Benefits and Covered Services
Certain benefits under the Health Choice Generations plan require a referral or
prior authorization. PCPs are required
to coordinate the member's care by sending the member to a contracted Health Choice
Generations specialist. If a member receives healthcare services from any physician,
hospital or other healthcare provider without getting a referral or authorization
in advance, the member may have to pay for these services. Please click on the "Find
a Doctor" link for a complete listing of Health Choice Generations providers.
The Health Choice Generations Summary of Benefits and Evidence of Coverage list
the benefits which are covered by our plan. Section four in the Evidence of Coverage
lists covered services that need prior authorization.
There are many services a member may obtain on their own, without prior approval
from a provider or Health Choice Generations.
The following services are covered as Preventive Care and do not require prior
There are exceptions to each of the services listed on the next page.
- Colorectal Screenings
- Mammography screenings
- Pap Smears, Pelvic Exams and Clinical Breast Exam
- Prostate Cancer Screening exams
- Cardiovascular Disease Testing
- Physical exams
- Outpatient substance abuse services
- Emergency services
- Urgently needed care
- Physician services, including doctor office visits
- Flu shots and pneumonia vaccinations
- Renal dialysis services that are obtained when a member is temporarily outside the
plan's service area and for the first Renal Dialysis visit so the Health Choice
Case Management department is aware of the member’s dialysis needs and can
coordinate follow-up care (along with the provider). Ongoing dialysis treatment
does not require additional authorization(s).
In addition to any exclusions or limitations described in the HC Generations Evidence
of Coverage and Summary of Benefits, the following items in the list below
are NOT covered except as indicated by Health Choice Generations. They include but
are not limited to:
- Services that are not covered under Original Medicare, unless such services are
specifically listed as covered in Section 4.
- Services that you get from non-plan providers, except for care for a medical
emergency and urgently needed care, renal (kidney) dialysis services that you get
when you are temporarily outside the plan’s service area, and care from non-plan
providers that is arranged or approved by a plan provider. See other parts of this
booklet (especially Sections 2 and 3) for information about using plan providers
and the exceptions that apply.
- Services that you get without a referral from your PCP, when a referral from your
PCP is required for getting that service.
- Services that you get without prior authorization, when prior authorization is required
for getting that service. (Section 4 gives a definition of prior authorization and
tells which services require prior authorization.)
- Services that is not reasonable and necessary according to the standards of original
Medicare unless these services are otherwise listed by Health Choice Generations
as a covered service. As noted in Section 4, we provide all covered services according
to Medicare guidelines.
- Emergency facility services for non-authorized, routine conditions that do not appear
to a reasonable person to be based on a medical emergency. (See Section 3 for more
information about getting care for a medical emergency).
- Experimental or investigational medical and surgical procedures, equipment and medications,
unless covered by Original Medicare or unless services covered under an approved
clinical trial. Experimental procedures and items are those items and procedures
determined by Health Choice and Original Medicare that are not generally accepted
by the medical community. See Section 7 for information about participation in clinical
trials while you are a member of Health Choice Generations.
- Surgical treatment of morbid obesity unless medically necessary and covered under
- Private room in a hospital, unless medically necessary.
- Private duty nurses.
- Personal convenience items, such as a telephone or television in your room at a
hospital or skilled nursing facility.
- Nursing care on a full-time basis in your home.
- Custodial care is not covered by Health Choice Generations unless it is provided
in conjunction with skilled nursing care and/or skilled rehabilitation services.
“Custodial care” includes care that helps people with activities of
daily living, like walking, getting in and out of bed, bathing, dressing, eating,
and using the bathroom, preparation of special diets, and supervision of medication
that is usually self-administered.
- Homemaker services.
- Charges imposed by immediate relatives or members of your household.
- Meals delivered to your home.
- Elective or voluntary enhancement procedures, services, supplies and medications
including but not limited to: weight loss, hair growth, sexual performance, athletic
performance, cosmetic purposes, anti-aging and mental performance unless medically
- Cosmetic surgery or procedures, unless it is needed because of accidental injury
or to improve the function of a malformed part of the body. Breast surgery is covered
for all stages of reconstruction for the breast on which a mastectomy was performed
and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected
- Routine dental care (such as cleanings, fillings, or dentures) or other dental services.
Certain dental services that you get when you are in the hospital will be covered.
- Chiropractic care is generally not covered under the plan, (with the exception of
manual manipulation of the spine, as outlined in Section 4) and is limited according
to Medicare guidelines.
- Routine foot care is generally not covered under the plan and is limited according
to Medicare guidelines.
- Orthopedic shoes unless they are part of a leg brace and are included in the cost
of the leg brace. There is an exception: Orthopedic or therapeutic shoes are covered
for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart
under “Outpatient Medical Services”).
- Supportive devices for the feet. There is an exception: orthopedic or therapeutic
shoes are covered for people with diabetic foot disease (as shown in Section 4,
in the Benefits Chart under “Outpatient Medical Services”).
- Hearing aids and routine hearing examinations.
- Routine eye examinations and eyeglasses (except after cataract surgery), radial
keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
- Self-administered prescription medication for the treatment of sexual dysfunction,
including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
- Reversal of sterilization procedures, sex change operations, and non-prescription
contraceptive supplies and devices. (Medically necessary services for infertility
are covered according to Original Medicare guidelines.)
- Naturopath services.
- Services provided to veterans in Veteran's Affairs (VA) facilities. However, in
the case of emergency services received at a VA hospital, if the VA cost sharing
is more than the cost sharing required under Health Choice Generations, we will
reimburse veterans for the difference. Members are still responsible for the Health
Choice Generations cost sharing amount.
Please see the Health Choice Generations Prior Authorization list for more information
on what services are covered and not covered by the Health Choice Generations plan.
This is not all-inclusive therefore Providers must verify both eligibility and
covered benefits prior to rendering services at (480) 968-6866 and (800) 322-8670.