Mountain Health Trust benefits and services 

Learn about your covered benefits and services with Highmark Health Options.

Quick guide to Mountain Health Trust benefits and services

Covered benefits and services

Use your Highmark Health Options member ID card to get these Mountain Health Trust covered benefits.

  • Behavioral Health Rehabilitation/Psychiatric Residential Treatment Facility (PRTF). Includes services for children under age twenty-one (21) with mental illness and substance abuse. Limits frequency and amount of services.
  • Inpatient. Hospital services for the diagnosis and treatment of behavioral health and substance use disorder (SUD).
  • Inpatient Psychiatric. Includes treatment through an individual plan of care including post-discharge plans for aftercare. Service is expected to improve the condition or prevent regression so the service will no longer be needed.
    • Under age twenty-one (21). Includes services at a psychiatric hospital or psychiatric unit of a hospital. Certification that community outpatient behavioral health services did not meet the member’s treatment needs is required. Pre-admission and continued stay prior authorization is required. Not covered under West Virginia Health Bridge.
    • Age twenty-one (21) to sixty-four (64). Includes services at an Institution for Mental Diseases (IMD).
  • Outpatient. Includes services for individuals with mental illness and substance abuse. Limits frequency and amount of services. Providers must be ACT certified. Children’s residential treatment is not covered.
  • Psychological Services. May be delivered using telehealth. Some evaluation and testing procedures have frequency restrictions.
  • Drug Screening. Includes laboratory service to screen for presence of one (1) or more drugs of use.
  • Substance Use Disorder (SUD) Services. Includes targeted case management and physician-supervised medication and counseling services provided to treat those with a SUD. Opioid treatment program services will be provided through fee-for-service (FFS) Medicaid.

  • Adults twenty-one (21) and older. Includes diagnostic, preventive, and restorative services. Services also include emergency procedures to treat fractures, pain, or infection. Non-emergency coverage limited to $2,000 per two-year budget period per member.
  • Children under age twenty-one (21). Includes emergency, non-emergency, and orthodontic services.

  • Post-Stabilization Services. Includes care after an emergency health condition is under control. Care provided in a hospital or other setting.
  • Emergency Transportation. Includes ambulance and air ambulance. Out of state needs prior authorization. To call for emergency transportation, dial 911.

  • Family Planning. Includes all family planning providers and services. No referral needed for out-of-network providers. Prior authorization is not required.
  • Sterilizations. Covers sterilizations for those who are age twenty-one (21) and older and not in an institution or considered mentally incompetent.
  • Hysterectomies, pregnancy terminations, and infertility treatments. Not covered.

Includes services given at member’s residence. This does not include a hospital nursing facility, ICF/IDD, or state institutions. Some suppliers have service limits.

Includes nursing care, physician services, medical social services, short-term care, durable medical equipment, drugs, biologicals, home health aide, and homemaker. Requires physician certification. For adults ages twenty-one (21) and older, rights are waived to other treatment services related to the terminal illness.

  • Inpatient. Includes all inpatient services (including bariatric and corneal transplants). Transplant services must be in a center approved by Medicare and Medicaid. Adults in institutions for mental diseases and some behavioral health inpatient stays are not included.
  • Outpatient. Includes preventive, diagnostic, therapeutic, all emergency services, and rehabilitative medical services.

  • Maternity Care. Includes prenatal, inpatient hospital stays during delivery, and postpartum care. Home birth is not covered.
  • Right From The Start. Includes prenatal care and care coordination. No prior authorization needed.

  • Primary Care Office Visits and Referrals to Specialists.
  • Physician Services. Certain services may need prior authorization or have service limits. May be delivered through telehealth.
  • Laboratory and X-Ray Services. Includes lab services related to substance use disorder (SUD) treatment. A physician must order the services, and certain procedures have service limits.
  • Clinics. Includes general clinics, birthing centers, and health department clinics. Vaccinations are included for children.

  • Nurse Practitioner Services. Some procedures have service limits.
  • Private Duty Nursing. Includes twenty-four (24)-hour nursing care (not covered for adults ages twenty-one (21) years and over). Prior authorization may be needed.

  • Federally Qualified Health Centers. Includes physician, physician assistant, nurse practitioner, and nurse midwife services.
  • Prosthetics. Customized special equipment is considered. Certain procedures have services limits or need prior authorization.
  • Durable Medical Equipment. Covered in nursing facilities and intermediate care facilities for individuals with intellectual/developmental disabilities (ICFs/IDD). Customized special equipment is considered. Certain procedures have services limits or need prior authorization.
  • Ambulatory Surgical Care. Includes services and equipment for surgical procedures. Physician services; lab and x-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs; and DME are not covered.
  • Organ and Tissue Transplants. Corneal transplants only.
  • Gender Affirmation for Gender Dysphoria. Procedure that aligns an individual’s biological sex with their gender identity. Adults must be twenty-one (21) years or older prior to being considered for the procedure. Prior authorization is required.

  • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Includes health care services for any medical or psychological condition discovered during screening (for children under age twenty-one (21) only).
  • Tobacco Cessation. Includes therapy and counseling and Quitline services. Guidance and risk-reduction counseling covered for children.
  • Sexually Transmitted Disease Services. Includes screening for a sexually transmitted disease from your PCP or a specialist in our network.

  • Physical Therapy. Twenty (20) visits per year (combined for physical and 
    occupational therapy).
  • Occupational Therapy. Twenty (20) visits per year (combined for physical and 
  • Occupational therapy).
  • Speech Therapy. Habilitative and rehabilitative services including hearing aid evaluations, hearing aids and supplies, batteries, and repairs for children under age twenty-one (21). Some procedures have service limits or need prior approval.
  • Chiropractor Services. Includes radiological exams and corrections to subluxation. Certain procedures have service limits.
  • Pulmonary Rehabilitation. Includes procedures to increase strength of respiratory muscle and functions.
  • Cardiac Rehabilitation. Includes supervised exercise sessions with electrocardiograph monitoring.
  • Inpatient Rehabilitation. Includes inpatient rehabilitation services and general medical outpatient services that meet the certification requirements.

  • Podiatry. Includes treatment of acute conditions for children and adults. Includes some surgeries, treatment of fractures and other injuries, and orthotics. Routine foot care is not covered.
  • Handicapped and Children with Special Health Care Needs Services. Includes coordinated services and limited medical services, equipment and supplies.

Includes eye exams, treatment, lenses, frames, and repairs for children under twenty-one (21) years of age. Includes medical treatment, one pair of glasses after cataract surgery, and contact lenses (for certain diagnosis) for adults twenty-one (21) years of age and older. Does not cover prescription sunglasses or designer frames.

back to top

 

 

Benefits and services not covered

Some services are not available through Highmark Health Options, Medicaid, or CHIP. If you choose to get these services, you may have to pay the entire cost of the service. Highmark Health Options is not responsible for paying for these services and others:

  • All services not considered medically necessary. 
  • Christian science nurses and sanitariums.
  • Services from non-enrolled or non-participating providers. 
  • Services that require a prior authorization but did not get a prior authorization. 
  • Organ transplants, except in some instances. 
  • Sterilization of a mentally incompetent or institutionalized individual. 
  • Except in an emergency, inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practice, who is responsible for the diagnosis or treatment of a particular patient’s condition. 
  • Treatment for infertility and the reversal of sterilization. 
  • All cosmetic services, except in the case of accidents or birth defects. 

Note, this isn’t a complete list of the services not covered by Medicaid

back to top

 

 

We’re here for you

Ready to Enroll? Answer some qualifyng questions.