We will explain the terminology you need to understand and talk about
the various programs to which you may be assigned under Medical
Assistance (MA) or CHIP. Each of these programs is somewhat different.
Reviewing this information will help you to make the most of your dental
“Medically Necessary” health
- Care necessary to prevent or eliminate disease,
infection and pain.
- Care necessary to restore form and function
to the body, including correction of disfigurement.
health services that, in the judgment of the health care provider, are
necessary for provision of optimal quality therapeutic and preventive
care. An example would be anesthesia for a surgical procedure or
- Medically Necessary Services and
Benefits (extracted from AMHP Member
- Services and benefits covered under the MA
program are medically necessary if they meet any one of the following
- The service or benefit will, or is reasonably expected to,
prevent the onset of an illness, condition or disability.
service or benefit will, or is reasonably expected to, reduce or lessen
the physical, mental or developmental effects of an illness, condition,
injury or disability.
- The service or benefit will assist the
member to achieve or maintain maximum functional capacity in performing
daily activities, taking into account both the functional capacity of
the member and those functional capacities that are appropriate for
members of the same age.
- A program that will provide some degree of
medically necessary care.
- The person, company or agency paying
the plan will determine the limits of coverage.
- Cost will be a
significant factor in plan design and its
health care plans for seniors (age 65 and
- Government health plans for low-income patient
recipients. Eligibility and services are determined by the government.
- Programs for Adults
- For recipients age 21 and older.
- The government
determines limitations on medically necessary care. These plans are not
- Programs for Children and Adolescents
- For recipients under age 21.
- These plans must be
- All “Medically Necessary” care,
including dental care, must be
- Money the patient/parent/guardian must
pay. Adult MA plans have co-pays and deductibles (pregnant AMHP members
do not have co-pays including the time they are receiving postpartum
care). MA programs for children and adolescents do not have co-pays and
deductibles. CHIP plans vary based on the insurance
- Health care
that is not covered under a specific plan.