Nebraska
Medicaid Program
Client Information
Client Benefit Booklet
Your Guide to Medicaid Services in Nebraska
This guide provides information about the Nebraska Medicaid program.
The Nebraska Medicaid program covers medical services for persons who are unable to pay
for their medical care, including persons who are aged, blind, disabled, children, and
others who meet eligibility guidelines. Kids Connection is part of the Medicaid program
and provides medical assistance to children age 18 and younger.
This guide describes the medical services for which the Nebraska Medicaid program pays.
If you have questions about any medical services not described in this booklet, ask your
health care provider or contact your local Department of Health & Human Services
(DHHS) office.
Your Medicaid Eligibility Card
Your Rights as a Patient
Your Responsibilities
Health Care Providers
Appointments
How to Use the Emergency Room
Copayment for Services
If You Receive a Bill
Out-of-State Services
Medicaid Managed Care – Nebraska Health Connection
Coordination with other Health Insurance
Appeals of Medicaid Decisions
Covered Services
Your Medicaid Eligibility Card
When you are eligible for Medicaid, you will receive a Medicaid eligibility card each
month. Everyone in the household who is eligible will be listed on the eligibility card.
Children 18 years or younger will have Kids Connection printed above their name. The card
is good for medical services only for that month. You should carry your card with you and
always show it to the health care provider each time you receive services. If you lose
your card, contact your local DHHS office. It is illegal to let anyone else use your card.
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Your Rights as a Patient
You have the right as a Patient to:
- Be treated with respect and without discrimination.
- Understand information about your illness and treatment.
- Talk with your health care provider about how your medical information will be kept
confidential.
- Choose your health care provider.
- Receive medical care in a timely manner.
- Receive proper medical care.
- Have interpreters available, if necessary, during appointments and in all discussions
with your health care providers.
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Your Responsibilities
As a patient you are responsible to:
- Take your Medicaid eligibility card to all your appointments.
- Keep scheduled appointments
- Call your health care provider in advance if you can not keep an appointment.
- Tell your health care provider your medical problems.
- Ask questions if you do not understand.
- Follow your health care provider’s orders.
You must notify your local Health and Human Services (DHHS) office if any of the
following applies to you:
- If someone else is responsible or liable for paying your medical expenses, including any
other health insurance plan;
- If you are injured in an accident and receive medical treatment;
- If you receive any settlements from lawsuits, insurance and/or Workers' Compensation
claims.
- If you fail to report any of these, DHHS can deny or terminate your Medicaid
eligibility.
- You must also notify your local DHHS office of any other circumstances that may affect
your eligibility, such as a change in income, resources, or living arrangements.
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Health Care Providers
Nebraska Medicaid covers specific health services when medically necessary and program
criteria are met. You may obtain covered services from any health provider qualified to
perform the services who participates in the Medicaid program. Some preventive services,
such as well child check-ups, are also covered.
Under most circumstances, you can choose your doctor, dentist, pharmacist, or other
health care provider. However, health care providers choose whether they wish to
participate in the program. Before you receive medical care, always ask your health care
provider if he or she accepts Medicaid payments and show your Medicaid eligibility card.
If a health care provider does not participate in Medicaid and you receive services, you
will have to pay for them. If a provider does not know you are eligible for Medicaid
before services are provided, you may have to pay for them. If you have questions about
what services Medicaid covers, ask your health care provider.
A health care provider who participates in the Medicaid program must accept the
payments that Medicaid makes. If you receive services not covered by Medicaid, the
provider may bill you. You are responsible for paying for services you receive that are
not covered by Medicaid.
You are responsible for obtaining only those services for which you have a medical
need. If you overuse or abuse your Medicaid coverage or benefits, you may be assigned to
specific health care providers. This restriction is called “lock-in.” Some
clients who receive services from multiple specialists may also be “locked-in”
to one health care provider to assist in management of referrals.
If you are notified by Medicaid that you have been locked-in, you will be given an
explanation of the restrictions and any exceptions. You will also be given an opportunity
to request an appeal hearing before you are restricted.
