Benefits & Services
Case & Disease Management
Case management is a benefit offered at no cost to you. Our goal is to help you be healthy. A staff of nurses will help you and/or a family member get the health care you need. The nurses can help you understand your medicines. They can also answer many health questions you have. They will work with you and your PCP to get any services you need to keep you healthy. They can help you with your medicines. A case manager is assigned to each ALTCS member. The case manager works with your primary care provider to coordinate your care. Your case manager must authorize all services provided through ALTCS. Your case manager will provide you with contact information in case you need information in between visits. For more information please call and ask about Case Management at (833) 318-4146.
Disease Management is another service offered at no cost to B – UFC members. If you have a health problem such as diabetes or asthma, or if you are looking for ways to stay healthy, our Disease Managers are here to help you. Please call and ask about Disease Management at (833) 318-4146 for more information.
If you are 21 years or older, you have covered dental services. Your dental services will have a limit of $1,000 per benefit year. Any unused benefit will not roll over to the next year. You may be billed for any services that are over the limit. Some dental services may have limits and/or prior authorization requirements. Please contact your Case Manager or Customer Care Center if you have any questions.
- All health plan members ages 20 and younger are assigned to a Dental Home, also known as a Primary Dental Provider (PDP). A Dental Home is a dentist’s office that is visited every six months for a check-up.
- All dental health checkups, cleanings and treatments are covered for health plan members ages 20 and younger.
- Children do not need to be referred by his/her PCP to see a dentist. (Go to page XX for help on making a dental appointment).
At 12 months of age children should begin to see a dentist for a checkup every six months. B – UFC sends dental checkup reminders. Dentists can help prevent cavities. They can use dental sealants (a coating painted on the back teeth) and fluoride treatments. Dentists also teach you and your child how to care for teeth. It is important for your child to go to the dentist every six months.
Look in the Provider Directory to choose a dental clinic near you or call our Customer Care Center for help scheduling a visit.
Use these guidelines for scheduling appointments for your child:
- Emergency dental appointments – same day appointments; for extreme pain and dental emergencies.
- Urgent dental appointments – within 3 days for lost fillings, broken tooth.
- Routine dental appointments – within 45 days, for routine checkups and dental cleanings.
- Make sure you take your child’s B – UFC ID card with you to the dental appointment.
Well-child Care / Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
B – UFC wants to help your children grow up healthy. Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid members in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS recipients less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in federal law 42 USC 1396d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS state plan.
Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness do not apply to EPSDT services.
A well-child visit is synonymous with an EPSDT visit and includes all screenings and services described in the AHCCCS EPSDT and dental periodicity schedules.
Amount, Duration and Scope
The Medicaid Act defines EPSDT services to include screening services, vision services, dental services, hearing services and “such other necessary health care, diagnostic services, treatment and other measures described in federal law subsection 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the (AHCCCS) state plan. This means that EPSDT covered services include services that correct or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening process when those services fall within one of the 29 optional and mandatory categories of “medical assistance” as defined in the Medicaid Act. Services covered under EPSDT include all 29 categories of services in the federal law even when they are not listed as covered services in the AHCCCS state plan, AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost effective.
EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory and x-ray services, physician services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also includes diagnostic, screening, preventive and rehabilitative services. However, EPSDT services do not include services that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions.
Coordination of care with schools and state agencies may occur within the limits of applicable regulations.
