Benefits and special services

• Covered Benefits
• Medicines
• Eye Exams and Eyeglasses
• Dental Care
• Special Needs
• Mental Health, Drug & Alcohol Services
• MOM Matters^® for Pregnant Women
• “AIR” Gateway^® Asthma Program
• Help Your Heart Program
• Healthy Returns Diabetes Program
• Growing Up with Gateway^SM
• Early Intervention
• Family Planning
• Chiropractic Services
• Services Not Covered

Some of the services that are covered by Gateway Health Plan^® at no cost to you include:

• Visits to your Primary Care Doctor
• Visits to the doctor while you are pregnant
• Visits to specialists with a referral from your Primary Care Doctor
• Yearly physical
• Well child care, including regular check-ups and shots
• Allergy tests and shots with a referral from your Primary Care Doctor
• Emergency dental care
• Non-emergency dental care, if eligible for non-emergency dental care under Medical Assistance.
• Braces for teeth for members under the age of 21, if medically necessary
• Eye exams
• Contraceptives (birth control), insulin, insulin syringes, vitamins, and certain over-the-counter medicines when prescribed by a doctor and covered by the approved drug list
• Drugs for members under age 21 when prescribed by a doctor and covered by the approved drug list
• Drugs for members age 21 and older if eligible for medicine coverage under Medical Assistance, prescribed by a doctor, and covered by the approved drug list
• Orthopedic shoes and hearing aids for members under the age of 21, if medically necessary
• Foot care
• Emergency care 24 hours a day, 7 days a week
• Hospitalization, if medically necessary, including semi-private rooms (a private room is covered if needed for a medical condition), inpatient drug and doctor services
• 24-hour toll-free member telephone service for non-emergency and urgent needs, through the Gateway Member Services Department
• Laboratory tests and cardiograms, as ordered by your doctor
• X-rays, when medically necessary and ordered by your doctor
• Surgery and anesthesia, if medically necessary
• EPSDT expanded services for members under the age of 21
• Extended home nursing services for members under the age of 21, if medically necessary
• Physical therapy, if medically necessary
• Occupational and speech therapy, if medically necessary
• Nursing facility care (limited to 30 days), if medically necessary
• Home health care visits, if medically necessary and ordered by your doctor
• On-going chiropractic services, if medically necessary
• Molded shoes, if medically necessary
• Medically necessary services for members under 21

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If you are under 21, or over 21 and eligible for drug coverage, your prescriptions can be filled at any pharmacy (drug store) that is part of Gateway Health Plan^®’s pharmacy network. Members that are not eligible for drug coverage can get contraceptives (birth control) and vitamins. Diabetic members that are not eligible for drug coverage from Medical Assistance can get insulin and syringes (needles) from Gateway. Members must get prescriptions from their Primary Care Doctor for insulin, syringes, contraceptives, and vitamins. Then the prescription can be taken to a pharmacy in Gateway’s network. If you need help finding a pharmacy that is in the network, please call Member Services at 1-800-392-1147.

Gateway Health Plan^® uses an approved drug list, called a drug formulary, to determine if your drug is covered. The drug formulary has FDA approved products from every major drug category, including vitamins and all over-the-counter medicines covered by Medical Assistance. If you would like a copy of the approved drug formulary, or have any questions on drug coverage, please call Member Services at 1-800-392-1147. Members can also notify Gateway Health Plan^® of their desire to have a new medication placed on the formulary.

If you are on a drug that is not on Gateway’s approved drug formulary, talk to your doctor to see if your drug can be switched to a drug from the formulary that has the same or similar effect. If your doctor feels that the drug you take now is medically necessary and cannot be switched, your doctor can call Gateway to request an exception. If the exception is approved, Gateway will cover your current drug. Gateway will approve for your pharmacy to give you enough of the drug for 72 hours if a decision on the exception cannot be made within 24 hours, and you need the drug.

You have the right to appeal any decision made about your drug coverage. Call the Member Services Department toll-free at 1-800-392-1147, 24 hours a day, 7 days a week.

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Regular eye exams are very important. That is why Gateway Health Plan^® gives this benefit to all Gateway members. Each Gateway member is eligible for eye examinations every calendar year. There is no waiting period to get your vision benefit.

You must go to an eye doctor who is part of Gateway Health Plan^®’s vision network. You do not need a referral. Be sure to show your Gateway ID card and say that you are a Gateway Health Plan^® member.