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Appointments
If you or your children get sick or need a checkup, call your doctor’s office to
make an appointment. It is your responsibility to keep all appointments with providers. If
you are unable to keep an appointment, call your provider right away to cancel and
reschedule. Many offices request notice 24 hours prior to the appointment for
cancellations. Even if you have to cancel on the same day as your appointment, it is
important to call the provider’s office. If you must cancel an appointment, make
arrangements for a new time. It you have arranged transportation, be sure to cancel your
transportation also.
If you do not keep scheduled appointments and do not show up, your health care provider
may refuse to reschedule or make new appointments for you.
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How to Use the Emergency Room
Call your doctor before you go to the Emergency Room unless it is a true emergency. A
true emergency is considered a sudden start of a condition that could end in serious
injury or harm if you don’t see a doctor immediately. Here are some examples of true
emergencies:
- Very heavy bleeding
- Severe pain
- Difficulty breathing
- Broken bones
- Chest pains
- Severe burns
If you have symptoms of a cold, headache, or flu, call your doctor.
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Copayment for Services
You may be required to share some of the costs of services you receive. This is called
a copayment. Your Medicaid eligibility card will show whether you are subject to the
copayment requirement. Copayment amounts are $1.00, $2.00, or $3.00, depending on the
service you receive. Children under the age of 18 and women who are pregnant do not have
copayments for the services they receive. If you are pregnant you must let your caseworker
know.
Your provider can advise you if you must make a copayment and the amount you must pay.
You are required to pay the copayment to the provider. If you believe the provider charged
you incorrectly, you can appeal to DHHS but you must continue to make copayments until
DHHS determines whether the amounts are correct.
If you are unable to pay the copayment, you must tell the provider. If you receive the
service and cannot pay the copayment, the provider may bill you
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If You Receive a Bill
If you receive a bill from a health care provider for a medical service you have
received, you should call the provider as soon as possible and tell the provider that you
are Medicaid eligible. Give the provider’s office staff your Medicaid ID number and
any additional information that they require. Do not ignore bills that you receive in the
mail from a provider. If you receive a bill for a service that is not covered by Medicaid,
you may be responsible for payment of the bill.
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Out-of-State Services
Medicaid may pay for services provided out of Nebraska under certain conditions, such
as a medical emergency, or if the service is not readily available from a Nebraska
provider. If you receive services out of state, you are responsible for informing the
provider that you are eligible for Nebraska Medicaid. Show the provider your Medicaid
card. Some out-of-state services require the provider to obtain authorization.
Out-of-state providers must agree to enroll as a provider for Nebraska Medicaid before
payment for services may be made. If the provider does not agree to enroll, you are
responsible for paying for the services. Before you travel out-of-state to receive a
service, you should check with your usual health care provider in Nebraska to be sure that
all of the necessary authorizations have been obtained.
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Medicaid Managed Care – Nebraska Health Connection
If you are a resident of Douglas, Sarpy, or Lancaster County you may be required to
access services through Nebraska Health Connection (NHC), the Medicaid managed care
program. An Access Medicaid Health Connection Counselor will contact you about enrolling
and will assist you with your choices.
All health care services available through the current Medicaid program will be
available through Nebraska Health Connection. The only difference will be how you access
these services. You will receive an NHC document once you are enrolled in a health plan
instead of a Medicaid eligibility card. You will also receive a customer handbook from the
managed care health plan you choose.
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Coordination with other Health Insurance
If you or anyone in your family has private medical insurance, or are covered by
someone else’s insurance, or you are eligible for Medicare, you must tell your local
DHHS office. Medicaid will pay only for medical services.
You must follow the rules of your private medical insurance plan and use the health
care providers in the health plan. You may be responsible for payment for the medical
services if you do not go to a doctor or health care provider that participates with your
private insurance or do not obtain the necessary referrals or authorizations.