EPSDT/WELL CHILD VISITS INCLUDE:
- A comprehensive health and developmental history, including growth and development screening which includes physical, nutritional and behavioral assessments
- Nutritional Assessment provided by a PCP
- Behavioral Health Screening and services provided by a PCP
- Developmental Screening Tools used by a PCP
- A comprehensive unclothed physical examination
- Appropriate immunizations according to age and health history
- Laboratory tests including blood lead screening assessment and blood lead testing appropriate to age and risk. Required blood lead screening for children under six years of age is based on the child’s risk as determined by either the member’s residential zip code or presence of other known risk factors
- Health education, counseling, and chronic disease self-management
- Appropriate oral health screening, intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician assist or nurse practitioner
- Appropriate vision, hearing and speech screenings
- TB testing as appropriate to age and risk
- Eye examinations and prescriptive lenses
- Ocular photoscreenng for children ages 3-5 is covered when due to challenges with a child’s ability to cooperate with traditional vision screening techniques. Limited to lifetime coverage of 1
- Medicines listed in the B – UFC Drug Formulary
- Special medical foods when medically necessary
- Well-Child* Care will also give you ideas about how to:
- Keep your child well
- Protect your child from getting hurt
- Spot health problems early
- Apply for services like WIC, Head Start, Children’s Rehabilitative Services (CRS), and the Arizona Early Intervention Program (AzEIP).
Some of the medical services may need prior approval by B – UFC. If they do, your provider must request prior authorization for these services. B – UFC must review these authorization requests before you can get the service.Your PCP’s office will let you know when authorization is obtained. No prior authorization is necessary for emergency care.
*Prior authorization means your doctor has requested permission for you to get a special service. B – UFC must approve these requests before the delivery of services. Prior authorization is approved based on a review of medical need.
You can also call our Customer Care Center to find out the status of the request. B – UFC will let you know by mail if prior authorization is denied. In the letter, you will have instructions on how to file an appeal. The letter will also describe the reason for the denial. If you have a question about the denial and need help, please call or our Customer Care Center or write to us.
You do not have to see your PCP for the following services:
- Emergency Services
- Behavioral Health issues
- OB/GYN services
- Dental services
The care listed below will be covered through B – UFC. Some services may have limitations and/or require a prior authorization, contact our Customer Care Center for more information:
- Ambulance for emergency care
- Behavioral Health Care
- Care while you are pregnant
- Case management
- Checkups for children, pregnant women, QMB, and SMI members
- Children’s services including routine dental care
- Chiropractic services for children and QMB
- Emergency medical and surgical services related to dental (oral) care
- Disease Management
- Emergency or Urgent Care medical treatment
- Eyeglasses or contacts for children, or adults only after cataracts are removed
- Family planning / birth control
- Health care services through screenings, diagnosis and medically necessary treatments for members 21 years of age or older
- Hospice care
- Hospital care
- Lab work and x-rays
- Medical tests
- Medically needed foot care performed by a licensed podiatrist,a Podiatrist may provide foot care for members when ordered by a primary care physician or primary care practitioner
- Medicine from the approved drug list, the B – UFC Drug Formulary.
- Organ transplants
- PCP office visits
- Preventative and routine gynecological services for female members (no referral needed)
- Transportation to health care visits
- Speech, Physical and Occupations Therapies
- Second opinions: You have the right to have a second opinion from a qualified health care professional within the network. If one is not available in the network, you have the right to request a second opinion outside the network at no cost to you.
- Skilled nursing home care
- Supplies and equipment, including B – UFC Drug Formulary diabetic testing equipment and supplies
- Well-child checkups including dental, hearing, shots and vision care
Your PCP may want you to see a specialist or get special services. He/she will arrange for the special care listed below. Some of these may require prior authorization from B – UFC:
- Diet and health teaching
- Home health care
- Organ transplants
- Skilled nursing home care
- Rehabilitation services like physical therapy
- Occupational therapy, or speech therapy (for members 20 years and younger)
- Specialist careSocial Services
Tobacco Education and Prevention
The B – UFC Tobacco Cessation Program offers a number of nicotine replacement products (patches, lozenges, gum) and medications to help you quit tobacco. When you and your doctor decide which product is best for you, a twelve week supply is available by prescription every six months as necessary. Only one product can be selected at a time. Members also have no cost telephone support from the Arizona Smoker’s Hotline (ASHLine) sponsored by the Arizona Department of Health Services and Prevention Program (ADHS-TEPP). ASHLine can help you at no cost by setting a quit date and giving you support. If you would like more information about quitting tobacco, please call the ASHLine at (800) 556-6222 or visit the ASHLine website.