Members age 21 and over will also be covered for one pair of standard eyeglass lenses or contact lenses per calendar year. In addition, members age 21 and over will be covered for one pair of eyeglass frames up to $20 each calendar year.

Members under the age of 21 are eligible for two basic pairs of eyeglasses (frames and lenses) from within Gateway’s network each calendar year and replacement pairs, if medically necessary. Members under the age of 21 may choose to receive one pair of contact lenses. 

If you have a medical condition such as cataracts, you will also be covered for glasses or contacts to treat your condition.

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All Gateway members may get the following dental services each year from any Gateway Health Plan^® participating dentist:

• One exam
• 2 Cleanings
• X-rays

All members under the age of 21 and some members age 21 and over have benefits for more dental services than are listed above. Call Member Services at 1-800-392-1147 (TTY/TDD 1-800-654-5988) with questions about your dental coverage or to get a list of Gateway Health Plan^® dentists. You can go to any Gateway dentist to get your services.

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If you have a special health care need, the Special Needs Unit can help. Nurses, social workers, and other health care staff help to make sure you get the medical care that you need. They can assist you with any problems you have in getting your care. 

If you would like information about programs in your community such as food banks, HIV programs, or programs for seniors, the Special Needs will help you. Call the Member Services Department at 1-800-392-1147 if you would like to talk to the Special Needs Unit.

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Services for mental health care such as depression, or drug and alcohol abuse are available to you. Please see the last page of the member handbook for the phone numbers for your county.

If you need help accessing these services, you can call Member Services at 1-800-392-1147.

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Babies that are born too early or too small can have eye, hearing, or learning problems. You can cut the risks to your baby’s health by getting prenatal care. Prenatal care is the care you get while you are pregnant or expecting a baby.

Gateway has a special program called MOM Matters^®. The MOM Matters^® program gives the support you need to help you have a healthy baby.

You can join the MOM Matters^® program as soon as you know that you are pregnant. Call 1-800-642-3550 (Option 2) to talk to a nurse, called a Maternity Care Manager, in the MOM Matters^® program. The nurse will answer your questions about taking care of yourself and your unborn baby. The nurse will work with your doctor to arrange services you need.

See your doctor as soon as you know you are expecting a baby. You do not need a referral from your Primary Care Doctor to see an (OB/GYN doctor) obstetrician or midwife. Your doctor will check you and help plan the care that you need. Your doctor will also give you advice to help you have a healthy baby.  Because regular prenatal care can help you have a healthy baby, it is a good idea to stay with the same health plan during your entire pregnancy.

After you see your doctor, the MOM Matters^® program can:

• Mail you information on pregnancy care.
• Help you get to your prenatal visits.
• Send a nurse for a home visit before you deliver the baby.
• Refer you to a program to help you stop smoking.
• Send a nurse for a home visit after your baby is born.
• Give you a baby gift.

The MOM Matters^® program will give you information about programs that are in your community.  WIC stands for the Women, Infants, and Children program. The Pennsylvania Department of Health sponsors WIC. WIC helps women and children to get the best possible nutrition. The program gives vouchers for healthy foods and baby formula. If you would like to be in WIC, call WIC at 1-800-942-9467.

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“AIR” Gateway^® is a program to help members get the care they need for asthma. It also helps members learn what things they can do to keep the asthma under control. If you have trouble controlling your asthma, call the asthma case manager. The case manager will ask you questions to find out what is causing your asthma flare-ups. The case manager can work with your doctor to make sure that you are getting the care that you need. You can learn about your asthma medicines and how to prevent flare-ups. The “AIR” Gateway^® program.

• Mail information on asthma to you.
• Refer you to a program to help you stop smoking.
• Send a respiratory therapist to your home for additional teachings.

Call 1-800-642-3550 (Press 3) to find out about the “AIR” Gateway^® program.

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Gateway offers a Help Your Heart Program for adult Gateway members age 18 and older who have been diagnosed with Congestive Heart Failure, a heart attack or coronary artery disease. Coronary artery disease is also called hardening of the arteries. Nurse Care Managers will help you to understand these conditions and will teach you the signs of problems. They can help you to understand what you can do so you can prevent your heart problems from getting worse. Sometimes people with heart problems are on a lot of different medicines. The nurses will help you understand why you are on the pills and teach you how to take them. The goal of the program is to help you understand what you can do to take control of your heart problems, rather than letting your heart problems take control of you.

The phone number for the Disease Management Team for the Help Your Heart Program is 1-800-642-3550, Option 3.