Your doctor or other health care provider must first file claims with Medicare or your
private insurance, whichever applies. If your primary health coverage is Medicare,
Medicaid will pay co-insurance and deductible amounts on those services that are
determined medically necessary and covered by Medicare. If the service is not covered by
Medicare or other insurance, Nebraska Medicaid will pay only if is it a Medicaid covered
service.
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Appeals of Medicaid Decisions
If you believe a decision regarding payment, including the amount of, or the denial of
a Medicaid claim is not correct, you have the right to question that decision. You should
contact your local DHHS office to discuss the decision. If you are still not satisfied you
have the right to file an appeal and ask for a hearing. During this hearing you will be
able to present your complaint. All the facts will be reviewed to see if the decision was
correct or should be changed. You may also file an appeal by writing to:
Health and Human Services
Department of Finance and Support
Medicaid Division
P.O Box 95026
Lincoln, Nebraska 68509-5026
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Covered Services
If you have a question about the services Medicaid covers or limitations on
services, ask your health care provider.
When medically necessary, benefits are available for the
following covered services:
Ambulance Services
Ambulatory Surgery Center
Chiropractic Services
Dental Services
Family Planning Services
HEALTH CHECK Services
Hearing Aids
Home Health Services
Hospice Services
Hospital Services
ICF/MR Services
Laboratory and X-Ray Services
Medical Equipment,
Orthotics, Prosthetics, Supplies
Medical Transportation Services
Mental Health & Substance
Abuse Services
Nursing Home Care
Personal Assistance Services
Physician Services
Podiatry
Prescription Drugs
Rural Health Clinic
Speech, Physical and Occupational
Therapies
Vision Care Services
Ambulance Services
Ambulance services are covered when you receive appropriate emergency care or to
transport you to and from one medical facility if your condition requires that you travel
by ambulance.
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Ambulatory Surgery Center
Services provided at an ambulatory surgery center are covered if the center has been
approved by Medicare and Medicaid. Covered services are those furnished in connection with
a medically necessary surgical procedure. Some procedures cannot be paid by Medicaid if
they are done in an ambulatory surgical center.
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Chiropractic Services
Manual manipulation of the spine and spinal x-rays are the only services covered when
provided by a chiropractor. Treatments are limited to twelve (12) a year for adults age 21
years and older. You will be responsible for paying for services that exceed the number of
treatments allowed.
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Dental Services
Covered dental services include cleaning of teeth, fillings, extractions, x-rays,
dental surgery and dental disease control. Coverage criteria must be met and some services
require that your dentist obtain approval from Medicaid before the service is provided.
Adults (age 21 and older) are limited to a maximum of $1000 of Medicaid approved or
covered dental treatment each year (July 1 – June 30th.) You will be responsible for
paying for services that exceed the $1000.
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Family Planning Services
Family planning services are covered including consultation and treatment. Services can
include initial physical examination and health history, annual visit and follow-up
visits, laboratory tests, prescribing and supplying contraceptive supplies and devices,
counseling services, and prescribing medications for specific treatment.
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HEALTH CHECK Services (Early Periodic Screening
Diagnosis and Treatment)
Your children age 20 and younger are eligible for a program of services called HEALTH
CHECK. HEALTH CHECK includes complete check-ups on a regular basis and provides diagnosis
and treatment services for health problems found at a check-up. Some treatment services
your child may receive as a result of a HEALTH CHECK examination require the health care
provider to obtain approval from Medicaid. Services included in HEALTH CHECK program are:
Health and development history; Complete physical examination; Immunizations; Necessary
lab tests; Health education; Hearing check-ups; Eye examinations; Dental examinations;
Treatment for identified problems; and Well-baby, well-child, Head Start, school, and
sport physicals.
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Hearing Aids
Hearing aids, hearing aid repairs, hearing aid rental, assistive listening devices and
the necessary batteries and supplies are covered when the services are medically
necessary, ordered by a physician and authorized by Medicaid. You must meet the coverage
criteria. Medicaid covers standard in-the-ear, behind the ear, or body hearing aids. Bone
condition aids may be approved with an Ear, Nose and Throat (E.N.T.) Specialist approval.