Transition of Care
The Arizona Long Term Care System (ALTCS) Transitional program is for current ALTCS members whose condition has improved. These members do not need care at a Nursing Facility (NF) or Intermediate Care Facility (ICF). These members still need some long term care services. Members qualify to get other ALTCS services that are medically needed.
ALTCS Transitional members may have a short stay in a NF or ICF if the medical condition gets worse for a short time. The member may have up to 90 straight days of care at any one admission if medically needed.
Your condition is a medical emergency when your life, body parts or bodily functions are at risk of damage or loss unless immediate care is received.
Members can get rides to doctor appointments in several ways. The easiest way is to find a ride with a family member or a friend. There is a mileage reimbursement program available. Before you have a family member or friend transport you to an appointment, please call us for more information. Your family member or friend may be paid for this service.
You can contact Customer Care to see if you qualify for bus tickets to go to medically necessary visits. This is usually only available in urban areas with a public bus system. Providers must be in our network for you to use your bus tickets.
Call Customer Care at least 72 hours before your scheduled visit. Same day transports may not always be available due to the number of transportation vehicles in all counties.
On weekends and holidays, you can call our Customer Care Center for taxi rides to urgent care centers when you are sick. Always remember to dial 911 if it is a medical emergency.
CAR SEAT, WHEELCHAIR OR STRETCHER
If you need a car seat, wheelchair or a stretcher for your ride to a routine doctor’s visit, please be sure to specify that when arranging a ride. You must call our Customer Care Center at least 72 hours before your appointment date.
CHILDREN, COMPANIONS OR ESCORTS
B – UFC allows Member and one additional passenger per transport. More than one additional passenger is allowed if that person is a minor under the care and supervision of the Member, or has a medical condition. If the member is a single caregiver with more than one minor child in his/her care, B – UFC allows the additional minor children to be transported. Please be sure to call 72 hours or more in advance if car seats are needed for the additional passengers. Not all taxis can accommodate more than 3 passengers.
IF YOU CALL TO GET A RIDE TO A MEDICAL APPOINTMENT, PLEASE BE READY TO TELL THE REPRESENTATIVE THE FOLLOWING:
- Your name, AHCCCS ID number, date of birth, address, phone number (for verification purposes)
- The date, time and address of your medical visit
- If you need a ride one way or a round trip
- Your travel needs (wheelchair, stretcher or other)
- Any special needs (oxygen, IVs, someone who needs to travel with you, an extra-wide or electric wheelchair, a high-top vehicle, etc.)
- Children under the age of 5 require a car seat. Let the representative know if you do not have a car seat
CANCELING RIDES TO YOUR APPOINTMENTS
If you cancel your doctor or dentist visit, you must also call B – UFC Customer Care Center to cancel your ride to your visit.
URGENT CARE AND EMERGENCY ROOM USE
An Urgent Care is a great place to get medical help because they usually have extended hours, specialists for common problems, and can see you quickly (usually less than an hour)! Urgent Care Centers can help you with ear infections, sore throats, urinary tract infections, minor cuts and burns, sprains, and other common health issues. The Urgent Care can be used for problems your doctor would normally help with. If your doctor wouldn’t be able to take care of the problem, the Urgent Care probably can’t either. Emergency rooms are good choices if you have broken bones, cannot stop bleeding, or you are experiencing chest pains or shortness of breath.
COPAYS for Taxi transportation
Members residing in Maricopa and Pima Counties may have a $2.00 per trip copayment.
*The copayment will be charged each time a taxi is called. B – UFC does not have the authority to waive co-pays for transportation per AHCCCS rules.
If a taxi waits for a member, e.g., while the member picks up a prescription, then a $2.00 copay cannot be charged for the continuation of the one-way trip. If you need to cancel your transportation please call the Customer Care Center 24 to 72 hours in advance.