AZ
| CA | CO | CT |
DE
| DC | FL | HI |
HIBH | IL | IN
| IA | KS | KY
| ME | MD | MA |
MI
MN
| MO | MT | NE |
NV
| NH | NJ | NM |
NY | NC | ND
| OH | OR | PA |
RI
| SC | TN | TX |
UT | VA | WA |
WV
| WI
"SECTION D:
PROGRAM REQUIREMENTS
1. SCOPE
OF SERVICES…
KidsCare Covered
Services: KidsCare members are eligible for the same services covered
for members under the Title XIX and state-only programs, with the following
differences, exclusions and/or limitations:
a.
Non-emergency transportation is not covered.
b.
Chiropractic services are not covered.
c.
Vision services are limited to one eye examination per contract year and
one pair of glasses or contacts every contract year...
Audiology: The Contractor shall provide audiology services to members under the age of 21 including the identification and evaluation of hearing loss and rehabilitation of the hearing loss through other than medical or surgical means (i.e. hearing aids). Only the identification and evaluation of hearing loss are covered for members 21 years of age and older unless the hearing loss is due to an accident or injury-related emergent condition...
Children's Rehabilitative Services (CRS): ... The Contractor shall refer children to the CRS program who are potentially eligible for services related to CRS covered conditions...
Chiropractic Services: The Contractor shall provide chiropractic services to Title XIX members under age 21 when prescribed by the member’s PCP and approved by the Contractor in order to ameliorate the member’s medical condition...
Dialysis: The Contractor shall provide medically necessary dialysis, supplies, diagnostic testing and medication for all members when provided by Medicare-certified hospitals or Medicare-certified end stage renal disease (ESRD) providers...
Eye Examinations/ Optometry: The Contractor shall provide all medically necessary emergency eye care, vision examinations, prescriptive lenses, and treatments for conditions of the eye for all members under the age of 21, with the exception of KidsCare members...
Health Risk Assessment and Screening: The Contractor shall provide these services for non-hospitalized members 21 years of age and older...
Hospice: These services are covered for members under 21 years of age who are certified by a physician as being terminally ill and having six months or less to live...
Indian Health Services (IHS): The Contractor may choose to subcontract with and pay an IHS or tribal facility for covered services provided to members...
Medically-Necessary Abortions: This service is covered for a member if the member suffers from a physical disorder, physical injury, or physical illness including a life endangering physical condition caused by or rising from the pregnancy itself, that would, as certified by a physician, place the member in danger of death unless an abortion is performed...
Nursing Facility: The Contractor shall provide nursing facility services, including religious nonmedical health care institutions, for members who require short-term convalescent care not to exceed 90 days per contract year...
Nutrition: Nutritional feeding through a non-oral method such as TPN or tube feeding is covered for all members when it is the sole source of nutrition due to severe pathology of the alimentary tract...
Podiatry: The Contractor shall provide podiatry services to include bunionectomies, casting for the purpose of constructing or accommodating orthotics, medically necessary orthopedic shoes that are an integral part of a brace, and medically necessary routine foot care for patients with a severe systemic disease which prohibits care by a nonprofessional person...
Rehabilitation Therapy: The Contractor shall provide occupational, physical and speech therapies...
Respiratory Therapy: This therapy is covered on an inpatient or outpatient basis when prescribed by the member’s PCP or attending physician and is necessary to restore, maintain or improve respiratory functioning.
Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: These services are covered within limitations defined in the AMPM for members diagnosed with specified medical conditions...
Transportation: These services include emergency and non-emergency medically necessary transportation...
Triage/ Screening and Evaluation: These are covered services when provided by acute care hospitals, IHS facilities and urgent care centers to determine whether or not an emergency exists, assess the severity of the member’s medical condition and determine services necessary to alleviate or stabilize the emergent condition…" Arizona Contract, pages 10-16.
"36. NURSING
FACILITY REIMBURSEMENT...
The Contractor
shall provide medically necessary nursing facility services for any member
who has a pending ALTCS application, who is currently residing in a nursing
facility and is eligible for services provided under this contract.
If the member becomes ALTCS eligible and is enrolled with an ALTCS Program
Contractor before the end of the maximum 90 days of nursing facility coverage,
the Contractor is only responsible for nursing facility coverage during
the time the member is enrolled with the Contractor. Nursing facility
services covered by a third party insurer (including Medicare) while the
member is enrolled with the Contractor shall be applied to the 90 day limitation."
