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. CHIP 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 Identification Card. Everyone in the household who is eligible will be listed on the eligibility card. The card is good for medical services as long as the person is eligible for Medicaid. 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 Identification 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. . Copayment amounts are $1.00, $2.00, or $3.00, depending on the service you receive. You will receive a written notice if you are responsible for a copayment. 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 Medicaid Enrollment Center 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 a Medicaid ID card and then once you are enrolled in a health plan you may receive a maaged care card if you are enrolled in ShareAdvantage. 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:

  1. Call the customer service line at 1-800-424-0333.
  2. Refer to your “Nebraska Medicaid Managed Care Provider Directory” from Magellan and make an appointment with a health care provider.
  3. 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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