CO
"EXHIBIT A
COVERED SERVICES…
A.17 Exclusions
The following
services are excluded from coverage hereunder:
PROCEDURE/SERVICE…
Examination
or treatment ordered by a court.
COMMENT
Except when
such treatment may be medically necessary and is provided by a network
provider and/or authorized by the primary care physician." Colorado
Contract, Exhibit A, pages 32-33.
DE
"For members
court-ordered for treatment, the following applies:
(a) The
MCO will be responsible for the provision of all behavioral health services
within the basic health benefit for Medicaid eligible adults ordered by
a court;
(b) The
MCO will not unilaterally indicate that the court-ordered treatment does
not meet medical necessity;
(c) The
MCO will ensure that, in the appropriate drug court related cases, the
MCO will work with the Treatment Access Center (TASC) and interface with
case managers in providing treatment." Delaware RFP, pages II.40-II.46.
DC
"12. General
Rules on Service Coverage
a.
In making coverage determinations under this contract, Provider shall adhere
to all applicable federal and District regulations relating to coverage
of Medicaid benefits, as well as to specific coverage criteria and procedures
set forth in this contract. Decisions must result in a level
of coverage that is sufficient to reasonably achieve the purpose, as defined
in federal law, of the service or benefit whose necessity is reviewed.
Provider may not arbitrarily deny or reduce the amount, duration or scope
of a benefit covered under this contract solely because of the diagnosis,
type of illness or condition.
b.
Provider may not deny coverage of otherwise covered medically necessary
services included in this contract on the grounds that services are excluded
because they are: ...
(1)
court-ordered...." District of Columbia Contract, page 28.
FL
"D. Additional
Behavioral Health Service Requirements...
2. Evaluation
and Treatment Services for Enrolled Children...
b. The
plan shall provide court-ordered evaluation and treatment required for
children who are members pursuant to the specifications in the Medicaid
Community Mental Health Services Coverage and Limitations Handbook..."
Florida Contract, pages 170-171.
FLMH
"2.4 Additional
Service Requirements
In addition
to the above requirements, the contractor shall also adhere to the
requirements specified below...
B. ...
At no time shall the plan be responsible for providing any mental health
services to children who are incarcerated in physically secure facilities.
C. Evaluation
and Treatment Services for Children...
1. The
contractor shall establish children's services in such a way as to minimize
disruption of services available to high risk populations currently served
by the department (e.g. children in delinquent programs)... The provider
will promptly evaluate, provide psychological testing to, and serve children
referred by the department in accordance with medical necessity and within
the time limits specified in Section 2.5A.
2. The contractor shall provide court-ordered evaluation and expert witness testimony required by children who are PMHP enrollees...
4. Case management of children in the plan is to include involvement of persons, schools, programs, networks and agencies which figure importantly in the child's life. The contractor will make determinations about care based on a comprehensive evaluation, consultation from the above parties, as indicated, and appropriate protocols for admission and retention. AHCA will monitor services for adequacy and conformity with agreements." Florida Mental Health RFP, pages 25-26.
"2.10 Care Coordination
and Management...
K) Providing
court ordered mental health evaluations for its enrollees as required by,
and within the time limits set by, the courts. The contractor shall
also provide expert mental health testimony for its enrolled recipients
(with the exception of children in specialized therapeutic foster care
and residential treatment) as ordered by the courts." Florida Mental
Health RFP, pages 32-33.
HI
"30.720 Behavioral
Health...
The health
plan is not obligated to provide behavioral health services to those adult
members who... 2) are the responsibility of the appropriate State agency
pursuant to a criminal commitment for evaluation or treatment under the
provisions of Chapter 706, HRS...
The health plan shall be responsible for behavioral health services for persons who have been involuntarily committed for evaluation and treatment under provisions of Chapter 334, HRS to the extent that these services are deemed medically necessary by the plan's utilization review procedures and are within the established limits. In the event that court-ordered diagnostic, treatment or rehabilitative services exceed the benefit maximums or are determined to not be medically necessary, the costs of continuing care under court order shall be borne by the appropriate State agency.
