SERVICES COVERED BY VITAL PLAN

SPECIAL PROGRAM

PAYMENT FOR SERVICES

BENEFICIARIES MANUAL
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SERVICES COVERED BY VITAL PLAN

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Vital Plan offers services to keep you healthy. Vital Plan works with Insurers, who coordinate with you and your doctors to help you access services you need.

You can start getting services as soon as your Medicaid Office tells that you are eligible for the Government Health Program. You don’t have to wait.

As a Vital Plan enrollee, you have a variety of health care benefits and services available to you. Not everyone in Vital Plan has the same benefits. The benefits that are covered for you depend on the group you’re in. Your ID card will tell you what coverage you can get.

Listed below are the services that Vital Plan covers. Some services may have limits. Call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired) if you want more information.

  • Routine doctor office visits, checkups, and sick visits
  • Well-baby visits, well-child visits, and immunizations
  • Tests and studies, laboratory work, and X-rays
  • Preventive services, including mammogram, colonoscopy, and well visits for adults
  • OB/GYN exams and annual Pap tests
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, including periodic preventive health screenings and other necessary diagnostic and treatment services for members ages 21 and under
  • Nutritional evaluations and tests
  • Vision and hearing test
  • Prenatal and postpartum care
  • Family planning
  • Health certificates
  • Dental services
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Physician home visits
  • Pharmacy
  • Care management and care coordination services
  • Emergency services
  • Post-stabilization services
  • Mental health services
  • Visits to specialists
  • Community health clinic services
  • Hospital: inpatient and/or outpatient care
  • Mental health hospitalization and partial hospitalization
  • Ambulatory service center services
  • Surgery: inpatient and/or outpatient
  • Ambulance services
  • Outpatient rehabilitation services
  • Syringes for the administration of medicines at home
  • Health Certificate covered by Vital Plan, any other certificate is excluded
  • Health Certificate that includes diagnosis of sexually transmitted diseases (VDRL) and Tuberculosis.  The Puerto Rico Department of Health charges a nominal fee up to $5.00 for the emission of the certificate.  This is not a copayment for receiving services.
  • Any Health Certificated related to the eligibility of the Medicaid & CHIP program (e.g.  prescription history) will be provided to the beneficiary free of charge.
  • Any Health Certificate required by programs such as Head Start, WIC and Child Care will be provided to the beneficiary free of charge.
  • Any applicable copayment for procedures or laboratories for the emission of a Health Certificate will be the sole responsibility of the beneficiary.
  • Annual Physical exam and follow up to Diabetic patients as per the treatment guide for such patients and the protocols of the Department of Health.  
  • The Contractor shall cover Post-Stabilization Services obtained from any Provider, regardless of whether the Provider is in the General Network or PPN, that are administered to maintain the Enrollee’s stabilized condition for one (1) hour while awaiting response on a Prior Authorization request. The attending Emergency Room physician or other treating Provider shall be responsible for determining whether the Enrollee is sufficiently stabilized for transfer or discharge. That determination will be binding for the Contractor with respect to its responsibility for coverage and payment. 
  • For the list of hospitals and providers network consult your copy of the Provider Directory or see the directory available here.

Vital Plan offers dental services. You can see any dentist that accepts Vital Plan. You can find information about participating dentists in your Insurer’s Provider Directory. When you sign up with your Insurer, they will mail you a Provider Directory. You can choose any pharmacy that works with your Insurer.

You can find a list of participating pharmacies here or you can call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).

Vital Plan offers mental health, alcohol and substances abuse services. You do not have to see your PCP first to see a doctor or other provider for mental health, alcohol or substances abuse services. You can ask for these services whenever you feel like you need them.

Vital Plan wants to make it easy for you to get physical and mental health, alcohol, and substance abuse services in the same place. This is called integrated care.

Your Primary Medical Group is one place you can go to get mental health, alcohol or drug abuse services. Your Primary Medical Group must have a psychologist and/or a social worker available at least from 4 to 16 hours per week during regular business hours.

