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Eligibility for the Ector County Hospital District Assistance Program (ECHDA)

General Overview

Ector County Hospital District was created in November of 1989. It is the responsibility of the District to provide an adequate level of healthcare services for needy inhabitants of the District. Such services shall be provided by the mandated provider, Medical Center Hospital, of Odessa, Texas.

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Policy

Reviewed Date: 9/21/2015 Effective Date: 10/01/2015

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Policy Memorandum & Financial Assistance

Reviewed Date: 9/20/2013 Effective Date: 9/20/2013

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General

This policy is intended as a guideline for eligibility determination of the individual and the responsibility of Ector County Hospital District Assistance (ECHDA). ECHDA shall exercise its best judgment in determining the ability of patients and/or legally responsible individuals to make payments for services provided, taking into consideration the rights and human dignity of the applicant.

The request for assistance and the proof of eligibility is the responsibility of the applicant. The District’s responsibility is:

  • To advise the applicant of policies and procedures governing the request for medical assistance.
  • To assist the applicant in completing the application.
  • To render a written decision based upon its findings.

Applicants are assured of confidentiality of both financial and medical information.

Since each application and the circumstances surrounding the applicant are closely reviewed, it may become necessary to make exceptions to this policy. The Chief Financial Officer or designee may waive or make exceptions to the guidelines governing this policy.

The department responsible in carrying out the Assistance Program of the District is ECHDA. The offices are located at 425 N Sam Houston, Odessa, TX. Hours of operation are Monday through Friday, except holidays, from 8:00 a.m. to 5:00 p.m. The phone number is (432) 640-1053.

Application

Applications for ECHDA are available upon request at the following locations:

Ector County Hospital District Assistance
425 N Sam Houston
Odessa, TX 79761
(432) 640-1053

Medical Center Health System Business Office
425 N Sam Houston
Odessa, TX 79761
(432) 640-1000

MCHS Family Health Clinic
840 W Clements
Odessa, TX 79763
(432) 333-3888

A copy of the application is attached to Addendum 1A. If assistance is needed in completing the application, please call or come by one of the locations listed above.

Applications must be completed, signed and submitted with required documents to one of the locations previously listed within two hundred forty (240) days from the first billing statement date, for inpatient and outpatient services. If an applicant is married (legally or common law) and the spouse is a household member, the spouse must also sign the application.

Approved applications are valid for a period not to exceed six (6) months. Approved applications for Medicare applicants are valid for a period not to exceed twelve (12) months. Any change in the applicant’s income, resources or residency other than federal cost of living adjustments will require notification to ECHDA for possible reapplication and reconsideration of eligibility.

Misrepresentations of facts or any attempt to circumvent the policy of ECHDA in order to become or remain eligible for medical assistance is grounds for refusal of assistance.

If an applicant qualifies for and fails to cooperate or follow through with an application for any other source of assistance, the application for ECHDA may be denied. All other federal, state, local and private sources must be exhausted before eligibility can be determined for ECHDA. ECHDA staff will assist the applicant in determining what other sources of assistance are available to the applicant.

Any applicant approved for state/local assistance programs with an appropriate verification process determining indigence may qualify for ECHDA.

All ECHDA applications will be pended if applicant is seeking assistance from another source (i.e. SSI, Medicaid, Section 1011, Liability) until applicant has received approval or denial from other source.

Subrogation – The filing of an application for or receipt of services constitutes an assignment of the applicant’s or recipient’s right to recovery from:

  • Personal injury insurance
  • Other sources
  • Another person for personal injury caused by the other person’s negligence or wrong.

ECHDA reserves the right to any of the recoveries listed above to reimburse the cost of services that have been previously paid by the program.

Eligibility

Residency Verification:

Social Security cards must be provided for all household members of a applicant’s household.