Adult recipients who have been criminally committed for evaluation or treatment in an inpatient setting under the provisions of Chapter 706, HRS shall be disenrolled from QUEST and become the clinical and financial responsibility of the appropriate State agency. The psychiatric evaluation and treatment of recipients who have been criminally committed to ambulatory mental health care settings shall be the clinical and financial responsibility of the appropriate State agency. The health plan shall be relieved of its responsibility for providing behavioral health services, but shall remain responsible for providing medical services." Hawaii RFP, pages 20, 22 & Hawaii RFP Amendment 4.0.
"Involuntary commitment: Please clarify whether health plans are responsible for services provided in non-contracted facilities...
We would like clarification of whether services mandated as part of a parole, probation, CPS requirement or plea arrangement are excluded from QUEST coverage.
ANSWER:
Health plans
are responsible for providing medically necessary behavioral health services
to recipients who have been involuntarily committed for evaluation and
treatment. Each health plan must have providers in its network which
can provide these services and a mechanism for its recipients to be evaluated
to determine which services are needed...
Medical and behavioral health services which are medially necessary and provided to QUEST recipients are not excluded from QUEST." Hawaii RFP, Q&A, page 13.
HIBH
"20.310
QUEST Health Plan: Behavioral Health Coverage
The QUEST health
plans are required to provide an array of medically necessary behavioral
health (mental health, drug abuse and alcohol abuse) preventive, diagnostic,
therapeutic and rehabilitative services within established limits below
to adult members, except for members who: …2) are the responsibility of
the appropriate State agency pursuant to a criminal commitment for evaluation
or treatment under the provisions of Chapter 706, HRS." Hawaii Behavioral
Health RFP, page 5.
IA
"4.2.4
Court Ordered Services
The HMO shall
pay for medically necessary court ordered Covered Services for its Enrollees.
If the HMO cannot provide medically necessary Covered Services through
its Providers, the HMO shall refer the Enrollee to an appropriate Non-Participating
Provider and shall pay fees no greater than Medicaid fees for a given Medically
Necessary Covered Service.
If the court
orders a Non-Participating Provider to provide the services, the HMO shall
pay for the service only if it could not have provided the court ordered
service through its Provider panel." Iowa contract, page 24.
IABH
"III.
Substance Abuse Services...
B. Court
Ordered Substance Abuse Evaluations (Proposal Section 7A.2.5)
This section
has been modified to include the residential level of care:
MBC of Iowa
will authorize one day for a court ordered evaluation in an approved substance
abuse facility at an inpatient or residential level of care prior to application
of the ASAM/IJPC criteria." Iowa Behavioral Health Contract, page
56.
"Other Required
Mental Health Services...
* Court
Ordered Mental Health Services: The Contractor shall reimburse all
covered and required mental health services ordered for enrollees through
a court action which fall within the Contractor's Utilization Management
Guidelines and are ordered from provider which is part of the Contractor's
provider network. Special requirements apply when those services
are ordered for enrollees over the age of 21 at a state Mental Health Institute
(see below).
* Court Ordered Evaluations for Mental Health: The Contractor also shall reimburse at least five days of inpatient services, or the duration of that evaluation period if less than five days is required, when an Iowa Plan enrollee is court-ordered for an inpatient mental health evaluation to a community hospital which is in the Contractor's provider network and has appropriately credentialed staff available to conduct the evaluation. The Contractor may establish policies to limit reimbursement to no more than one evaluation per inpatient episode. The Contractor has the right to establish policies which require providers of court-ordered mental health services to provide notification and documentation of court ordered treatment" Iowa Behavioral Health Contract, pages 81-82.
"I.
COVERED AND REQUIRED SUBSTANCE ABUSE SERVICES...
The Contractor
shall develop a network of providers to assure availability of the following
services listed for both adults and children, on a statewide basis…
16. Emergency
room services for substance abuse conditions available 24 hours a day,
seven days a week. (Medicaid enrollees only)...