If you get mental health, alcohol or drug abuse services at another place (like a mental health clinic or a psychiatric hospital), they must have services from a PCP in the office at least part of the time to care for your physical health needs.

If you need help finding mental health, alcohol and substance abuse services, call your Insurer at 1-844-336-3331(toll free), TTY 787-999-4411 (for the hearing impaired).

Vital Plan covers prescription medicines. If you need medicine, your provider will write you a prescription to take to a participating pharmacy. You can choose any pharmacy that works with your Insurer. You can choose any pharmacy that works with your Insurer. You can find a list of participating pharmacies here or you can call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).

Prescription medicines are free for children up to the age of 20 and for pregnant women. Other adults will need to pay for prescription drugs. For more information on payments for prescription medicines, look here.

Your Covered Drugs Formulary (CDF) is the list of medicines Vital Plan covers. This list helps your doctor prescribe medicines for you. Brand-name and generic medicines are on the CDF. A generic version of a medicine is the first choice. If a generic version of a medicine is available, your doctor has to prescribe the generic version.

If you have a chronic condition, your doctor can write a prescription for a 90-day supply of some medicines. This way, you only have to pay for the medicine once instead of paying three times (1 payment per month).

Here is a general list of some services that are not covered by Vital Plan. You can call your Insurer at 1-844-336-3331(toll free), TTY 787-999-4411 (for the hearing impaired) for a full list.

Some non-covered services are:

1. Services for non-covered illnesses or trauma.
2. Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its acronym in Spanish).
3. Accidents on the job that are covered by the State Insurance Fund Corporation.
4. Services covered by another insurance or entity with primary responsibility (third party liability).
5. Specialized nursing services for the comfort of the Patient when they are not medically necessary.
6. Hospitalizations for services that can be rendered on an outpatient basis.
7. Hospitalization of a Patient for diagnostic services only.
8. Expenses for services or materials for the Patient’s comfort such as telephone, television, admission kits, etc.
9. Services rendered by Patient’s relative (parents, children, siblings, grandparents, grandchildren, spouse, etc.).
10. Organ and tissue transplants, except skin, bone and corneal transplants.
11. Weight control Treatments (obesity or weight increase for aesthetic reasons).
12. Sports medicine, music therapy and natural medicine.
13. Cosmetic surgery to correct physical appearance defects.
14. Services, diagnostic tests ordered or provided by naturopaths, and iridologists.
15. Health Certificates except for (i) venereal disease research laboratory tests, (ii) tuberculosis tests and (iii) any certification related to the eligibility for the Medicaid program.
16. Mammoplasty or plastic reconstruction of breast for aesthetic purposes only.
17. Outpatient use of fetal monitor.
18. Services, Treatment or hospitalization as a result of induced, non-therapeutic abortions or their complications.
19. Medications delivered by a provider that does not have a pharmacy license, with the exception of medications that are traditionally administered in a doctor’s office such as an injection.
20. Epidural anesthesia services.
21. Educational tests, educational services.
22. Peritoneal dialysis or hemodialysis services (Covered under the Special Coverage).
23. New or experimental procedures not approved by ASES to be included in the Basic Coverage.
24. Custody, rest and convalescence once the disease is under control or in irreversible terminal cases (hospice care for members under 21 is part of basic coverage).
25. Services covered under the Special Coverage.
26. Services received outside the territorial limit of the Commonwealth of Puerto Rico, except for emergency services for Medicaid or CHIP beneficiaries.
27. Judicial order for evaluations for legal purposes.
28. Counseling services or referrals based on moral or religious objections of the Insurer are excluded.
29. Travel expenses, even when ordered by the PCP, are excluded.
30. Eyeglasses, contact lenses and hearing aids (for members over age 21).
31. Acupuncture services.
32. Procedures for sex changes, including hospitalizations and complications.
33. Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to procreate.

 

 

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