Adults (age 21 or older) are limited to one hearing aid per ear within a four-year period.
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Home Health Services
Home health services are covered when provided by a certified home health agency and
prescribed by a physician. Your physician must certify that you are homebound and that
staying home is necessary for your care. The services must be prior authorized by
Medicaid.
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Hospice Services
The Medicaid hospice benefit includes coverage for services provided in response to
palliative management of a terminal illness. Hospice services include nursing services,
physician services, medical social services, counseling services, home health
aide/homemaker, medical equipment, medical supplies, drugs and biologicals, physical
therapy, occupationaltherapy, speech language pathology, volunteer services and pastoral
care services offered on the individual’s needs and choice for terminally ill
patients and their families. Hospice services require authorization by Medicaid.
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Hospital Services
Inpatient and outpatient hospital care is covered. There are no specific limitations on
the amount of care that will be paid for as long as the care you receive is medically
necessary (required). Medicaid does not pay for the services of a private duty nurse while
you are in the hospital or pay additional for a private room or for items of convenience.
Inpatient hospital care and payment to physicians for surgical procedures which can safely
and effectively be performed on an outpatient basis are not covered.
Diagnostic services such as x-rays and laboratory services provided on an outpatient basis
at a hospital are covered when medically necessary and ordered by a physician. Treatment
services such as physical therapy, dialysis and radiation may also be covered when
coverage criteria are met.
IMPORTANT: You should use the services of the hospital emergency room only when your
condition actually warrants emergency attention. Routine nonemergency medical care should
be obtained from your doctor.
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ICF/MR Services
Intermediate Care Facility for Persons with Mental Retardation and Related
Conditions, ICF/MR, is a service funded by Medicaid for individuals with Mental
Retardation, or a Related Condition, who meet ICF/MR criteria, and who are Medicaid
–eligible. The ICF/MR Services are designed to serve individuals who cannot be served
in the community through DD Services. The ICF/MR services help the individual achieve
their greatest independence possible by providing training in all aspect of daily living,
social behavior, pre-vocational training, nursing care to the same degree as in a Nursing
Home, physical, occupational, and speech therapies. A Related Condition is not the same as
a Developmental Disability. Medicaid does not fund ICF/MR services for individuals who can
be served in Community DD services or whose medical needs take precedence. Placement in an
ICF/MR is never considered permanent as individuals needs and alternatives can change over
time; other services may be more appropriate.
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Laboratory and X-Ray
Services
Diagnostic services such as laboratory and x-ray services are covered when they are
medically necessary and ordered by a physician. Therapeutic radiology services are covered
when medically necessary and ordered by a physician. Medicaid does not pay for services
that are experimental or investigational or not standard of care for treatment of medical
conditions. Some services may require authorization from Medicaid. There may be
limitations on the frequency for some diagnostic or therapeutic laboratory or x-ray
services.
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Medical
Equipment, Orthotics, Prosthetics and Supplies
Certain medical equipment, medical supplies, orthotics and prosthetics are covered when
medically necessary and prescribed by a physician. Medicaid covers only items that
primarily serve a medical purpose and meet Medicaid coverage criteria. Some medical
equipment requires authorization from Medicaid.
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Medical Transportation Services
Medicaid covers transportation services for trips necessary to obtain medical care when
you have no other means of transportation. The lack of money for gas does not meet the
need for Medicaid to pay for your transportation if you have a car. Medicaid may cover
transportation services for a parent, caretaker, or attendant to escort an eligible person
to and from medical care when necessary and when there is no other means of
transportation. Contact your local DHHS office if you need assistance with transportation.
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Mental Health &
Substance Abuse Services
Mental health and substance abuse services are available statewide. Most persons are
enrolled in a program of care managed by Magellan Behavioral Health and will receive a
handbook from Magellan. Available services include: Mental Health and Substance Abuse
evaluation and treatment for persons age 20 and younger; Mental Health and Substance Abuse
for persons in managed care and age 21 and older; and Adult Psychiatric Rehabilitation
services for persons who are diagnosed with severe and persistent illness. Mental health
services are also covered for persons who are 21 and older but not part of the managed
care program. If you are participating in managed care and need mental health or substance
abuse services you should:
- Call the customer service line at 1-800-424-0333.
