Covered Services

Blue Cross and Blue Shield of Texas (BCBSTX) gives health care benefits and access to care to help your child stay well. BCBSTX covers all medically necessary care that Medicaid covers.

This includes:

  • Visits to PCPs, specialists (with an OK ahead of time for out-of-network providers), or other providers
  • Routine physicals for children from birth through 20 years of age
  • Yearly adult well exams

In addition, the chart below tells you about the benefits covered by this plan. All services must be medically necessary. This chart is a summary only. For a complete list of these services and their limitations, please see the Member Handbook.

Benefit Needs an OK from Us? Coverage
Ambulance services An OK from us is not needed for emergency ambulance transport
  • A licensed ambulance company
  • An emergency
Audiology services No The Texas Health Steps program gives audiology services and hearing aids for ages 0 through 20
Chiropractic services You do not need an OK from us to see a chiropractor in your network Covers services that help keep the spine and other body structures straight
Community First Choice services Yes For those members who qualify for these services. The state provides an array of services to members who would otherwise qualify for care in a nursing facility, an ICF/IDD, or an institution for mental diseases (IMD).
  • Personal Care Services - CFC - All qualified members may receive medically and functionally necessary Personal Assistance Services under CFC.
  • Acquisition, maintenance and enhancement of skills – All qualified members may receive this service to enable the member to accomplish ADLs, IADLs and health-related tasks.
  • Emergency Response Services - CFC - (Emergency call button) - All qualified members may receive necessary emergency response services under CFC.
  • Support Management - All qualified members may receive voluntary training on how to select, manage and dismiss attendants.
Diagnostic and therapeutic radiology Some radiology services need an OK from us before you get the service. These include CT, MRI, MRA, PET and SPECT Testing and X-rays that are:
  • not invasive
  • done to find out what is wrong
  • ordered and done by (or under the guidance of) your provider
Doctor services No
  • Visits to doctors, specialists or other providers
  • Well exams
Durable Medical Equipment(DME) and disposable supplies yes
  • Medical equipment given for use in the home
  • Medically necessary
  • Within the limits of what is covered by Medicaid
Emergency services No
  • Emergency room
  • Ambulance services
Family planning No
  • Medical visits for birth control
  • Marriage and family planning, education and counseling services
  • Birth control medications, including long acting reproductive contraception (LARC)
Home health services Yes
  • Nursing services
  • Personal care services
Inpatient hospital services Yes
  • Hospital room with two or more beds
  • Nursing care
  • Operating room
  • Surgery
  • Anesthesia
Lab services Yes All authorized lab services
Medically Dependent Children Program (MDCP) STAR Kids Yes The following is a list of covered services for members who qualify for MDCP STAR Kids services. BCBSTX must provide medically and functionally necessary services to members who meet the functional and financial eligibility for MDCPSTAR Kids.
  1. Respite Care;
  2. Supported Employment;
  3. Financial Management Services;
  4. Adaptive Aids;
  5. Employment Assistance;
  6. Flexible Family Support Services;
  7. Minor home modifications; and
  8. Transition Assistance Services.
OB/GYN services No
  • Care that has to do with pregnancy
  • Care for any female medical condition
  • One well-woman checkup per year
Orthotics and prosthetics Sometimes needs an OK from us Parts needed such as man-made arms or legs and the parts needed to attach them
  • Orthotic braces, splints or ankle and foot supports
  • Covered when medically necessary
Outpatient hospital services Yes
  • Dialysis
  • Giving you someone else’s blood
Physical, Occupational and Speech Therapy Sometimes needs an OK from us These services are covered when ordered by a doctor and are part of a written plan of care
Podiatry No Covered services include:
  • Medical problems of the feet
  • Medical or surgical treatment of disease, injury or defects of the foot
Pregnancy and maternity care No
  • Pregnancy
  • After-delivery care when medically necessary
  • Newborn exams
Prescription Drugs Some drugs including brand name drugs need an OK from BCBSTX
  • BCBSTX uses Medicaid/CHIP Vendor Drug Program's (VDP) preferred drug list
  • Most generic and over-the-counter drugs are covered
Therapies Sometimes needs an OK from us
  • Developmental assessments
  • Physical, occupational or speech therapy
Texas Health Steps Medical Checkups No
  • Routine shots
  • Lab tests
  • Comprehensive Care Program services for members 20 years and under
  • DME
  • Home health and other medically necessary services
Transplant Yes
  • Human organ and tissue transplants that are not still being tested
  • All corneal, bone marrow and peripheral stem cell transplants that are not still being tested
Vision Services No An eye exam every 12 months