall be limited to eye injuries and medically related vision problems such as diabetic retinopathy, hypertensive retinopathy, glaucoma, eye injuries, or complex cataracts. After initial screening, the provider must submit a plan for further treatment (surgery or intravitreal injections, etc.) for pre-approval.

Unclassified injection medications are not covered.

PCHP/HCH Covered Services (Effective 9/1/2024) Page 15

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

• Simple cataract and nonspecific vision problems are not covered.

ORGAN HARVESTING AND

TRANSPLANTS

No Coverage No N/A N/A

ORTHOPEDIC/NEUROSURGERY See Pain Management. Limited coverage with a focus on acute injuries, exacerbations or neurological deficits.

All spinal surgery for chronic issues and all joint replacement procedures must be pre-authorized;

detailed pre-operative criteria include weight loss and other limitations. Tobacco product cessation for 60 days is required. Note: Blood work will be required to document tobacco cessation prior to authorization.

Limited Limited Yes

OUTREACH Outreach services are a broad range of culturally and linguistically appropriate activities focused on recruiting and retaining patients from the target population/service area.

At a minimum, these services must promote awareness of the health center’s services and support entry into care.

If a substantial number of the individuals in the population served by a program are of limited English-speaking ability, the services of appropriate personnel

PCHP/HCH Covered Services (Effective 9/1/2024) Page 16

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

fluent in the language spoken by a predominant number of such individuals).

PAIN MANAGEMENT, ACUTE Covered for acute injury, dental, and pre- and post-surgical ONLY.

Prescription coverage for controlled substances including Tramadol is limited to short term events

ONLY.

Limited Medical Home Yes

PAIN MANAGEMENT, CHRONIC Chronic pain management (defined as 6 months or more in duration) is NOT covered.

Back surgeries are NOT covered unless related to an acute injury or significant neurological deficit.

Other chronic orthopedic surgeries will be reviewed on a case by case basis; approval will be based on client’s use/ cessation of tobacco and alcohol and weight loss, if indicated.

Pain management for hematology/ oncology diagnosis and treatment will be reviewed on a case by case basis and may be covered.

Prescriptions for controlled substances including Tramadol will be covered only when written for acute injury /short-term pain relief, pre- or post-surgical events (neither to exceed 30 days), dental relief of pain, or hematology-oncology clients.

PCHP/HCH Covered Services (Effective 9/1/2024) Page 17

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

Trigger point and Synvisc injections are allowed for clients who have failed conservative management treatment plan; prior review required.

Maximum number of allowable steroid injections is 3 per 12 month period, with 3 month interval and with positive progress report. Note: Provider must document improvement or failure before additional injections will be approved.

Hylagen injections must be obtained from the PAP program. PCHP will administer the medication only.

PHARMACEUTICAL SERVICES

/PRESCRIPTION MEDICATIONS

Pharmaceutical services provide access to prescribed medications. These services may include a broad spectrum of functions ranging from the dispensing and tracking of medications to pharmacist-delivered patient care services (e.g., disease state management, medication reconciliation, therapeutic monitoring, wellness promotion, and disease prevention).

Limitations:

• Prescription coverage is limited to the approved formulary. See link below for full list:

http://www.pinellascounty.org/humanservices/ medical-home.htm

• Prescriptions are limited to ten (10) medical prescriptions and five (5) non-medical

Yes By Referral No http://www.pinellascounty.org/humanservices/medical-home.htm http://www.pinellascounty.org/humanservices/medical-home.htm

PCHP/HCH Covered Services (Effective 9/1/2024) Page 18

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

prescriptions (i.e. supplies) per month with a 30 or 90 day supply.

• Prescriptions for controlled substances are NOT covered unless written for acute injury /short-term pain relief or pre- or post-surgical events-neither to exceed 30 days- and for dental relief of pain or hematology-oncology clients.