Any person convicted of a crime who during the commission of that crime sustained injuries which required hospital care will not be eligible for ECHDA

Inmates or residents of a state school or institution operated by the Texas Department of Corrections, Texas Department of Mental Health and Mental Retardation, Texas Youth Commission, Texas School for the Blind, Texas School for the Deaf, or any other state agency or who are inmates, patients, or residents of a school or institution operated by a federal agency, are not considered residents of the county in which the facility is located.

Only legal residents of Ector County are eligible for benefits under this program except for the MCH Family Health Clinic. A legal resident is defined as one who voluntarily lives in Ector County, Texas and who is a citizen or has obtained permanent resident alien status. All applicants must prove residency. Proof of residency may include, but is not limited to any of the following:

  • Valid voter registration card for Ector County
  • Current enrollment of children of the household in a public or private school
  • Current/recent utility bills
  • Current notes payable or accounts payable to financial institutions
  • Current property tax receipts, Attorney General Letters, Social Security Letters
  • Current rent receipt or lease or mortgage payment

Individuals residing in Ector County temporarily for medical purposes only will not be eligible for ECHDA, except for the MCH Family Health Clinic. The burden of proving residency is the applicant’s responsibility.

Income

Applicants that have no source of income and are eligible to work will be required to show proof of registration with the Texas Workforce Commission.

Income types and income limits are found in Addendum 1.

Resources

Resource types and limits are found in Addendum 2.

Hospital Indemnity Plans

Applicants who are covered under Hospital Indemnity Plans (Daily Benefit Plans) may still be eligible to receive assistance from ECHDA. However, the applicant will be required to assign these benefits to ECHDA.

Household Verification

A household unit consists of all dependents of the head of the household. In determining the composition of a household, the following guidelines will be followed:

  • One person household:
    • An adult living with others who are not legally responsible for supporting each other.
    • An adult living alone
    • A minor child living alone or with others who are not legally responsible for the child’s support
  • Household Groups:
    • Two persons legally married or common law who live together
    • One or both legal parents and their legal minor children
    • A managing conservator and a minor child. (A managing conservator is a person designated by a court to have daily legal responsibility for a child).
  • Separate Households:
    • One household may live with another household. Determine eligibility for each of these households independently, regardless of household configurations
    • Minor child with minor child(ren) or unborn child(ren)

Medicaid Recipients

All Medicaid Recipients are disqualified from ECHDA Per Texas Department of Health for the County Indigent Health Care Program, except for Medicaid non-covered services.

Service Programs

If an applicant is approved for ECHDA, he/she and dependents are eligible for the following services depending upon which income guidelines are met.

Hospital Services

Inpatient hospital care, emergency room care, and/or outpatient care to include diagnostic testing and therapy treatments available only at Medical Center Hospital in Odessa, TX. Services shall not include durable medical equipment.

Pharmacy

Prescriptions will be limited to 3 prescriptions per month for 90 days supply and shall be authorized for applicants meeting the income and resource guidelines with the following stipulation and limitations:

  • Prescriptions must be written by a MCHS authorized provider or a specialist consulted by the MCHS authorized provider
  • Prescriptions may require a copay ($9 for all formulary medications $20 for all approved non-formulary)
  • ECHD assistance will not subsidize other prescription programs, including the Medicare Discount Prescription Program
  • In all cases the lowest cost alternatives medicines shall be issued (see formulary)
  • Authorized prescriptions are restricted to those listed on the approved ECHDA formulary
  • No over the counter medications shall be authorized except insulin syringes, test strips, needles, and glucometers
  • Pain medications will be approved for eligible applicants who are terminally ill or for one time coverage after an accident or surgery
  • There may be a onetime emergency issuance of medications not to exceed a fourteen (14) day supply prior to application processing / completion

Guidelines for Reimbursement, Non-Formulary, & 3408 Drugs

Guidelines for Indigent Pharmacy Reimbursement from Drug Vendors

Some pharmacy costs provided to the indigent program can be reimbursed by participating drug vendors. When possible, the district will apply for these recoveries and will obtain the following documentation from the recipient in order to submit the application for reimbursement:

  • Patient power of Attorney Form – Patients will sign patient power of attorney form required by the vendor for drug reimbursement when completing application.
  • Proof of Income – Proof of patient’s income will be provided to the Pharmacy on patients that have applied for assistance with ECHDA to be included with the request for reimbursement.