25. Court
ordered evaluation for substance abuse
26. Court
ordered testing for alcohol and drugs (Medicaid enrollees only)
27. Court
ordered treatment which meets criteria for treatment services (except for
adult Medicaid enrollees at a state mental health institute)…"
Iowa Behavioral Health Contract, pages 84-85.
"III.
SPECIAL CONSIDERATIONS FOR SUBSTANCE ABUSE SERVICES...
4. Court
Ordered Substance Abuse Services
The Contractor
is responsible for the provision of all substance abuse services ordered
for eligible persons through a court action when:
(a) except
for evaluations, the covered and required services ordered by the Court
meet the criteria of service necessity, and
(b) the
Court orders treatment with a substance abuse licensed provider, and,
(c) for
DPH Participants, the court orders treatment with a network provider contracted
to serve DPH participants.
The Contractor shall work with the Courts to examine the appropriateness of Court placements while examining the potential of offering more efficient alternatives and shall develop specific alternatives for the Courts to consider.
The Contractor has the right to establish policies which require providers of court-ordered substance abuse services to provide notification and documentation of court-ordered treatment." Iowa Behavioral Health Contract, pages 86- 87.
"SPECIAL SERVICE
REQUIREMENTS
Ensuring Safety
through Adequate Discharge Planning...
When 24-hour
services provided through the Iowa Plan to an en enrollee under age 18
are being decertified, the Contractor is required to authorize on an administrative
basis up to 14 calendar days of additional funding if a safe and appropriate
living arrangement is not available because:
a) a
court order is in effect which must be modified to allow the placement
of the child into that living arrangement
b) a
court order is required to allow placement of the child into the appropriate
living arrangement
c) a
bed is not available in the level of acre which has been determined as
clinically appropriate for the child
d) additional
services or supports must be arranged to assist the natural family, foster
family or other living arrangement become ready to assist the enrollee
after the enrollee's return to that environment...
See Attachment on Child Welfare and Juvenile Justice Services System for special requirements when a person under the age of 198 is being discharged forma 24-hour setting and is also receiving services through the CW/JJ delivery system." Iowa Behavioral Health Contract, pages 88-89.
ME
"H. COURT
ORDERED TREATMENT
The Contractor
shall provide all court ordered treatment within the scope of services
described in this Contract." Maine Contract, page 29.
MABH
"5.2 Reimbursement
Methodology for DMH Acute Care Consumers
Payment by
the Division to the Contractor for DMH Acute Care Consumers shall be as
follows, provided, however, that notwithstanding any other provision
of this Contract, DMA shall not be required to make any of the payments
for DMH Acute Care Consumers described below unless and until it has received
funding from DMH in the amounts necessary to make any and all such payments:
A. Compensation
Rates...
5. Enrollees
ordered hospitalized by a judge pursuant to M.G.L. c. 123 Section 12(e)
following clinical evaluation through a court clinic shall be admitted
to a hospital pursuant to court order without regard to Medical Necessity.
The Contractor shall require its Providers to provide continued inpatient
mental health services if the Contractor determines they are Medically
Necessary. The Contractor shall be responsible for payment of only
those services to Enrollees which the Contractor determines are Medically
Necessary, as defined in Appendix E to this Contract." Massachusetts MH/SAP
Contract, Appendix A, pages 51-53.
MN
"Section 6.1. MA and MinnesotaCare/MA Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to MA and MinnesotaCare/MA Enrollees comprehensive preventive, diagnostic, therapeutic and rehabilitative health care services as defined in Minnesota Statutes… These services shall include but are not limited to, the following…
Section 6.1.1. Care Management Services… At a minimum, the HEALTH PLAN's Care Management System must incorporate the following elements...
C. A method for coordinating the medical needs of an Enrollee with his/her social service needs… Coordination with the county social service staff will be required when the Enrollee is in need of the following services: … court ordered treatment…
B. Court-Ordered Treatment. The following procedures apply to mental health services that are court-ordered.
1) When a person is ordered held or other care or treatment is ordered, pursuant to Minnesota Statutes, Section 253B.05, Subdivision 1 and 2 and 253B.07, Subdivision 6, by a court for a MA Recipient who is enrolled in a the HEALTH PLAN, the HEALTH PLAN must do an assessment to determine Medical Necessity. Pursuant to Minnesota Statutes, Section 253B.11, Subdivision 2, when the confinement of an Enrollee is provided at a STATE regional treatment center, the HEALTH PLAN shall be responsible for the Enrollee's Medically Necessary hospitalization.
