Health Care Education and Wellness Program

Plan de Salud Menonita (PSM) offers a Health Care Education and Wellness Program (Wellness Program) focused on helping you stay healthy and happier. All the services in this program are planned to help you live a healthy life by preventing and dealing with chronic conditions. When our bodies feel right, our minds work right. PSM will show how to avoid risk factors such as: an unhealthy diet, lack of physical activity, smoking, obesity among others that can affect your health.

PSM Wellness Program includes:

• Health promotion and preventive programs
• Chronic Disease Management education program
• Health Education and Wellness materials

All services take into consideration your physical and behavioral health. Some of the health areas are:

• Annual health checkup
• Proper use of the services of Vital, including the PSM Beneficiary Service Line available and how to navigate the managed care system
• Women’s health test including: mammograms, pap smears, cervical screenings, and tests for sexually transmitted infections
• Maintain a healthy body weight, through good nutrition and exercise
• Annual dental exam
• Behavioral Health screening
• Medical and developmental needs of children and adolescents, including vaccinations
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program
• Education regarding the diagnosis and treatment of high-risk conditions such as: Depression; Schizophrenia; Bipolar disorders; Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder; Substance abuse; and Anxiety disorders.
• Stress management, Anxiety
• Educational workshops on Diabetes, CKD, CHF, Prenatal and maternity care, etc.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program

The Plan de Salud Menonita (PSM) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program is the child health component of Medicaid. EPSDT means:

• Early: Identifying problems early, starting at birth
• Periodic: Checking children’s health at periodic, age-appropriate intervals.
• Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
• Diagnosis: Performing diagnostic tests to follow up when a risk is identified
• Treatment: Control, correct or reduce health problems found.

This benefit covers evaluation and diagnostic services to uncover any physical and mental deficiencies in the beneficiaries with less than twenty-one (21) years of age. The care services are preventive. The PSM It also identifies health care, prevention, treatment, and other measures to correct or ameliorate any deficiencies and chronic conditions discovered.

Grow Healthy with Plan de Salud Menonita (PSM)

PSM created the “Crece Saludable con PSM” (Grow Healthy with PSM) Program to promote good health in the children enrolled in Vital.

The “Crece Saludable con PSM” Program includes:

• Complete evaluation of health and developmental history.  Includes physical, behavioral and nutritional conditions
• Laboratory tests (including Lead Toxicity Testing)
• Complete physical examination, including weight, height and growth charting
• Health education, including anticipatory guidance.
• Vaccines- offered and paid by the Puerto Rico Health Department for Medicaid and CHIP eligible beneficiaries
• Developmental evaluations for social-emotional conditions
• Screening for vision and hearing
• Dental Services
• Fine/gross motor screening
• Tuberculosis screening
• Perinatal depression for mothers of infants

Prenatal Wellness Program

The PLan de Salud Menonita (PSM) Prenatal Wellness Program will bring services to the beneficiaries during their pregnancy.  Since the beginning of the pregnancy, this program will offer you support and guidance during this important part of your life.

The Prenatal Wellness Program will help you:

• Ensure access and maintain enrollment in the Pregnancy Health Management Program.
• Check-ups for potential risk factors
• Assist you in getting and meeting your basic needs
• Get education, and your family,  about: the pregnancy process, your soon to come baby, family planning, and others.

If you need medicine, your provider will write you a prescription to take to a participating pharmacy. You can choose any pharmacy that works with PSM. You can find a list of participating pharmacies in our Provider Directory. Or you can call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free.

Prescription medicines are free for children up to the age of 20 and for pregnant women that are Medicaid or CHIP beneficiaries. Other adults will need to pay for prescription drugs. For more information about payments click HERE.

Your Covered Drugs Formulary (CDF) is the list of medicines VITAL covers. This list helps your doctor prescribe medicines for you. Brand-name and generic medicines are on the CDF. A generic version of a medicine is the first choice. If a generic version of a medicine is available, your doctor has to prescribe the generic version.

