Investing in Maternal and Child Health

Maternal and Child Health Balanced Scorecard & Analysis Tools

Plan Benefit

Model Components HMo & PPo Models Comparison Plan variance Summary

Key opportunities

for Improvement

Coverage Limits No limits

Inclusions All medically necessary assessment and treatment.

Exclusions All others as defined by the health plan.

Copay $25 - $40 per visit

Coinsurance 15% per visit

OOP Maximum Applies

Iv e. nutritional Services

Coverage (Y/N) Y

Covered Providers By or under the direction of a physician, nurse
practitioner, or other licensed provider working
under the direction a physician; registered

dietician.

Coverage Limits Limited to 25 visits per calendar year.

Inclusions All medically necessary care.

Exclusions All others as defined by the health plan.

Copay $25 - $40 per visit

Coinsurance 15% per visit

OOP Maximum Applies

Ivf. occupational, Physical, and Speech Therapy Services

Coverage (Y/N) Y

Covered Providers By or under the direction of a primary care
provider, a licensed occupational therapist,
physical therapist, speech pathologist, or speech
therapist.

Coverage Limits 75 services per calendar year

Inclusions All medically necessary care.

Exclusions All others as defined by the health plan.

Copay $25 - $40 per visit

Coinsurance 15% per visit

OOP Maximum Applies

Ivg. Infertility Services

Coverage (Y/N) Y

Covered Providers By or under the direction of a primary care
provider (family physician, general practitioner,
internal medicine physician, nurse practitioner)
or qualified physician specialist (e.g., OB-GYN,
fertility specialist).

Coverage Limits Medications are subject to formulary require-
ments.

Side-by-Side Analysis Tool