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Gateway members with diabetes can benefit from the Healthy Returns Diabetes Program. This program will help you, or your family members understand diabetes. This program does not replace your doctor, so your doctor will still be in charge of your care.

The program has nurses you can call 24 hours a day with questions. You can talk to the nurse about your diet or talk to a pharmacist about your medicine.  A nurse can come to your home to teach you about insulin. You can learn to check your blood sugar from the nurse and get tips to keep your blood sugar under control.

If you need more information, call your doctor or call Gateway Health Plan^® at 1-800-551-6923, Option 4 for the Healthy Return Diabetes Program.

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Gateway members from birth to age 21 are eligible for a special program called Growing Up with Gateway^SM. Growing Up with Gateway^SM includes all of the services that are under the Pennsylvania Department of Welfare’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. The purpose of the Growing Up with Gateway^SM program is to find children’s health problems early and to keep checking to be sure that children stay healthy.

Your child’s Primary Care Doctor can do the screenings and services under this program. The doctor will give your child a complete physical exam and shots, when needed. The exam covers 11 areas of health: eyesight, hearing, teeth, growth and development, healthy diet, heart, lungs, urine test, anemia (iron) test, and a lead screening. Any other areas that the doctor feels are important will also be checked.

It is very important that you keep these EPSDT appointments with the doctor. These physical exams can sometimes be used for the physical exam that is needed for starting Head Start, school, or driver’s license physicals.

Your child’s doctor may find that your child needs a medically necessary service or a piece of equipment to treat a problem found during a screening visit. If so, your child’s doctor can call Gateway to ask for the service or equipment, and it will be reviewed for approval.

If you need more information about the Growing Up with Gateway^SM program, please call Member Services at 1-800-642-3550, Option 4. Member Services can also help you set up an appointment for your child, or help you get a ride for these appointments.

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Gateway Health Plan^® participates in Early Intervention Services by identifying infants, toddlers, and preschool children who have special needs due to developmental delays or disabilities. Primary Care Doctors and school districts may also help identify members in need of Early Intervention Services. When a member is identified, the parent is contacted and given the CONNECT Helpline at 1-800-692-7288. The CONNECT staff will answer questions and refer a family to the appropriate local agency for a developmental assessment.

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Family planning (birth control) services are available to Gateway Health Plan^® members. You do not need a referral from your Primary Care Doctor for family planning services. You can see any doctor that offers family planning. If you would like more information on a doctor in Gateway’s network, please call 1-800-392-1147. However, you may choose to use a family planning clinic that is not part of Gateway’s network. There is no cost for these services. When you go to a family planning provider, just show your Gateway Health Plan^® ID card.

Treatment for infertility (cannot have a baby) is not covered by Gateway Health Plan^®.

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Gateway Health Plan^® members can get chiropractic care. You may go to a chiropractor from Gateway’s list of doctors on your own for the first visit, or your Primary Care Doctor can call Gateway before you go. After your first visit, the chiropractor must talk to a Gateway nurse about your treatment plan, and the nurse may approve more visits, if medically necessary.

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There are some services not covered by Gateway Health Plan^®. Limitations and most exclusions do not apply to members under the age of 21. Services not covered include:

• Braces for teeth (called orthodontics) for members age 21 or older
• Cosmetic Surgery (also called plastic surgery), unless medically necessary
• Custodial care including Personal Care Homes
• Experimental procedures, except those approved by Gateway Health Plan^®
• Nursing home care for more than 30 days. If you need to stay in a nursing home for more than 30 days, you will be switched back to Medical Assistance/ACCESS.
• Personal items or services such as television or a telephone while you are in the hospital.
• Prescription drugs for adult members age 21 or older that are not eligible for Medical Assistance drug benefits (other than vitamins, insulin, syringes, and birth control)
• Prescription drugs not listed on the approved drug list, unless an exception is made
• Treatment for infertility (cannot become pregnant)
• Home modifications
• Respite care
• Services that are not covered by the Medical Assistance program
• Non-medical items or services

Extended home nursing services, private duty nursing, shift nursing care, and EPSDT home health services are not covered for members age 21 and older. This applies to members receiving these services before turning age 21.

There may be other services that are not covered by Gateway Health Plan^®. If you are not sure if the service you need is covered, call Member Services at 1-800-392-1147. You may have to pay for services that are not covered by Gateway Health Plan^® or services not provided by a Pennsylvania Medical Assistance participating provider.

Remember, in most cases, Gateway will only cover those services that are ordered by your PCP, except in a medical emergency.

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