2) The HEALTH PLAN must provide a 24-hour telephone number answered in-person that a County may call to get an expeditious response to situations involving the HEALTH PLAN'S Enrollees where court ordered treatment and disability certification are involved.
3) County social workers or probation officers who are involved in making a recommendation to the court regarding a treatment plan for a HEALTH PLAN Enrollee must obtain the approval of the HEALTH PLAN prior to initiating a diagnostic evaluation, recommendation, or referral for treatment, in order to get paid by the HEALTH PLAN...
4) When the HEALTH PLAN is made aware of the court ordered treatment, but only after an assessment or evaluation by an Out of Plan provider has been performed, the plan must review the assessment/evaluation and if it disagrees with the results, it must conduct its own assessment...
5) When an organization outside of the HEALTH PLAN does the assessment/evaluation and the HEALTH PLAN reviews and agrees with the recommended treatment, the HEALTH PLAN is then responsible for providing the treatment through its provider network, or at its option, it may authorize a referral for the Out of Plan provision of the services...
6)… when the HEALTH PLAN has not been consulted in court ordered treatment and Out of Plan treatment is recommended, the HEALTH PLAN is not responsible for payment of the court ordered treatment, the county will bear the full financial responsibility in such cases." Minnesota Contract, pages 48-49, 55-56.
"Section 6.1.16.
Mental Health Services...
B. Court-Ordered
Treatment. The following procedures apply to mental health services
that are court-ordered.
1) When
a person is ordered held or other care or treatment is ordered, pursuant
to Minnesota Statutes, Section 253B.05, Subdivision 1 and 2 and 253B.07,
Subdivision 6, by a court for a MA Recipient who is enrolled in a the HEALTH
PLAN, the HEALTH PLAN must do an assessment to determine Medical Necessity.
Pursuant to Minnesota Statutes, Section 253B.11, Subdivision 2, when the
confinement of an Enrollee is provided at a STATE regional treatment center,
the HEALTH PLAN shall be responsible for the Enrollee's Medically Necessary
hospitalization...
4) When the HEALTH PLAN is made aware of the court ordered treatment, but only after an assessment or evaluation by an Out of Plan provider has been performed, the plan must review the assessment/evaluation and if it disagrees with the results, it must conduct its own assessment. If, after performing its own assessment/evaluation, the HEALTH PLAN determines that the services are not Medically Necessary, the HEALTH PLAN will not be responsible for providing the services. The HEALTH PLAN must provide its Enrollees with a notice indicating that the services have been denied and the specific reason for the denial.
When an organization outside of the HEALTH PLAN does the assessment/evaluation and the HEALTH PLAN reviews and agrees with the recommended treatment, the HEALTH PLAN is then responsible for providing the treatment through its provider network, or at its option, it may authorize a referral for the Out of Plan provision of the services. The HEALTH PLAN shall communicate its treatment plan and discharge plans with the county social workers and probation officers." Minnesota Contract, pages 55-56.
MO
"e. Consent
Decree Medical Case Management: Children in the custody of the Jackson
County office of the Missouri Division of Family Services and residing
in Jackson County also receive targeted medical case management services…The
medical case management services provided by the Medical Case Management
Agency include, but are not limited to:
1) promoting
the effective and efficient access to comprehensive medical services for
the targeted children,
2) facilitating
the coordination of medical services,
3) maintaining
confidential centralized files for each child,
4) assisting
in the education of Division of Family Services staff, caregivers, and
health care providers regarding the child's medical care,
5) providing
information regarding the need for specialized health services,
6) coordinating
and monitoring all primary and specialty care necessary for the child,
and
7) ensuring
that essential medical care received by the child complies with the Consent
Decree, Part III…" Missouri RFP, page 65.