If you have a chronic condition, your doctor can write a prescription for a 90-day supply of some medicines. This way, you only have to pay for the medicine once instead of paying three times (1 payment per month).

Vital offers mental health, alcohol and substances abuse services. You do not have to see your PCP first to see a doctor or other provider for mental health, alcohol or substances abuse services. You can ask for these services whenever you feel like you need them.

We wants to make it easy for you to get physical and mental health, alcohol, and substance abuse services in the same place.

Your Primary Medical Group (PMG) is one place you can go to get mental health, alcohol or drug abuse services. Your PMG must have a psychologist and/or a social worker available at least from 4 to 16 hours per week during regular business hours.

If you get mental health, alcohol or drug abuse services at another place (like a mental health clinic or a psychiatric hospital), they must have services from a PCP in the office at least part of the time to care for your physical health needs.

If you need help finding mental health, alcohol and substance abuse services and providers, call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free.

You can find information about participating dentists in the PSM Provider Directory . Your Primary Medical Group and the PSM Service Centers also have a copy of the list.

For questions about your dental benefits, call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free.

Enrollees with special health care needs can get a Special Coverage that will provide services for the care they need.

The special health care needs are:

1. Aplastic Anemia
2. Rheumatoid Arthritis
3. Autism
4. Cancer
5. Skin Cancer such as Invasive Melanoma or squamous cells with evidence of metastasis.
6. Skin Cancer – Carcinoma IN SITU
7. Chronic Renal Disease
8. Scleroderma
9. Multiple Sclerosis (MS) and Amiotrophic Lateral Sclerosis (ALS)
10. Cystic Fibrosis
11. Hemophilia
12. Leprosy
13. Systemic Lupus Erythematosus(SLE)
14. Children with Special Health Needs
15. Obstetric
16. Tuberculosis (Tb)
17. HIV/AIDS
18. Adults with phenylketonuria (PKU)
19. Pulmonary Hypertension
20. HCV (Chronic Hepatitis C)
21. Congestive Heart Failure (CHF): Class III and Class IV, NYHA
22. Primary Ciliary Dyskinesia (PCD) or Immotile Ciliary Syndrome

Your PCP or your Primary Medical Group can give you more information on which people qualify for the special coverage. If you qualify for Special Coverage, they can also help you sign up for it.

People with Special Coverage can choose any provider that works with your Preferred Provider Network or your Insurer’s General Network. People with Special Coverage can get prescription medications, tests and other services through the Special Coverage without a referral or needing their PCP to sign off.

Your Insurer will let you know if you are qualified and if you are will make sure that you get access to the services. VITAL Special Coverage will begin when the enrollee reaches the limits of the Special Coverage for any other health plan.

The benefits under Special Coverage include the list below. Some services may have limits. For information call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free.

Some people with high needs and special conditions can receive Care Management. When you are eligible for Care Management, nurses, social workers and nutritionists are available to help you create a plan for your care.

The PSM Care Management Program will support you with your high needs and special conditions and assist you in meeting your health goals. These services will help you receive the right care, at the right time, in the right place. You should have fewer gaps in service and better coordination between all your health care providers.

The Plan de Salud Menonita (PSM) Care Management Program (CM) facilitate access and coordination of services for all beneficiaries with high needs and special conditions. Beneficiaries with these conditions are chosen to be managed more closely by the PSM Case Managers.

The PSM Care Managers are available to do an evaluation, and create and carry out a care plan for your care. Our team, Primary Care Physicians (PCP), pharmacists, social workers, and behavioral health and community professionals, will review your care plan with you at least once a year, if your health needs change, or or if you ask for a review.

If you have questions and want to speak to someone you may do so by calling the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free. We look forward to continuing to serve you and helping you achieve your best possible health.

For any question related to your health conditions call Medical Advice Line- TeleCuidado Menonita at 1-844-736-3345 or 1-844-716-3345 TTY (hearing impaired).  This phone call is free. TeleCuidado Menonita is available 24 hours a day, 7 days a week.