- Refer to your “Nebraska Medicaid Managed Care Provider Directory” from
Magellan and make an appointment with a health care provider.
- Access any hospital emergency services department.
If you are not participating in managed care, you may access any hospital emergency
service department or any community based mental health clinician who participates as a
Nebraska Medicaid provider for mental health services.
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Nursing Home Care
Medicaid assists you with the cost of care in a nursing home if your doctor certifies
that you require nursing home level of care and you meet Nebraska Medicaid nursing
facility (nursing home) criteria and you are currently eligible for Medicaid. You are
allowed to retain $50 per month of your income. The remainder of your income will be
applied to the cost of your nursing home care.
It is important to make sure you are both medically and financially eligible for care
in a nursing home. If you are admitted to a nursing home and it is later determined that
you are either not medically or financially eligible for medical assistance, Medicaid will
not pay for any care you have received.
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Personal Assistance Services
Personal assistance services are medically oriented tasks related to your physical
needs and include bathing, dressing, assisting with medications and nutrition, and
accompanying you to medical appointments. Medicaid covers personal assistance services
when ordered by your physician and when medically necessary. Contact your local Health and
Human Services (DHHS) office if you need personal assistance services.
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Physician Services
Medicaid covers medically necessary medical and surgical services provided by a
physician, podiatrist, nurse practitioner, nurse midwife or physician assistant. Payment
may also be made for diagnostic tests, x-rays, and other procedures that are part of your
treatment. Medicaid does not cover cosmetic, experimental or investigational services.
Some services have special requirements, limitations, and/or require your health care
provider to obtain approval from Medicaid.
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Podiatry Services
Medicaid covers services provided by a podiatrist when medically necessary. Covered
services include routine foot care, surgery, supportive devices, injections and supplies.
Limitations apply to the frequency some services may be received
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Prescription Drugs
Medicaid covers most drugs prescribed by your physician. Some over-the-counter-drugs
may be covered if prescribed by your physician and approved by Medicaid. Your pharmacist
will know which drugs Medicaid will cover and which must be approved by Medicaid. If
Medicaid does not approve or pay for the drugs, you will be responsible for payment
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Rural Health Clinic
Services provided by a rural health clinic are covered if the clinic has been certified
to participate in the Medicare and Medicaid programs. Covered services include physician,
physician assistant, nurse practitioner, and nurse midwife services, visiting nurse
services and other ambulatory services within the scope of the program.
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Speech, Physical and
Occupational Therapies
Nebraska Medicaid covers speech, physical, and occupational therapies in the office, in
the client’s home, hospital, nursing facilities, or other out-patient facilities. The
services must be prescribed by a physician. Therapy is limited to services which are
medically necessary that meet coverage criteria.
Adults (age 21 and older) are limited to a maximum of 60 combined total (occupational,
speech and physical therapy) out-patient therapy visits each year (July 1 – June
30th). You will be responsible for paying for services that exceed the number of visits
allowed.
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Vision Care Services
Medicaid covers eye care provided by ophthalmologists and optometrists to diagnose and
treat eye conditions. This includes eye examinations to determine the need for glasses and
purchase and repair glasses. Medicaid covers one examination for adults 21 years and older
once every twenty four months. Medicaid covers one pair of eyeglasses in a 24-month period
for adults 21 years and older. There are restrictions regarding the frequency of eye
examinations, replacement for broken glasses, and the type of eye care covered. There is a
maximum amount paid by Medicaid for frames and lenses. You cannot select more expensive
frames or lenses and pay the difference. You may pay for a permanent tint on lenses if you
choose. You may not pay the difference for transitional or photogrey lenses. If you choose
to purchase transitional or photogrey lenses, you must pay the cost of the entire lens.
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