NEBH
"11.52.7 PHP Coordination and Responsibility for Court Ordered Services: The PHP shall coordinate with Nebraska Health and Human Services Child Protective Services Staff the preparation to the court proposed treatment plans for State Wards. Signature of the appropriate PHP staff on the proposed treatment plan shall be considered prima facie evidence of collaboration and approval of the proposed treatment plan by the PHP.
The PHP shall be responsible for court ordered services under the following conditions:
(1) The
court adopts the treatment plan proposed by the Nebraska Health and Human
Services Child Protective Services Staff and:
(A) The Nebraska Health and Human Services Child Protective Services Staff
and the PHP have coordinated the proposed treatment plan prior to hearing
and both consider the court ordered services service a Medically Necessary
MH/SA Package Service, or,
(B) If the PHP has received reasonable notice and has not coordinated the
proposed treatment plan with the Nebraska Health and Human Services Child
Protective Services Staff prior to hearing and the Department considers
the court ordered service a Medically Necessary MH/SA Package Service,
or,
(2) The court adopts a treatment plan other than the treatment plan proposed by the Nebraska Health and Human Services Child Protective Services Staff and the PHP considers the court ordered service a Medically Necessary MH/SA Package Service., or
(3) The PHP and the Nebraska Health and Human Services Child Protective Staff have not, through no fault of the Nebraska Health and Human Services Child Protective Services Staff, coordinated the treatment plan prior to hearing and the court adopts a treatment plan other than the treatment plan proposed by the Nebraska Health and Human Services Child Protective Services Staff, and the service is a MH/SA Package service
The PHP shall
not be responsible for the court ordered service under the following conditions:
(1) The court ordered service is not a MH/SA Package Service, or,
(2) The Nebraska Health and Human Services Child Protective Services
Staff and the PHP have coordinated the proposed treatment plan prior
to hearing and both consider the court ordered services service not a Medically
Necessary MH/SA Package Service, or,
(3) The PHP and the Nebraska Health and Human Services Child Protective
Staff have coordinated prior to hearing and the court adopts a treatment
plan other than the treatment plan proposed by the Nebraska Health and
Human Services Child Protective Staff and the PHP considers the service
not a Medically Necessary MH/SA Package Service.
(4) The Nebraska Health and Human Services Child Protective Services
Staff and the PHP have coordinated but not agreed on services which are
medically necessary and the court adopts the plan which the PHP disagrees
with." Nebraska Behavioral Health Contract, pages 65-66.
NJ
"APPENDIX S
NJ KIDCARE
- PLAN D
BENEFITS PACKAGE-INCLUSIONS
AND EXCLUSIONS
The
health care services listed below shall be provided by the contractor to
enrollees as covered benefits rendered under the terms of this contract.
Provision of these services shall be provided in accordance with medical
necessity without any predetermined limits, unless specifically stated,
and as set forth I the Medicaid Providers Manuals: The New Jersey
Administrative Code, Title 10, Department of Human Services-Subtitle I
- Division of Medical Assistance and Health Services Medicaid and NJ KidCare
Alerts; and Medicaid and NJ KidCare Newsletters...
EXCLUSIONS
Services not
covered for NJ KidCare - Plan D participants include, but are not limited
to: ...
29. Court-ordered
services…" New Jersey Contract, Appendix S, pages 233-237.
NY
"10. BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES…
10.7 Child
Protective Services
The Contractor
shall comply with the requirements specified for…court ordered services....Medically
necessary services, whether provided in or out of plan, must be provided…
10.10
Court-Ordered Services
a) The
Contractor shall provide any Benefit Package services to Enrollees as ordered
by a court of competent jurisdiction, regardless of whether such services
are provided by Participating Providers within the plan or by a Non-Participating
Provider in compliance with such court order.
b) Court Ordered Services are those services ordered by the court performed by, or under the supervision of a physician, dentist, or other provider qualified under State Law to furnish medical, dental, behavioral health (including treatment for mental health and/or alcohol and/or substance abuse or dependence), or other Medicaid covered services. The plan is responsible for payment of those Medicaid services as covered by the Benefit Package.
c) Court Ordered Services are not covered if they are ordered for the purpose of determining some legal disposition, e.g., custody or visitation determinations…" New York Contract, pages 10-1-10-5.