• Prescriptions for cancer treatments may be obtained through a Prescription Assistance Program (PAP) (see below) for chemotherapy agents, other medications used to treat cancer cells, and medications to counteract the side effects of chemotherapy, such as damage to bone marrow/blood cells, digestive and reproductive tract lining and hair follicles, nausea and vomiting The PCHP Formulary does not include these medications, and will NOT reimburse unless the PAP option is not available. All oncology medications must be pre-authorized.

• Injectable items such as normal saline, heparin sodium, diphenhydramine HCL, mannitol and selected generic medications are covered.

Prescription Assistance Program:

PCHP/HCH Covered Services (Effective 9/1/2024) Page 19

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

Brand name or non-covered medications may be obtained a Prescription Assistance Program (PAP). The medical home will make referrals/linkages to an available contracted or community provider. See link below for more information.

http://www.healthcouncils.org/html/hc_mednet_bene fits.html

PLASTIC SURGERY Plastic surgery is defined as a surgical specialty dedicated to reconstruction of facial and body defects due to birth disorders, trauma, burns, and disease.

Covered medically necessary plastic surgery procedures may include Breast Reconstruction, Burn Repair Surgery, Congenital Defect Repair: Cleft Palate, Extremity Defect Repair, Lower Extremity Reconstruction, Hand Surgery, Scar Revision Surgery.

Limitations:

• Surgery post-op visits are covered in the Global period (90 days). Any visits after the global period must be pre-authorized.

• Repeat procedures are not covered. Exceptions may be made on a case by case basis and must be pre-approved.

PROSTHETICS and ORTHOTICS Not Covered No N/A N/A

PCHP/HCH Covered Services (Effective 9/1/2024) Page 20

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

PODIATRY Podiatry services treat disorders of the foot, ankle, and related structures of the leg. Yes By Referral Yes

RADIOLOGY Diagnostic radiology services are the processing and interpreting of radiologic images to guide the health center provider’s subsequent care and/or treatment of a patient.

Types of diagnostic radiology (e.g., CT, MRI, diagnostic mammogram, advanced ultrasound, advanced imaging or nuclear medicine) are considered specialty services.

If pre-approved, may be provided at participating doctor’s office if at same rate as free- standing facility.

Limitations: One (1) MRI,CT, or PET scan per body part within a twelve (12) month period is covered.

Note: cervical, thoracic, lumbar and sacral spine are considered separate body parts.

Yes By Referral Yes

RECUPERATIVE CARE

PROGRAM SERVICES

Recuperative care program services are short-term care and case management provided to individuals recovering from an acute illness or injury that generally does not necessitate hospitalization but would be exacerbated by their living conditions (e.g., street, shelter or other unsuitable places).

No N/A N/A

PCHP/HCH Covered Services (Effective 9/1/2024) Page 21

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

SCREENINGS (BREAST,

CERVICAL, PROSTATE,

COLORECTAL, BONE DENSITY,

ETC.)

Screening services are performed based on identified risk factors in the patient population and/or communities to evaluate, treat, and educate a health center patient.

At a minimum, these services include all of the following: cancer, communicable disease, cholesterol and blood lead.

Cancer screenings at a minimum must include, but are not limited to, screening for breast, cervix, and colorectal cancers (e.g., mammography, Pap testing, fecal occult blood testing, sigmoidoscopy, colonoscopy).

Communicable disease screenings at a minimum must include, but are not limited to, testing for tuberculosis, HIV, Hepatitis B and C, and other sexually transmitted diseases/infections based on a patient’s identified risk factors.

Cholesterol screenings are blood tests used to assess and understand a patient’s risk for cardiovascular disease.

Blood lead screenings at a minimum must comply with recommendations of state and/or local health departments for children at-risk for elevated blood lead levels

Yes Medical Home or By Referral

No

PCHP/HCH Covered Services (Effective 9/1/2024) Page 22

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

SEXUAL DYSFUNCTION No Coverage No N/A N/A

SLEEP DISORDERS INCLUDING

INSOMNIA

No Coverage No N/A N/A

STERILIZATION PROCEDURE

INCLUDING REVERSAL

No Coverage, refer to Department of Health-Pinellas at

(727) 462-MALE. No N/A N/A

SUBSTANCE USE Substance use services are screening, diagnosis, and treatment services for substance use disorders (e.g., abuse of alcohol, tobacco, prescription drugs).