Non-formulary process

  • Any non-formulary medication can be filled one time if the medication cost is $20 $50or less at the contract pharmacist’s discretion by e-mailing the MCH Director of Pharmacy (DOP) the patient’s name and the name and quantity of the medication filled.
  • Any non-formulary medication with a cost between $20.01 $50.01 and $50.00 $100.00 will need approval from the case manager before filling. The case manager shall notify the DOP by e-mail of the onetime approval and shall request a review for approval of any subsequent refills if a maintenance medication is involved.
  • Any non-formulary medication with a cost greater than $50.01 $100.01 will need approval from the DOP or designee before filling.

ECHDA use of 340B drugs MCHS

MCH provides an assistance program for patients living in Ector County. Patients requesting this program must follow all guidelines set by the ECHDA business office policies. If the patient is enrolled in the ECHDA program then the following requirements are to be followed if the patient is to use the 340B discount program.

  • Theindividual must meet the “patient” definition for MCH:
  1. The covered entity has established a relationship with the individual, such that the covered entity maintains records of the individual’s health care.
  2. The individual receives health care services from a health care professional who is either employed by the covered entity or provides health care under contractual or other arrangements (referrals) such that the responsibility for the care provided remains with the covered entity.
  • MCH patients enrolled in the ECHDA program MCHSmust use contracted pharmacies that are listed on the PSA/HRSA data base when a prescription is generated from a qualified visit.
  • Family Health Clinic (FHC) patients enrolled in ECHDA program must use contracted pharmacies that are listed under the Federally Qualified Health Center Look-Alike (FQHCLA) PSA/HRSA data base when a prescription is generated from a qualified visit.
  • Patient will not qualify for the 340B drugs if a prescription is the only service provided to the patient. A visit must be documented and verification of the visit must be available for review using MCH or MCH affiliates electronic medical records (EMR).

Physicians

Physician office visits shall be authorized prior to services being performed for individuals who meet the approved income and resource guidelines. A list of participating Physicians will be given to the patient at time of application approval. Physician office visits will be limited to:

  • One primary care physician visit per month with a co-pay of $10.00
  • One Specialist office visit per month with a co-pay of $10.00

**Co-pays to be paid to physician upon arrival with voucher at physician office.**

ECHDA reserves the right to utilize the services of the MCH Family Health Clinic and MCH Procare for applicants who qualify for physician office visit assistance. ECHDA will not cover physician office visits for non MCH Family Health Clinic or MCH Procare Participating physicians unless referred to a specialist by said physician. Reimbursement for services rendered will be under the most current Medicaid Fee Schedule as set by the County Indigent Health Care Program for the State of Texas. Utilization of physicians shall be monitored and may be limited or eliminated if deemed necessary.

The MCH Family Health Clinic is available to both residents and non residents of Ector County or the United States of America. A sliding fee schedule is utilized to determine the amount owed by the applicant. Applicants who seek a physician office visit can be required by ECHDA to utilize the MCH Family Health Clinic. Failure to do so can result in the applicant being denied future assistance.

Limitations

Limitations and exclusions of services provided are set forth in Addendum 3.

Reporting Changes

Applicants must report changes, which affect eligibility within 14 days after the date that the change actually occurred. Changes may be reported by mail, by telephone, in person or by someone acting for the applicant. ECHDA staff will document any changes reported on the case files.

Annual Review

The policy of the Ector County Hospital District Assistance Program shall be subject to review at least annually by the ECHD Board of Directors.

