There are limits for certain MA covered benefits for adult MA and adult General Assistance (GA) MA recipients. These recipients include (a) adult MA and adult General Assistance MA recipients who have cash benefits under TANF, (SSI), or GA and (b) adult MA recipients authorized under (MAWD), (BCCPT), and MA (Home and Community Based Services (HCBS) Waivers). The MA benefit limits are described below.
NOTE: These MA benefit limits do not apply to the following individuals:
Any recipient under 21 years of age
Pregnant women, including throughout the 60-day period following birth
State Blind Pension recipients
Up to a total of 18 clinic, office, or home visits each fiscal year for doctors, podiatrists, optometrists, certified registered nurse practitioners, chiropractors, outpatient hospital clinics, independent medical clinics, rural health clinics, and federally qualified health centers
NOTE: Only a specific list of billable procedures count toward this limit. Providers should have information about these procedures.
1 inpatient medical rehabilitation hospital admission each fiscal year.
Up to 30 days of inpatient psychiatric hospital services each fiscal year.
Up to 540 hours of psychiatric partial hospitalization services each fiscal year.
Up to 5 full-hour or 10 half-hour sessions of psychotherapy (individual, group, family, or collateral) in an outpatient psychiatric clinic in a 30-day period.
NOTE: If a recipient needs more services beyond these limits, the recipient or provider may ask for an exception through DHS. See Section 338.54 Exception Requests information.
Up to total of 18 clinic, office, or home visits each fiscal year for doctors, podiatrists, optometrists, certified registered nurse practitioners, chiropractors, outpatient hospital clinics, independent medical clinics, rural health clinics, and federally qualified health centers
NOTE: Only a specific list of billable procedures count toward this limit. Providers should have information about these procedures.
1 inpatient medical hospital admission each fiscal year.
1 inpatient medical rehabilitation hospital admission each fiscal year.
Up to 30 days of inpatient psychiatric hospital services each fiscal year.
Up to 540 hours of psychiatric partial hospitalization services each fiscal year.
Up to 5 full-hour or 10 half-hour sessions of psychotherapy (individual, group, family, or collateral) in an outpatient psychiatric clinic in a 30-day period.
Up to 30 visits each fiscal year by a home health agency.
Up to 6 prescriptions and refills each month, for General Assistance MA recipients who qualify for pharmacy benefits.
Up to 30 days of drug and alcohol inpatient hospital care each fiscal year.
Services in an emergency room, limited to emergency care only.
Ambulance services, limited to medically necessary emergency transportation and transportation from a hospital to a non hospital drug and alcohol detoxification and rehabilitation facility.
NOTE: If a recipient needs more services beyond these limits, the recipient or provider may ask for an exception through the DHS. See Section 338.54 for information about Exception Requests.
New Pharmacy limits have been implemented for those individuals under Fee-of-Service. For more information see:
Updated February 14, 2012, Replacing June 28, 2007