At a minimum, these services include:

• age appropriate, harm/risk reduction and age appropriate counseling to address identified risk factors, support abstinence, and/or decrease negative consequences of substance use;

• detoxification to manage withdrawal symptoms associated with substance abuse; and

• treatment/rehabilitation, to include individual and/or group treatment, counseling and case management.

Treatment may occur in out-patient or short-term residential settings and may include medication-

Yes By Referral No

PCHP/HCH Covered Services (Effective 9/1/2024) Page 23

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

assisted treatment (e.g., buprenorphine products, methadone, naltrexone).

SURGICAL PROCEDURES

Must be medically necessary, not for cosmetic purposes. Cosmetic surgery that is not covered includes but is not limited to implants, augmentation, reduction, scar revision, hair transplants, lifts/stretches/injections, weight loss or reconstructive surgery.

Repeat procedures are not covered. Exceptions may be made on a case-by-case basis and must be pre-approved.

Surgery post-op visits are covered in the Global period (90 days). Any visits after the global period must be pre-authorized.

Yes Referral Yes

TEMPORO MANDIBULAR JOINT

SYNDROME

No Coverage No N/A N/A

TRANSPORTATION Transportation services are services that enable patients to access medical home services when transportation would otherwise be a barrier to care (e.g., providing transport vans, bus tokens or vouchers for public transportation, or linkages to other community transportation programs).

Limited By Referral No

PCHP/HCH Covered Services (Effective 9/1/2024) Page 24

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

A 10-day per month bus pass is offered at no charge for patients with a medical appointment in the past 12 months. Patients may upgrade to a monthly pass at the current rate ($6 as of 08/24).

Other direct to appointment car services may be available on a case-by-case basis (cab, uber, etc)

TRANSLATION Translation services are services to make care linguistically accessible and culturally responsive for individuals with limited English proficiency and/or a disability impacting communication.

At a minimum, these services includes the timely availability of professional translation (written) and interpretation (oral) services (e.g., access to bilingual providers, onsite interpreters, language telephone line) based on the primary language(s) spoken by a substantial number of individuals in the health center's target population and service area.

These services also include auxiliary aids to ensure effective communication with individuals who have disabilities.

Yes Medical Home or By Referral

No

VOLUNTARY FAMILY

PLANNING

Voluntary family planning services are appropriate counseling on available reproductive options consistent with Federal, state, local laws and regulations.

Yes Medical Home or By Referral No

PCHP/HCH Covered Services (Effective 9/1/2024) Page 25

SERVICE TYPE SERVICE DESCRIPTION

(definition and/or details on coverage limitations)

COVERED

(YES,

LIMITED OR

NO)

MEDICAL HOME

OR OUTPATIENT

SPECIALTY

REFERRAL

CLINICAL PRE-

AUTHORIZATION

REQUIRED

These services include management/treatment and procedures for a patient's chosen method, e.g., vasectomy, tubal ligation, placement of long-acting reversible contraception (LARC) (IUDs and implants).

Please note pursuant to existing law, and consistent with Executive Order 13535 (75 FR 15599), health centers are prohibited from using Federal funds to provide abortion services (except in cases of rape or incest, or when the life of the woman would be endangered).

WELL CHILD SERVICES Well child services are age-appropriate preventive care and treatment for newborns through adolescents.

At a minimum, these services include regular/periodic physical exams and measurements; appropriate screenings and tests to assess vision, hearing, oral health, growth and development, and immunization status; and health education and counseling.

Services provided by referral only.

Yes By Referral No

WOUND CARE Debridement of wounds must be pre-authorized and must be provided at physician’s office, outpatient surgery contracted facility or through home health provider. Hospital wound care centers may be authorized on case-by-case basis.

Hospital care for burns is covered.

Limited Medical Home & By Referral Yes

PCHP/HCH Covered Services (Effective 9/1/2024) Page 26