Appeals

If an applicant is denied benefits under ECHD Assistance due to income exceeding the guidelines the applicant has the right to appeal. All regular monthly receipts must be provided to ECHDA staff. Expenses incurred, such as credit card receipts (unless it can be proven that the debt was incurred from medical charges), will not be included.

All other instances for appeal will need to be submitted in writing to the ECHDA office where the applicant applied. This also must be done within ninety (90) days of the ineligibility determination date. A response from ECHDA must be made within ten (10)

days of receipt. The appeal process may be continued following the current County Indigent Health Care Program guidelines set forth by the Texas Department of Health.

Disclaimer

Any issue not directly addressed by this document will require a review and written approval by the CFO of Medical Center Hospital with the approval by Medical Center Hospital Administration and the ECHD Board of Directors.

All individuals will be eligible for screening for this program and authorized by this program without regard to race, age, creed, color, national origin, sex or physical handicap.

ECHDA shall have the right to amend or modify the eligibility guidelines from time to time by approval of the MCH Board of Directors. Said amendments of modifications shall be effective after publication of such changes in a newspaper of general circulation in Ector County, Texas.

Addendum 1

INCOME

DEFINITION:

For the purposes of eligibility for this program, income shall be defined as total cash receipts from all sources before taxes. The limits of allowable income are listed in Addendum 2B

A household must pursue and take advantage of all income to which they are legally entitled. There are deductions for earned income that are not allowed for unearned income.

TYPES OF INCOME:

Income is a type of payment that is a regular and predictable gain to a household. Income is either earned or unearned.

  • Earned Income is income related to work
  • Unearned income is income received without performing work. And includes benefits from other programs.

Alien Sponsor – Count income if the applicant is a legal alien of less than 3 years and was required to have a sponsor per immigration statutes, count the income and resources of the sponsor.

Cash Contributions – Counts as unearned income unless provided by:

  • A person living in the home but not a member of the applicant’s household
  • A person who shares household expenses with the applicant
  • No landlord/tenant relationship exists

Child Income – Exempt if minor child:

  • Is still a student and
  • Is not considered emancipated and
  • Is working less than thirty (30) hours a week

Child Support – Counts as unearned income

Crime Victim Compensation – Exempt

Disability Insurance Benefits – Counts as unearned income

Dividends and Royalties – Counts as unearned income

Educational Assistance – Exempt

Energy Assistance – Exempt

Lump Sum Payment – Count lump-sum payments received once a year or less frequently as a resource in the month received, unless specifically exempt.

Mineral Rights – Count as unearned income.

Pension/Retirement Benefits – Count as unearned income.

Property Income – Count as self employment income if received:

  • As rent;
  • As lease; or,
  • In an installment plan as a result of property sold. The balance of the note is not considered a resource.

Self-Employment Income – Count as earned income minus the following allowed expenses:

  • Labor
  • Sales tax/property tax
  • Raw material/seed/fertilizer
  • Rent/utilities
  • Fuel
  • Repair and maintenance to maintain property for income purposes
  • Supplies
  • Interest from business loans on income producing property
  • Insurance premiums

Note:Depreciation, capital asset improvements or costs not related to self-employment are not counted.

Social Security Benefits – Count, a copy of the most recent social Security check or a benefit printout from social Security must be supplied by applicant.

Trust Fund Withdrawals – Counts as unearned income.

Unemployment Compensation – Gross benefits are counted as unearned income.

Veterans/VA Benefits – Counts as unearned income.

Wages/Salaries/Commissions – Counts as earned income.

VERIFYING INCOME

Income must be verified at initial application, when changes are reported or when a case is reviewed if questionable.

