| MMA Expanded
|Adult Dental Services
||One (1) exam
every six (6) months; one (1) cleaning every six (6) months; one
comprehensive exam every thirty-six (36) months; one (1) comprehensive x-ray
every thirty-six (36) months; two (2) preventive x-rays every (12) months;
two (2) simply extractions per year by a general dentist.
preventive hearing screening per year.
|Home and Community Based Services
services post hospitalization discharge; limited to two (2) visits within
seven days of discharge; maximum two (2) hours per visits; limited to
enrollees without in-home supports; subject to prior authorization.
|Home Health Care (Non-Pregnant Adults)
||Three (3) visits
per day; limited to enrollees post hospitalization.
|Influenza Vaccine (Adult)
vaccination per year.
|Medically Related Lodging & Food
($70) per day for enrollee's parent or caregiver; limited to child enrollees;
only available if enrollee is required to travel more than one-hundred-twenty
(120) miles from home for medically necessary treatment; limit of twenty-five
dollars ($25) per day for food included in per diem; not available for the
days an enrollee is receiving inpatient treatment; not available if staying
overnight in a private residence; subject to prior authorization.
male enrollees upon request up to twelve (12) weeks old.
visits per year referral required; subject to prior authorization.
||One (1) speech
therapy evaluation; maximum three (3) speech therapy visits per week for
three (3) weeks (9 visits total); limited to adult enrollees; subject to
|Over-The-Counter OTC) Medication/Supplies
dollars ($25) per household per month.
|Physician Home Visits
||Two (2) primary
care specialty visits per month; limited to homebound enrollees; subject to
|Pneumonia Vaccine (Adult)
vaccinations per lifetime; subject to prior authorization.
|Post Discharge Meals
||Two (2) meals
per day for five (5) days; limited to enrollees post hospitalization where no
in-home support present; physician request required; subject to prior
prenatal visits for high-risk pregnancies; one (1) postnatal visit within
eight (8) weeks of delivery for all pregnancies.
|Primary Care Visits (Non-Pregnant Adults)
||One (1) visit per day.
|Shingles Vaccine (Adult)
vaccination per lifetime; subject to prior authorization.
||One (1) set of
glasses every two (2) years; subject to medical necessity and prior
not be subject to co-payment charges with the exceptions of: denture