"1. DEFINITIONS...
'Court-Ordered
Services' means those services that the Contractor is required to provide
to Enrollees pursuant to orders of courts of competent jurisdiction, provided
however, that such ordered services are within the Contractor's Medicaid
managed care Benefit Package and reimbursable under Title XIX of the Federal
Social Security Act…" New York Contract, page 1-1.
"3. COMPENSATION...
3.11
Mental Health and Alcohol/Substance Abuse Stop-Loss
a) …Any Court
Ordered Services for mental health treatment outpatient visits which specify
the use of Non-Participating Providers shall be compensated at the Medicaid
rate of payment.
b) … Any Court
Ordered Services for alcohol and substance abuse treatment outpatient visits,
which specify the use of Non-Participating Providers, shall be compensated
at the Medicaid rate of payment.." New York Contract, pages 3-1-3-5.
"APPENDIX K-1
MANAGED CARE
PLAN PREPAID BENEFIT PACKAGE...
Covered Services
Court-Ordered
Services
Managed Care
Plan Scope of Benefit
Coverage includes
such services ordered by a court of competent jurisdiction if the services
are in the Contractor's benefit package." New York Contract, Appendix
K, pages K-5-K-8.
"K_2
MANAGED CARE
PLAN PREPAID HEALTH ONLY BENEFIT PACKAGE
For SSI
and SSI Related Recipients...
Covered Services
Court-Ordered
Services
Managed Care
Plan Scope of Benefit
Coverage includes
such services ordered by a court of competent jurisdiction if the services
are in the Contractor's benefit package." New York Contract, Appendix
K, pages K-9-K-12.
PABH
"4. HealthChoices
Program Eligible Groups...
d. Children
and Adolescents in Substitute Care Issues...
The MCO will
be required to pay for out-of-network medically necessary behavioral health
care services for up to ten days for a child enrolled in its plan who is
placed in substitute care if the county placement agency cannot identify
the child nor verify MA coverage. However, this out-of-network coverage
will only be required in certain circumstances, such as emergency placement
as determined by county child welfare or juvenile probation…" Pennsylvania
Behavioral Health RFP, pages 45-46.
"3) In-Network
Services
The MCO will
be responsible for making timely payment for medically necessary, covered
services rendered by in-network providers when: ...
b)
Medically necessary involuntary treatment services were rendered pursuant
to a court order...
4) Out-of-Network
Services
The MCO will
be responsible for making timely payments to out-of-network providers for
medically necessary, covered services when: ...
b)
Medically necessary involuntary treatment services were rendered pursuant
to a court order…" Pennsylvania Behavioral Health RFP, page 73.
RI
"SCHEDULE OF
IN-PLAN BENEFITS...
Mental Health
and Substance Abuse Services- Outpatient
Both short
an long term treatment covered as needed based on medical necessity, subject
to stop-loss limitations in Definition Section 1.30 and groups/services
out-of-plan in Attachment B. Includes methadone detoxification collateral
visits, and medically necessary court-ordered services subject to limitations
described in Attachment B..." Rhode Island RFP, Attachment A. pages
1, 3.
"SCHEDULE OF
OUT-OF-PLAN-BENEFITS
All RIte Care
Enrollees...
Court ordered
mental health an substance abuse services in which the court order specifies
a non-network provider…" Rhode Island RFP, Attachment B, page
1.
TX
"6.12
TUBERCULOSIS (TB)...
6.12.4.2
HMO must coordinate with the TDH South Texas Hospital and Texas Center
for Infectious Disease for voluntary and court-ordered admission, discharge
plans, treatment objectives and projected length of stay for Members with
multi-drug resistant TB." Texas Contract, pages 47-48.
"7.17
COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICES
7.17.1
HMO must cooperate and coordinate with the Texas Department of Protective
and Regulatory Services (TDPRS) for the care of a child who is receiving
services from or has been placed in the conservatorship of TDPRS.
