Prosthodontics We Cover prosthodontic services as follows: • Removable complete or partial dentures, for Members 15 years of age and above, including six (6) months follow-up care; • Additional services including insertion of identification slips, repairs, relines and rebases and treatment of cleft palate; and • Interim prosthesis for Members five (5) to 15 years of age. We do not Cover implants or implant related services. Fixed bridges are not Covered unless they are required: • For replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with an otherwise full complement of natural, functional and/or restored teeth; • For cleft palate stabilization; or • Due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis, as demonstrated by medical documentation.
Orthodontics We Cover orthodontics used to help restore oral structures to health and function and to treat serious medical conditions such as: cleft palate and cleft lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of the temporomandibular joint; and other significant skeletal dysplasias. Procedures include but are not limited to: • Rapid Palatal Expansion (RPE); • Placement of component parts (e.g. brackets, bands); • Interceptive orthodontic treatment; • Comprehensive orthodontic treatment (during which orthodontic appliances are placed for active treatment and periodically adjusted); • Removable appliance therapy; and • Orthodontic retention (removal of appliances, construction and placement of retainers).
Family Care and Medical Leave An unpaid Family Care and Medical Leave shall be granted, to the extent of and subject to the restrictions as set forth below, to an employee who has been employed for at least twelve (12) months and who has served for one hundred thirty days (130) workdays during the twelve (12) months immediately preceding the effective date of the leave. For purposes of this section, furlough days and days worked during off-basis time shall count as "workdays". Family Care and Medical Leave absences of twenty (20) consecutive working days or less can be granted by the immediate administrator or designee. Leaves of twenty (20) or more consecutive working days can be granted only by submission of a formal leave application to the Classified Personnel Assignments Branch.
Child Care A. Employees employed as of March 1 who meet the following criteria shall be eligible for a lump sum payment each year. Eligible employees may apply for this payment between March 1 and April 15 of each year. Payment shall be made within thirty (30) days of receipt of the completed application. Any application received after April 15 will be considered on a case by case basis and shall not be arbitrarily rejected.
Medical Care Leave An Employee who is unable to make the necessary arrangements for maintenance of personal health care outside of scheduled work time, shall be granted time off with pay. Such time off shall not exceed sixteen (16) working hours per calendar year. Hours in excess of sixteen (16) hours per calendar year shall be deducted from the Employee's sick leave accumulation.
Community Mental Health Center Services Assertive Community Treatment Staffing Full Time Equivalents Community Mental Health Center March 2021 December 2020 Nurse Masters Level Clinician/or Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner 01 Northern Human Services - Wolfeboro 1.00 0.00 0.00 0.57 6.81 0.27 8.27 0.25 01 Northern Human Services - Berlin 0.34 0.31 0.00 0.00 3.94 0.14 4.17 0.14 01 Northern Human Services - Littleton 0.00 0.14 0.00 0.00 3.28 0.29 3.31 0.29 02 West Central Behavioral Health 0.60 1.00 0.00 0.00 5.40 0.30 5.90 0.30 03 Lakes Region Mental Health Center 1.00 1.00 0.00 1.00 5.00 0.40 7.00 0.38 04 Riverbend Community Mental Health Center 0.50 1.00 6.90 1.00 10.40 0.50 10.50 0.50 05 Monadnock Family Services 1.91 2.53 0.00 1.12 11.17 0.66 10.32 0.62 06 Greater Nashua Mental Health 1 1.00 1.00 3.00 1.00 7.65 0.15 8.50 0.15 06 Greater Nashua Mental Health 2 1.00 1.00 4.00 1.00 8.65 0.15 8.50 0.15 07 Mental Health Center of Greater Manchester-CTT 1.33 10.64 2.00 0.00 19.95 1.17 21.61 1.21 07 Mental Health Center of Greater Manchester-MCST 1.33 9.31 3.33 1.33 19.95 1.17 25.27 1.21 08 Seacoast Mental Health Center 1.00 1.10 5.00 1.00 10.10 0.60 10.10 0.60 09 Community Partners 0.50 0.00 3.40 0.88 7.28 0.70 7.41 0.70 10 Center for Life Management 1.00 0.00 2.28 1.00 6.71 0.46 6.57 0.46 Total 12.51 29.03 29.91 9.33 126.29 6.96 137.43 6.96 2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies Community Mental Health Center Substance Use Disorder Treatment Housing Assistance Supported Employment March 2021 December 2020 March 2021 December 2020 March 2021 December 2020 01 Northern Human Services - Wolfeboro 1.27 1.27 5.81 6.30 0.00 0.40 01 Northern Human Services - Berlin 0.74 0.74 3.29 3.29 0.00 0.23 01 Northern Human Services - Littleton 1.43 1.29 2.14 2.14 1.00 1.00 02 West Central Behavioral Health 0.20 0.20 4.00 0.40 0.60 0.60 03 Lakes Region Mental Health Center 1.00 3.00 5.00 7.00 2.00 2.00 04 Riverbend Community Mental Health Center 0.50 0.50 9.40 9.50 0.50 0.50 05 Monadnock Family Services 1.69 1.62 4.56 4.48 0.95 1.18 06 Greater Nashua Mental Health 1 6.15 7.15 5.50 6.50 1.50 1.50 06 Greater Nashua Mental Health 2 5.15 5.15 6.50 6.50 0.50 0.50 07 Mental Health Center of Greater Manchester-CCT 14.47 15.84 13.96 15.62 2.66 2.66 07 Mental Health Center of Greater Manchester-MCST 6.49 7.86 15.29 19.28 1.33 2.66 08 Seacoast Mental Health Center 2.00 2.00 5.00 5.00 1.00 1.00 09 Community Partners 1.20 1.20 4.50 4.50 1.00 1.00 10 Center for Life Management 2.14 2.14 5.42 5.28 0.29 0.29 Total 44.43 49.96 90.37 99.39 13.33 15.52 Revisions to Prior Period: None. Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report. Notes: Data compiled 04/26/2021. For 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) This plan covers durable medical equipment and supplies, prosthetic devices and enteral formula or food as described in this section. Durable Medical Equipment (DME) DME is equipment which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. DME includes supplies necessary for the effective use of the equipment. This plan covers the following DME: • wheelchairs, hospital beds, and other DME items used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition or if the device is not functional, no longer under warranty, or cannot be repaired. DME may be classified as a rental item or a purchased item. In most cases, this plan only pays for a rental DME up to our allowance for a purchased DME. Repairs and supplies for rental DME are included in the rental allowance. Preauthorization may be required for certain DME and replacement or repairs of DME. Medical Supplies Medical supplies are consumable supplies that are disposable and not intended for re- use. Medical supplies require an order by a physician and must be essential for the care or treatment of an illness, injury, or congenital defect. Covered medical supplies include: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary DME (these accessories are included as part of the rental allowance for rented DME); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment. Diabetic Equipment and Supplies This plan covers diabetic equipment and supplies for the treatment of diabetes in accordance with R.I. General Law §27-20-30. Covered diabetic equipment and supplies include: • therapeutic or molded shoes and inserts for custom-molded shoes for the prevention of amputation; • blood glucose monitors including those with special features for the legally blind, external insulin infusion pumps and accessories, insulin infusion devices and injection aids; and • lancets and test strips for glucose monitors including those with special features for the legally blind, and infusion sets for external insulin pumps. The amount you pay differs based on whether the equipment and supplies are bought from a durable medical equipment provider or from a pharmacy. See the Summary of Pharmacy Benefits and the Summary of Medical Benefits for details. Coverage for some diabetic equipment and supplies may only be available from either a DME provider or from a pharmacy. Visit our website to determine if this is applicable or call our Customer Service Department. Prosthetic Devices Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. Enteral Formulas or Food (Enteral Nutrition) Enteral formula or food is nutrition that is absorbed through the intestinal tract, whether delivered through a feeding tube or taken orally. Enteral nutrition is covered when it is the sole source of nutrition and prescribed by the physician for home use. In accordance with R.I. General Law §27-20-56, this plan covers enteral formula taken orally for the treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of amino acids and organic acids. Food products modified to be low protein are covered for the treatment of inherited diseases of amino acids and organic acids. Preauthorization may be required. The amount that you pay may differ depending on whether the nutrition is delivered through a feeding tube or taken orally. When enteral formula is delivered through a feeding tube, associated supplies are also covered. Hair Prosthesis (Wigs) This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. Early Intervention Services (EIS) This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. Members not living in Rhode Island may seek services from the state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.
Primary Care Clinic Employees and each of their covered dependents must individually elect a primary care clinic within the network of providers offered by the plan administrator chosen by the employee. Employees and their dependents may elect to change clinics within their clinic’s Benefit Level as often as the plan administrator permits and as outlined above.
Health Care Operations Health Care Operations shall have the meaning set out in its definition at 45 C.F.R. § 164.501, as such provision is currently drafted and as it is subsequently updated, amended or revised.
Chiropractic Services This plan covers chiropractic visits up to the benefit limit shown in the Summary of Medical Benefits. The benefit limit applies to any visit for the purposes of chiropractic treatment or diagnosis.
