Ch 4: Member Benefits, Exclusion, & Limitations

This Chapter Includes:

1. Member Benefit Plans

2. Network Development & Maintenance 3. Tertiary Care

Alert

Alert draws attention to critical information that has changed this year.

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Contact information on who to contact for assistance.

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Back to Chapter 4 Table of Contents

VHP network providers render a variety of health care services pursuant to the benefit limitations and exclusions reflected in the member’s Evidence of Coverage (EOC). You can find the EOCs for the Covered California/IFP and the Employer Group Lines of Business on the VHP website at https://www.

valleyhealthplan.org/sites/m/mm/Pages/evidenceofcoveragebookletanddisclosureform.aspx.

For specific benefits questions or assistance, please contact Member Services at 1.888.421.8444.

Providers need to validate VHP Commercial Employer Group, Covered California and Individual & Family Plan member eligibility and benefits prior to rendering services to VHP members. To confirm a VHP member’s eligibility, please refer to the Valley Express online eligibility system available at https://www.valleyhealthplan.org/sites/p/fr/auths/Pages/home.aspx or contact VHP’s Member Services Department Monday through Friday, 8 am to 5 pm (Pacific) at 1.888.421.8444.

If you do not have access to the online system, and you wish to obtain access to Valley Express to verify eligibility, please call Provider Relations at 1.408.885.2221. A copy of the VE Access Form is included in the Appendix.

Disclaimer: Members must present their VHP identification card whenever they seek services. Providers must check eligibility at each visit. Possession of a VHP ID card does not guarantee eligibility or payment.

Member Benefit Plans

Employer Group Plan (Classic and Preferred): Members are not responsible for any cost sharing for covered services unless specified (e.g., cost share applies to acupuncture and chiropractic care). Refer to the member’s EOC at https://www.valleyhealthplan.org/sites/m/

mm/Documents/VHP-Employer-Group-EOC-2020-Final.pdf

Covered California and Individual & Family Plan: Members are responsible for deductibles, coinsurance, and copayments, which apply to many covered services. Refer to the member’s EOC at

https://www.valleyhealthplan.org/sites/m/mm/Documents/2021-CoveredCalifornia-IFP-EOC.pdf

The following list is not intended to be an all-inclusive list of covered and non-covered benefits. All services are subject to benefit coverage, limitations, and exclusions as described in the EOC. Some services require prior authorizations before services are rendered. For more information on services requiring prior authorization, see Chapter 17, “Utilization Management” for additional information.

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Benefits

Abortion

Acupuncture

Allergy Testing

Bariatric Surgery

Clinical Trials

Chemotherapy, Radiation CC & IFP EG Details and Limitations

Refer to “Family Planning” in the EOC.

Acupuncture services are provided for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain. Services are available within VHP’s contracted provider network and may be authorized through the member’s PCP or other VHP contracted providers. In the event services require more than 20 prescribed visits per calendar year, justification is required from the requesting provider.

Allergy testing and treatment including serum and injection services are covered.

Provided for the treatment of morbid obesity when medically necessary.

Coverage is limited to routine patient care costs in accordance with State and Federal regulations. Covered services are only available if: • Member has been diagnosed with cancer or other life-threatening disease or condition; • Member is accepted into a Phase I through Phase

IV clinical trial; or • VHP’s contracted provider has recommended member’s participation in the trials because it will have a meaningful potential benefit to the member.

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Benefits CC & IFP

Chiropractic Care

Cosmetic Surgery

Contraceptive Methods

Dental Anesthesia

Diabetes Education, Management, & Treatment

Dialysis Durable Medical Equipment (DME) EG Details and Limitations

Employer Group Members – Covered

Services are available within VHP’s network of contracted providers and may be authorized through the member’s PCP or other VHP contracted provider. Coverage is limited to a maximum of 20 prior authorized visits per calendar year. In the event services require more than 20 prescribed visits per calendar year, justification is required from the requesting provider. Services, which are not chiropractic related such as x-rays or nutritional counseling, are not covered benefits and will not be reimbursed by VHP.

Except for medically necessary cosmetic surgery or plastic surgery as specified under the EOC section “Mastectomies and Lymph Node Dissections,” cosmetic surgery and plastic surgery are excluded from coverage by VHP.

Coverage includes diaphragms, cervical caps, contraceptive rings, contraceptive patches, and oral contraceptives (including emergency contraceptive pills). All FDA-approved contraceptive drugs, devices, and products available over the counter (OTC) are covered when prescribed by VHP contracted providers and filled at a VHP contracted pharmacy.

Diabetes education and management are covered. For diabetes medication treatment, refer to VHP’s preferred medication formulary on VHP’s website.

https://www.valleyhealthplan.org/sites/m/pn/Pharm/

Pages/Pharmacy.aspx

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Benefits CC & IFP EG Details and Limitations

Emergency Room Services Emergency Transportation/ Ambulance Hearing Aids Home Health Care Services Hospice Services Infertility Treatment

Emergency room services for non-emergency care are

excluded from coverage.