Budgeting income is the process of calculating income and deductions using a best estimate of the household’s current and future income and circumstances:

  • Income that is received in one month AND is likely to be received in the next month; OR,
  • Income that is received in one month AND was received on a regular and predictable basis in past months; OR,
  • Income that is received in one month AND is more than the maximum income limit for the household’s size.
    • Earned income may be verified by any of the following:
      • Current pay stubs for current/recent month
      • W-2 forms
      • Sales records
      • Signed statements by employers
    • Unearned income may be verified by any of the following:
      • Award letters
      • Court orders or public decrees (support documents)
      • Notes for cash contributions unless the person providing the cash is also a member of the household or shares household expenses with the applicant
      • Printouts or letters from Social Security
    • Self-employment income may be verified by any of the following:
      • Business records
      • Current income tax returns
      • Quarterly profit and loss statements from CPA
    • Terminated income may be verified by any one of the following:
      • A written statement from employer with termination date
      • Notice of termination of benefits from government agency

If the applicant claims to have no income, support must be verified by one or more of the following:

  • Applicant that is able to work must provide proof of registration with TWC
  • Information from the last employer, showing the last date of employment, address and phone number of company, copy of last check stub, etc.
  • If supported by a friend or relative, the friend or relative must sign a statement of that support
  • If living off savings, a bank statement must be presented for the past 3 months

DETERMINING MONTHLY AMOUNT:

If information received is:

Yearly income – divide by 12

Weekly income – multiply by 4.33

Bi-weekly income – multiply by 2.17

From the household’s monthly gross income, deduct $120.00 per employed household member for work related expenses.

ADDENDUM 1A

ECTOR COUNTY HOSPITAL DISTRICT

FINANCIAL INCOME GUIDELINES

INPATIENT/OUTPATIENT HOSPITAL SERVICES

&

PRESCRIPTION PROGRAM

ANNUAL INCOME

Family Size Income Limits/Yr. 225%

  • $26,483
  • $35,843
  • $45,203
  • $54,563
  • $63,923
  • $73,283
  • $82,643

100% assistance for up to 225% of FPL.

Addendum 2

RESOURCES

Resources will be used to determine eligibility for all assistance programs of the District except for the Family Health Clinic. Definitions and examples of resources are listed in Addendum 3.

DEFINITIONS

Resources – assets or possessions. Examples are cash, bank accounts, stocks, bonds, certificates of deposit, vehicles, boats, campers, land other than homestead, and mineral rights.

Fair Market Value – the amount a resource would bring if sold on the current local market.

Equity – the amount of money that would be available to the owner after the sale of a resource. This amount is determined by subtracting from the fair market value any money still owed on the item and the costs normally associated with the sale and transfer of the item.

Personal possessions – furniture, appliances, jewelry, clothing, livestock, farm equipment and other items if the household uses them to meet personal needs essential for daily living.

Inaccessible resources – resources not legally available to the household.

RESOURCE LIMIT

Total household resources cannot exceed $3,000 for hospital bill assistance and $2,000 for physician office visit and prescription assistance.

Total household resources cannot exceed $3,000.00 for assistance when a person who is aged or disabled and who meets relationship requirements lives in the home.

TYPES OF RESOURCES

Resources are either countable or exempt as follows:

401K = Exempt if applicant is still employed by the employer offering the plan.

Homestead – Exempt. A homestead is the household’s usual residence (within the state of Texas) and surrounding property that is not separated by property owned by others. Surrounding property that is separated by public rights of way such as roads is considered as part of the homestead. Temporary unoccupied residence due to employment training or future employment, illness, casualty, or natural disaster if the household intends to return is exempt.

Exempt a household that does not currently own a home but owns or is purchasing real property on which they intend to build or are building a permanent home, receive an exemption for the real property and if partially completed, for the home.

Burial Plot – Exempt

Income Producing Property

  • Exempt if the property is essential to a client’s employment or self-employment. (Examples: tools of a trade, farm machinery, stock and inventory). Continue to exempt this property during temporary periods of unemployment if the client expects to return to work.
  • Exempt if the property annually produces income consistent with its fair market value, even if used only on a seasonal basis.

