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Covered Services

Below is a list of services you can receive from CountyCare. All services must be medically necessary. Some services require approval from us. This is called “Prior Authorization” or PA. Your doctor will contact CountyCare if you need PA for a service.

  • Advanced practice nurse services
  • Ambulatory surgical treatment center services
  • Assistive/augmentative communication devices
  • Audiology services
  • Blood, blood components, and the administration thereof
  • Chiropractic services for enrollees under age 21
  • Coverage for one or more vendors procured by Chicago Public Schools (CPS) to manufacture eyeglasses for children in CPS
  • Dental services: Exams (1 every six months for members under age 21)
  • Dental services: Fluoride treatments (1 per year for members under age 21)
  • Dental services: Oral surgeons for enrollees under age 21 and dental cleanings two (2) times per year
  • Dental services: Eligible adults (age 21 and over) will be able to get limited and comprehensive exams; restorations; dentures; extractions; and sedation
  • Dental services: Eligible pregnant women can get these additional dental services PRIOR to the birth of their babies: periodic oral examination; teeth cleaning; and periodontal work
  • Durable medical equipment (DME)
  • Emergency dental services
  • EPSDT services for enrollees under age 21 (excluding shift nursing for enrollees in the MFTD HCBS waiver for individuals who are medically fragile and technology dependent (MFTD))
  • Family planning services and supplies
  • FQHCs, RHCs, and other encounter rate clinic visits
  • Genetic radiology services
  • Genetic counseling and testing
  • Home health agency visits
  • Hospital emergency room visits
  • Hospital inpatient services
  • Hospital ambulatory services
  • Laboratory and x-ray services
  • Medical supplies, equipment, prostheses and orthoses, and respiratory equipment and supplies
  • Mental health services provided under the Medicaid Clinic Option, Medicaid Rehabilitation Option, and Targeted Case Management Option
  • Nursing care for enrollees under age 21 not in the HCBS waiver for individuals who are MFTD
  • Nursing care for the purpose of transitioning children from a hospital to home placement or other appropriate setting for enrollees under age 21
  • Nursing facility services
  • Optical services and supplies
  • Optometrist services
  • Palliative and hospice services
  • Pharmacy services (drugs used in the treatment of hepatitis C are covered only if dispensed in accordance with coverage criteria approved by the Illinois Department of Healthcare and Family Services)
  • Physical, occupational, and speech therapy services
  • Physician services
  • Podiatric services
  • Post-stabilization services
  • Practice visits for enrollees with special needs
  • Pregnancy termination if medically necessary as defined by Illinois law
  • Renal dialysis services
  • Respiratory equipment and supplies
  • Services to prevent illness and promote health
  • Subacute alcoholism and substance abuse services, residential day treatment, and detox day treatment
  • Transplants using transplant provider certified by HFS
  • Transportation to get to covered services

Care Coordination

At times, you may need extra help to meet your health needs. CountyCare has a program called “Care Coordination” to help. You may be given a “Care Coordinator” if your doctor or CountyCare think you could benefit from this program. Your Care Coordinator can provide extra help for you and your family.

A Care Coordinator is here to:

  • Answer questions about your care
  • Help you navigate getting health care
  • Help you consider your care choices
  • Help with finding a specialist
  • Help with benefits
  • Help with your transition out of the hospital
  • Help connect you with community resources

Care coordinators work with you to keep you healthy. You may receive a call from a Care Coordinator or meet one in your PCP’s office. You may be assigned a Care Coordinator if:

  • You have a chronic illness such as asthma, diabetes, or heart failure
  • You have been to the ER or in the hospital
  • You have a complex pregnancy
  • Your PCP thinks it can help you

What you tell your Care Coordinator is confidential. It is shared only when needed to help plan your care. If you want to know more about the program, call Member Services or your PCP.

Services Not Covered

CountyCare does not cover all health services. Services that are not covered are:

  • Cosmetic surgery
  • Experimental treatments
  • Infertility
  • Elective pregnancy termination

Call Member Services if you have questions about what is covered. Also, remember that some services need our approval first. This is called Prior Authorization or PA. If you need a PA for a service, call your PCP.

Out of Plan Coverage

Members must use providers that are part of CountyCare.  The only exceptions are emergency room (ER) care and women’s health care.  For these two services, you can use any provider.  Visit the Find-A-Provider page on our website to find a provider that takes CountyCare.

If you travel out of state and need emergency services, go to the nearest ER.  Ask the ER to send claims to us.  If the ER does not send a claim, or does not accept our payment, you may be responsible for the bill.  Care provided outside of the U.S. is not covered.

Long-Term Services and Supports (LTSS)

CountyCare provides LTSS waiver services for certain members with special needs.

Members who are eligible may be:

  • Elderly
  • Disabled
  • Living with HIV/AIDS
  • Have a brain injury

The State of Illinois determines who can receive waiver services. Contact Member Services if you think you may qualify for a waiver program. We can help you apply.

CountyCare members in a waiver program may be eligible for additional services such as:

  • Adult Day Service
  • Adult Day Service Transportation
  • Environmental Accessibility Adaptions-Home
  • Supported Employment
  • Home Health Aide
  • Nurse Intermittent
  • Nursing Skilled
  • Occupational, Physical and Speech Therapy
  • Prevocational Services
  • Day Habilitation
  • Placement Maintenance Counseling
  • Medically Supervised Day-Care
  • Homemaker
  • Home Delivered Meals
  • Personal Assistant (contingent upon compliance with collective bargaining agreement and accompanying side letter between SEIU and the state)
  • Personal Emergency Response System (PERS)
  • Respite
  • Nurse Training
  • Family Training
  • Specialized Medical Equipment and Supplies
  • Behavioral Services
  • Assisted living
  • Nursing facility services (over the first 90 days)

  

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