Ambulances are covered for emergencies.

For non-emergencies, transportation is a covered benefit with prior authorization from VHP.

COCA/IFP Members – Not Covered

Only covers internally-implanted devices as described in the “Prosthetic and Orthotic Devices section of the member’s EOC.

Employer Group Members – Covered

Hearing Aid benefits are limited to once every 36 months and up to a coverage maximum of $1,000.00, regardless of the number of hearing aids or devices prescribed under the member’s benefit plan.

Limitations & Exclusions include:

Meals, childcare, in-home day care, & housekeeping services.

Coverage is limited to members who have been given a prognosis of 12 months or less to live. Coverage is limited to a maximum of 366 days of hospice care, including five (5) consecutive days of inpatient respite care.

Employer Group Members – Covered

Covered when medically necessary. Please refer to the EOC section “Family Planning Services, Infertility Diagnosis and Treatment” for detailed benefits, exclusions, and limitations.

Covered when medically necessary. Please refer to the information under the “Family Planning Services” section of the EOC for detailed benefits, exclusions and limitations.

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Benefits

Infusion Therapy CC & IFP

Inpatient Hospital Services (e.g., Hospital Stay)

Laboratory Outpatient & Professional Services

Long-Term/Custodial Nursing Home Care EG Details and Limitations

Refer to VHP’s preferred medication formulary:

https://www.valleyhealthplan.org/sites/m/pn/Pharm/ Pages/Pharmacy.aspx

Services include: • Semi-private room and board, intensive care, operating room, inpatient drugs, X-rays, lab tests, supplies, acute rehabilitation, dialysis, and medically necessary blood, blood derivatives, and transfusions (blood bank); • Ancillary services, such as laboratory, pathology, radiology, radiation therapy, cathode ray scanning, inhalation and respiratory therapy, physical therapy, occupational therapy, and speech therapy; • Diagnostic and therapeutic services; • Discharge planning services and the coordination and planning of such continuing care; • Surgical and anesthetic supplies furnished by the hospital as a regular service; • Physician and surgeon care; and • Inpatient skilled nursing care.

Routine laboratory testing as part of an approved office visit do not require authorization. VHP follows the guidelines provided by the U.S. Preventive Services Task Force Grade A and B preventive services:

https://www.uspreventiveservicestaskforce.org/ uspstf/recommendation-topics/uspstf-and-brecommendations

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Benefits

CC & IFP

Maternity Care

Mastectomies & Lymph Node Dissections

Mental/Behavioral Health Inpatient Services

Mental/Behavioral Health Outpatient Services

Nutritional Counseling

Outpatient Facility (e.g., Ambulatory Surgery Center) EG Details and Limitations

Coverage includes prenatal and postnatal care with in-network providers. The mother and newborn child are entitled to at least 48 hours of inpatient hospital care following a normal vaginal delivery or 96 hours following a delivery by cesarean section. An earlier discharge may be arranged when the decision is made jointly by the member and attending physician. Ipatient hospital services for the baby after the member has been discharged are considered a separate hospital admission.

Enrollment of the newborn is required for continued coverage. To ensure continued coverage, members must enroll their newly eligible dependent(s) within 31 days after birth. If members fail to do so, they must wait until their employer’s next Open Enrollment Period to enroll the baby.

Amniocentesis, ultrasounds, or any other procedure performed solely for the purpose of sex determination are excluded.

Coverage includes medically necessary mastectomies and lymph node dissections. This includes hospitalization, office visits, and physician and surgeon costs. Covered services include prosthetic devices and reconstructive surgery, including devices or surgery to restore and achieve symmetry for the patient incident to the mastectomy.

Refer to Chapter 19, “Behavioral Health Services.”

Refer to Chapter 19, “Behavioral Health Services.”

Except for health education classes, nutritional counseling is not a covered benefit.

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Benefits

Outpatient Surgery Physician/Surgical Services

Phenylketonuria (PKU) CC & IFP

Prescription Drugs: Generic/Preferred Brand/ Non-Preferred Brand/ Specialty

Previously Prescribed Prescription Drugs

Preventive Care/Screening/ Immunization EG Details and Limitations

Prescriptions filled at an out-of-network pharmacy are covered if related to care for a medical emergency or urgently needed care. If the requested prescription is not listed on the formulary, a prior authorization is required.

Refer to VHP’s preferred medication formulary for drug benefit coverage:

https://www.valleyhealthplan.org/sites/m/pn/Pharm/ Pages/Pharmacy.aspx

Refer to Chapter 16, “Pharmacy Services.”

Preventive and immunization services are covered services in accordance with the Centers for Disease Control (CDC), Preventive Services Task Force A and B guidelines.

Refer to the U.S. Preventive Services Task Force for a complete list of preventive services:

https://www.uspreventiveservicestaskforce.org/Page/ Name/uspstf-a-and-b-recommendations/

Travel health immunization consultations are not a covered benefit.