Individual Retirement Accounts (IRA’s) – Deduct any amount of penalty incurred for early withdrawal and the remainder is counted.

Jointly Owned Property – Exempt if the property is jointly owned by the household and other owners and the household proves that:

  • The property cannot be sold or divided without the other owner’s consent; and,
  • The other owners will not sell or divide the property.

Keogh Plans – Deduct any penalty for early withdrawal and count the remainder. Exception: The Keogh Plan does not count if there is a contractual withdrawal agreement with other people who are not household members and who share the same fund. This type of Keogh Plan is considered an inaccessible resource.

Insurance Settlements – Counts minus any amount earmarked and spent for the household’s bills for burial, medical expenses or damaged /lost possessions.

Lawsuit Settlements – Counts minus any amount earmarked and spent for the household’s bills for burial, legal expenses, medical expenses or damaged/lost possessions.

Life Insurance – Exempt

Liquid Resource – Counts if readily negotiable. Examples: cash, checking account, savings account, a savings certificate, notes, bonds and stocks.

Lump Sum Payment – Counts for lump sum payments included but not limited to: retroactive lump sums from Social Security, railroad retirement benefits or other payments, and refunds of security deposits on rental property or utilities.

Non-Liquid Resource – Counts. Examples: personal property, a licensed vehicle, a building and land.

Personal Possessions – Exempt. If a personal possession is sold, the money received from the sale as a liquid resource is counted.

Prepaid Burial Insurance – Exempt up to $1,500 cash value of a prepaid burial insurance policy, funeral plan or funeral agreement for each certified household member.

Real Property – Counts, unless the household is making a good faith effort to sell it. Real property is land and any improvement on it.

Retirement Account – Exempt until the money is withdrawn, if the money is withdrawn as a monthly check, it counts as income. If the money is withdrawn as a lump sum, it counts as a resource.

Trust Funds – Exempt irrevocable trust funds or property in probate. Any withdrawals count as unearned income, not as a resource.

Vehicles – Each vehicle with a fair market value of less than or equal to $5,000 is exempt, regardless of the number of vehicles owned by the household. The fair market value in excess of $5,000 of each licensed vehicle is counted toward the household’s total limitation on available resources.

A licensed vehicle is exempt if it is used more than fifty percent (50%) of the time for income-producing purposes. Example: a self employed applicant uses a tow truck, welding truck or tractor trailer to make a living.

The following are suggestions for determining the fair market value of a vehicle:

  • The average trade-in value listed in the current National Automobile Dealer’s Association (NADA) Car Guide is used. The loan value of the vehicle is used only if other sources are unavailable.
  • If the household thinks that the average trade-in value listed in the NADA is incorrect because of the vehicle’s condition (body damage), the household may provide verification from a reliable source, such as a bank loan officer or licensed car dealer.
  • Increased value due to low mileage or optional equipment is not counted.
  • The household must prove the value of antique, custom-made, or classic vehicles if an accurate appraisal cannot be made by staff.
  • The household’s estimated value of vehicles no longer listed in NADA is accepted unless the value is questionable and would affect eligibility. In this case the household should provide an appraisal from a licensed car dealer or some other evidence of the value, such as a tax assessment or newspaper ad showing the sale price of a similar vehicle.
  • For new vehicles not yet listed in the NADA, the household should provide an estimate of the trade-in value from a new car dealer or a bank loan officer. If this is not possible, the household’s estimate is accepted unless it is questionable and would affect eligibility.

PENALTY FOR TRANSFERRING RESOURCES – A household is ineligible if within three months before application or any time after certification it transferred a countable resource for less than the fair market value to qualify for county medical assistance.

The household is ineligible for two years beginning with the date that the resource was transferred. If spouses are legally separated, transfer of separate property by one spouse does not affect the eligibility of the other spouse.