If you have certain conditions, you may benefit from Plan de Salud Menonita High Cost High Needs Program (HCHN Program) to help you get all the care you need. This program is free.

If your PCP tells you that you have:

Plan de Salud Menonita (PSM) High Cost High Need Program (HCHN or HCHN Program) focuses on members with high risk and/or chronic conditions. Beneficiaries in the HCHN Program have the assistance from an individual intervention plan.

The purpose of this program is to help Beneficiaries with chronic conditions to take care of their health, by receiving education and the medical care they need. The persons that offer the services to the Beneficiaries are: nurses, nutritionist, social workers, behavioral specialist under a guidance of a Medical Director and Pharmacists.

Eligible Beneficiaries are automatically enrolled in the program and receive the help they need. Participation, however, is voluntary and the Beneficiary has the right to decline or “opt out” of all or any part of the HCHN program. Beneficiaries who opt out may reenter the program at any time, simply by contacting the Case Manager or calling the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free.

Here is a general list of some services that are not covered by Vital. Or, you may call the PSM Beneficiary Service Line at 1-866-600-4753 or 1-844-726-3345 TTY (hearing impaired). The phone call is free. Some non-covered services are:

1. Services for non-covered illnesses or trauma.
2. Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its acronym in Spanish).
3. Accidents on the job that are covered by the State Insurance Fund Corporation.
4. Services covered by another insurance or entity with primary responsibility (third party liability).
5. Specialized nursing services for the comfort of the Patient when they are not medically necessary.
6. Hospitalizations for services that can be rendered on an outpatient basis.
7. Hospitalization of a Patient for diagnostic services only.
8. Expenses for services or materials for the Patient’s comfort such as telephone, television, admission kits, etc.
9. Services rendered by Patient’s relative (parents, children, siblings, grandparents, grandchildren, spouse, etc.).
10. Organ and tissue transplants, except skin, bone and corneal transplants.
11. Weight control Treatments (obesity or weight increase for aesthetic reasons).
12. Sports medicine, music therapy and natural medicine.
13. Cosmetic surgery to correct physical appearance defects.
14. Services, diagnostic tests ordered or provided by naturopaths, and iridologists.
15. Health Certificates except for (i) venereal disease research laboratory tests, (ii) tuberculosis tests and (iii) any certification related to the eligibility for the Medicaid program.
16. Mammoplasty or plastic reconstruction of breast for aesthetic purposes only.
17. Outpatient use of fetal monitor.
18. Services, Treatment or hospitalization as a result of induced, non-therapeutic abortions or their complications.
19. Medications delivered by a provider that does not have a pharmacy license, with the exception of medications that are traditionally administered in a doctor’s office such as an injection.
20. Epidural anesthesia services.
21. Educational tests, educational services.
22. Peritoneal dialysis or hemodialysis services (Covered under the Special Coverage).
23. New or experimental procedures not approved by ASES to be included in the Basic Coverage.
24. Custody, rest and convalescence once the disease is under control or in irreversible terminal cases (hospice care for members under 21 is part of basic coverage).
25. Services covered under the Special Coverage.
26. Services received outside the territorial limit of the Commonwealth of Puerto Rico, except for emergency services for Medicaid or CHIP beneficiaries.
27. Judicial order for evaluations for legal purposes.
28. Counseling services or referrals based on moral or religious objections of the Insurer are excluded.
29. Travel expenses, even when ordered by the PCP, are excluded.
30. Eyeglasses, contact lenses and hearing aids (for members over age 21).
31. Acupuncture services.
32. Procedures for sex changes, including hospitalizations and complications.
33. Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to procreate.
34. Rebetron or any medication for the treatment of Hepatitis C. For every medication therapy for Hepatitis C, you should be referred to P. R. Health Department.
35. Sleep or polysomnography tests.
36. Clinical Laboratories processed outside of Puerto Rico.
37. Hospitalization for services that would normally be considered outpatient services or for diagnostic purposes only.