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Benefits CC & IFP

Preventive Services

Private-Duty Nursing

Reconstructive Surgery

Rehabilitative Occupational, Speech, & Physical Therapy

Routine Foot Care

Routine Vision Services EG Details and Limitations

Services for children and adults include but are not limited to preventive health assessment visits, well-child screenings and immunizations. Well-child preventive exams are covered for members through age 23 months.

Pediatric/well-child care, including periodic office visits, diagnostic laboratory services, immunizations, pediatric asthma services, and the testing and treatment of phenylketonuria (PKU) may be covered. The age, health status, and medical needs of the child determine the frequency of these examinations.

Reconstructive surgery is covered to reconstruct a breast after it is fully or partially removed. Reconstructive surgery is also a covered benefit if the provider determines it is medically necessary improve the function or create a normal appearance of an abnormal structure.

Vocational rehabilitation is excluded.

Excludes the trimming of corns, calluses, and nails, unless medically necessary.

For Covered California and IFP: Prior authorization for low vision aids and low vision exams. Eyeglasses and contact lenses are covered for children who are under the age

of 19 only.

For Employer Group: Eye examinations, eyeglass lenses, frames and contact lenses and other routine services are covered through Vision Service Plan (VSP).

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Benefits CC & IFP

Skilled Nursing Facility (SNF)

Specialist Visit

Substance Abuse Disorder Inpatient Services

Substance Abuse Disorder Outpatient Services

Transplant

Transportation EG Details and Limitations

Covered CA and IFP members: Coverage is limited to 100 days per calendar year of prescribed and authorized skilled nursing services in a VHP contracted SNF or a skilled nursing bed in a VHP contracted hospital.

Employer Group members (Classic and Preferred):

Coverage is limited to a maximum of 100 days per calendar year.

A referral from the member’s PCP is required.

Failure to receive prior authorization approval by VHP will result in the denial of the unapproved specialty visit and all services rendered in conjunction with that visit.

Refer to Chapter 19, “Behavioral Health Services.”

Refer to Chapter 19, “Behavioral Health Services.”

Limitations & Exclusions include:

Services for organ, tissue and bone marrow transplant treatment are subject to the limitations and exclusions as outlined under the member’s EOC. Services must meet the medically necessary criteria and be approved by VHP.

Organ donor searches and recipient or donor transportation costs to the transplantation center are excluded from coverage under the benefit plan.

Emergency medical transportation: Covered. Non-emergent medical transportation: Covered only for medically necessary inter-facility transportation.

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Benefits CC & IFP EG Details and Limitations

Treatment for Temporomandibular Joint (TMJ) Disorders Urgent Care Centers or Facilities X-Ray & Diagnostic Imaging (CT/PET Scans, MRIs)

Services include the evaluation and treatment of medically necessary TMJ dysfunction, including the provision of prescribed intra-oral appliances.

Limitations & Exclusions includes:

A lifetime limitation of $800.00 applies to the cost of any intra-oral positioning device and related services.

Routine dental services and dental treatment are excluded

services.

Routine x-rays and diagnostic imaging performed as part of an approved office visit do not require an authorization.

Network Development and Maintenance

VHP facilitates the provision of covered services as specified by Department of Managed Health Care (DMHC). Our approach to developing and managing the provider network begins with a thorough analysis and evaluation of the DMHC network adequacy requirements. VHP maintains a network of qualified providers in sufficient numbers, geographic distribution, and specialty coverage to meet the medical needs of its members. This includes consideration of the needs of adults and children, as well as members’ travel requirements, so that VHP’s network complies with DMHC access and availability requirements.

VHP offers a network of PCPs to provide each member with access to primary care within the required travel distance standards. Providers who may serve as PCPs include internists, pediatricians, obstetrician/ gynecologists, family, and general practitioners.

In the event VHP is unable to provide medically necessary services required for a member, VHP will facilitate timely and adequate coverage of these services through an out-of-network provider, and coordinate the authorization and payment in these circumstances, until such time that a network provider is contracted.

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For assistance in making a referral to a non-contracted specialist or subspecialist for a VHP member, contact VHP’s Utilization Management team at 1.408.885.4647 (For TTY, contact California Relay by dialing 711 and provide the number 1.800.735.2929) and VHP will identify a provider for the necessary referral.

Tertiary Care

VHP offers a network of tertiary care providers inclusive of level one and level two trauma centers, neonatal intensive care units, perinatology services, comprehensive cancer services, comprehensive cardiac services, and pediatric subspecialists available 24 hours per day. In the event VHP is unable to provide the necessary tertiary care services required, VHP will facilitate timely and adequate coverage of these services through an out-of-network provider, until a network provider is contracted, and coordinate the authorization and payment in these circumstances.

VHP has contracted with tertiary and quaternary care hospitals which may only be utilized when services are not otherwise available in the primary network chosen by the member. For further information about referrals to these facilities or for assistance in making a referral to a non-contracted tertiary and quaternary care hospital for a VHP member, contact VHP’s Utilization Management team at 1.408.885.4647 (for TTY, contact California Relay by dialing 711 and provide the number 1.800.735.2929) and VHP will identify a provider for the necessary referral.

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