THIS PENALTY APPLIES ONLY IF THE VALUE OF THE TRANSFERRED RESOURCE PLUS THE HOUSEHOLD’S OTHER COUNTABLE RESOURCES WOULD HAVE AFFECTED ELIGIBILITY.

Addendum 3

EXCLUSIONS AND LIMITATIONS

GENERAL EXLUSIONS
The following services and supplies are excluded:

  • Not specifically provided by the Ector County Hospital or an approved provider.
  • Not medically necessary
  • Provided to a patient before or after the date the patient is eligible for the program
  • Provided outside the United States
  • Not claimed (billed) by the provider within 90 days from the date of service or 90 days from the date of eligibility, if the patient was eligible in one or more of the three months before the application month
  • Elective surgeries
  • Provided by a patient’s immediate relative or household member
  • Payable by or available under any health, accident or other insurance coverage, by any private or other governmental benefit system, by any legally liable third party or under other contract
  • Provided by military medical facilities, or Veterans provided by military medical facilities, or Veterans Administration facilities, or United States public health service hospitals
  • Related to any condition covered under the worker’s compensation laws.

SPECIFIC EXCLUSIONS

The following specific services or supplies are excluded:

  • Separate payments for services and supplies to an institution that receives a vendor payment or has a reimbursement formula that includes the services and supplies as a part of institutional care.
  • Whole blood or packed red cells available at no cost to the patient
  • Take home items and drugs or non-prescribed drugs
  • Treatment of flatfoot conditions, subluxations of the foot, and routine foot care and hygiene, including cutting or removal of corns, warts, calluses, and nail trimming
  • Prosthetic and orthopedic devices
  • Social and educational counseling with the exception of diabetic teaching/counseling provided at Medical Center Hospital
  • Custodial care
  • Autopsies
  • Recreational therapy
  • Separate fees for completing or filing a claim under the program
  • Services or supplies that are not reasonable and necessary for diagnosis and/or treatment
  • Dentures
  • Prescriptions for and the cost of supportive devices and special shoes
  • Eyeglasses and examinations for the prescription and fitting of eyeglasses
  • Hearing aids
  • Medical transportation unless ECHDA approved for emergency medical services as an optional service
  • Chiropractors

LIMITED SERVICES

Exclude the following services and supplies unless the specified conditions are met:

  • Immunizations and vaccines unless directly related to the treatment of an injury, direct exposure to a disease, or provided by the MCH Family Health Clinic.
  • Services or supplies provided in a routine physical examination except in connection with family planning services provided by MCH Family Health Clinic
  • Services or supplies provided in connection with cosmetic surgery unless they are:
    • Required for the prompt repair of an accidental injury;
    • Required for improvement of the functioning of a malformed body member; or,
    • Authorized for specific purposes by ECHDA or its designee before the services or supplies are received.
  • Routine circumcision if the patient is more than three days old
  • A private inpatient hospital room unless a patient
    • Has a critical or contagious illness;
    • Is disturbing other patients; or,
    • Is admitted on an emergency basis and other rooms are not available.
  • Dental care except for reduction of a jaw fracture or treatment of an oral infection when a physician determines that a life threatening situation exists and refers the patient to a dentist.
  • Ambulation aids and other durable medical equipment and supplies unless they are provided in a hospital setting.
  • Parenteral hyperalimentation therapy as an outpatient hospital service unless medically necessary to sustain life.
  • Alcohol and drug abuse treatment services unless provided in mandated hospital, Medical Center Hospital, and the hospital admission is medically necessary for the treatment of a physical condition other than the alcohol or drug abuse.
  • Alcohol and drug detoxification treatment alone, unless the patient is admitted to mandated hospital, the physician determines hospital admission is medically necessary, and the hospital stay does not exceed 5 days.
  • Abortions are not covered unless the attending physician certifies in writing that, in his professional judgement, the mother’s life would be endangered if the fetus is carried to term.
  • Outpatient psychiatric services performed by a psychiatrist, a mental health worker, or a social worker are excluded.