7.17.2 HMO must comply with all provisions of a Court Order or TDPRS Service Plan with respect to a child in the conservatorship of TDPRS (Order) entered by a Court of Continuing Jurisdiction placing a child under the protective custody of TDPRS or a Service Plan voluntarily entered into by the parents or person having legal custody of a minor and TDPRS, which relates to the health and behavioral health care services required to be provided to the Member.
7.17.3 HMO cannot deny, reduce, or controvert the medical necessity of any health or behavioral health care services included in an Order entered by a court." Texas Contract, page 75.
UT
"F. Clarification
of Payment Responsibilities
1.
Covered Services Received Outside CONTRACTOR's Network but Paid by CONTRACTOR
The
CONTRACTOR will not be required to pay for Covered Services,... which the
Enrollee receives from sources outside The CONTRACTOR's network, not arranged
for and not authorized by the CONTRACTOR except as follows: ...
b.
Court ordered services that are Covered Services defined in Attachment
C and which have been coordinated with the CONTRACTOR..." Utah Contract,
Attachment B, page 24.
UTMH
"B. Clarification
of Covered Services...
11.
Evaluations requested by a court or the Utah Division of Child and Family
Services to determine if a Medicaid eligible child or parent has a diagnosis
of mental illness or other mental disorder and to recommend a course of
treatment are Covered Services. For children in foster care, the
CONTRACTOR may bill DHCF on a fee-for-service basis." Utah Mental
Health Contract, page 6.
VA
"4. Court-Ordered
Services
The Contractor
shall be liable for covering all Medallion II covered court-ordered services,
with the exception of those which the Contractor has determined are not
medically necessary, in accordance with the terms set forth in this Contract.
In the absence of an agreement otherwise, out-of-network payments will
be made in accordance with the Medicaid fee schedule." Virginia Contract,
page 37.
WA
"EXCLUSIONS
The following
services and supplies are excluded from coverage under this agreement.
This shall not be construed to prevent the Contractor from covering any
of these services when the Contractor determines it is medically necessary…
SERVICES NOT
COVERED BY EITHER MAA OR THE CONTRACTOR: ...
- Court-ordered
services…" Washington Contract, Exhibit 6, Attachment 1, pages 5,
7.
WI
"III.
FUNCTIONS AND DUTIES OF THE HMO
In consideration
of the functions and duties of the Department contained in this Contract
the HMO shall: ...
B. PROVISION
OF CONTRACT SERVICES...
12. The actual
provision of any service is subject to the professional judgment of the
HMO providers as to the medical necessity of the service, except that the
HMO must provide assessment and evaluation services ordered by a court…"
Wisconsin Contract, pages 5, 11.
"5. COURT-RELATED CHILDREN'S SERVICES-The HMO shall be liable for the cost of providing assessments under the Children's Code, s. 48.295, Wis. Stats., and shall be responsible for reimbursing for the provision of medically necessary treatment if unable to itself provide for such treatment ordered by a juvenile court. The medical necessity of court-ordered evaluation and treatment is assumed to be established and the HMO may be allowed to provide the care through its network, if at all possible. The HMO may not withhold or limit services unless or until the court has agreed.
6. COURT-RELATED SUBSTANCE ABUSE SERVICES-The HMO shall be liable for the cost of providing all medically necessary substance abuse treatment, as long as the treatment occurs in an HMO-approved facility or by an HMO-approved provider prescribed in the subject's Driver Safety Plan, pursuant to Chapter 343, Wis. Stats., and HFS 62 of the Wis. Administrative Code. The medical necessity of services specified in this plan is assumed to be established, and the HMO shall provide those services unless the assessment agency agrees to amend the enrollee's Driver Safety Plan. This is not meant to require HMO coverage of substance abuse educational programs. Necessary HMO referrals or treatment authorizations by providers must be furnished promptly...
8. COURT-RELATED COMMITMENT COVERAGE-The HMO shall be financially liable for the enrollee's court ordered assessment and/or treatment where an HMO enrollee is defending him/herself or a member of his/her Medicaid case against a mental disability or substance abuse commitment." Wisconsin Contract, Addendum II, pages 81-82.