Arizona Contract, page 38.
"Attachment
C - Covered Services...
D. General
Preventive Services
The CONTRACTOR
must develop or adopt practice guidelines consistent with current standards
of care, as recommended by professional groups such as the American Academy
of Pediatric and the U.S. Task Force on Preventive Care.
A minimum of
three screening programs for prevention or early intervention (e.g. Pap
Smear, diabetes, hypertension).
E. Vision
Care
Services provided
by licensed ophthalmologists or licensed optometrists, and opticians within
their scope of practice. Eyeglasses will be provided to eligible
recipients based on medical necessity. Services include, but are
not limited to, the following:
1.
Eye refraction, examination
2.
Laboratory work
3.
Lenses
4.
Eyeglass Frames
5.
Repair of Frames
6.
Repair or Replacement of Lenses
7.
Contact Lenses (when Medically Necessary)...
G. Physical
and Occupational Therapy
1. Physical
Therapy
Treatment and
services provided by a licensed physical therapist...
2. Occupational
Therapy
Treatment of
services provided by a licensed occupational therapist...
H. Speech
and Hearing Services
Services and
appliances, including hearing aids and hearing aid batteries, provided
by a licensed medical professional to test and treat speech defects and
hearing loss.
I. Podiatry
Services
Services provided
by a licensed podiatrist.
J. End
Stage Renal Disease - Dialysis
Treatment of
end
stage renal dialysis for kidney failure. Dialysis is to be rendered
by a Medicare-certified Dialysis facility...
L. Hospice
Services
Services delivered
to terminally ill patients (six months life expectancy) who elect palliative
versus aggressive care. Hospice care is to be rendered by a Medicare-certified
hospice.
M. Private
Duty Nursing
Services provided
by licensed nurses for ventilator-dependent children and technology dependent
adults in their home in lieu of hospitalization if Medically Necessary,
feasible , and safe to be provided in the patient's home...
O. Abortions
and Sterilizations
These services
are provided to the extent permitted by Federal and State law and must
meet the documentation requirement of 42 CFR 441, Subparts E and F...
Q. Organ
Transplants
The following
transplantations are covered for all Enrollees: Kidney, liver, cornea,
bone marrow, heart, intestine, lung, pancreas, small bowel, combination
hearty/lung, combination intestine/liver, combination kidney/pancreas,
combination liver/kidney, multi visceral, and combination liver/small bowel...
R. Other
Outside Medical Services
The CONTRACTOR
may provide long term care for Enrollees in skilled nursing facilities
requiring such care as a continuum of a medical plan when the plan includes
a prognosis of recovery and discharge within thirty (30) days or less..
T. Transportation
Services
Ambulance (ground
and air) service for medical emergencies...
X. Services
for Children with Special Needs...
3. Definition
of Children with Special Health Care Needs
The definition
of children with special health needs includes, but is not limited to,
the following conditions:
a.
Nervous System Defects...
b.
Craniofacial Defects...
c.
Complex Skeletal Defects...
d.
Inborn Metabolic Disorders...
e.
Neuromotor Disabilities...
f .
Congenital Heart Defects
g.
Genetic Disorders...
h.
Chronic Illnesses...
z.
Diabetes Education
The CONTRACTOR shall provide diabetes self-management education from a Utah certified or American Diabetes Association recognized program…" Arizona Contract, pages C1-C4, C8-C10.
"ARTICLE II
- DEFINITIONS...
S. Covered
Services means Medical Case Management and those services set forth in
Title 22, CCR, Division 3, Subdivision 1, Chapter 3, beginning with Section
51301, and Title 17, CCR, Chapter 4, Subchapter 13, Article 4, beginning
with Section 6840. Covered Services do not include:
1. Services for major organ transplants as specified in Section 6.7.2.1, Major Organ Transplants.
2. Long term care services as specified in Section 6.7.2.3, Long Term Care (LTC).
3. Home and community based services (HCBS) as specified in Sections 6.7.2.2, Waiver Programs, and 6.7.3.8, Department of Developmental Services Administered Medicaid Home and Community Based Services Waiver...
4. California Children Services (CCS) as specified in Section 6.7.3.2, CCS Services...
7. Fabrication of optical lenses as specified in Section 6.7.3.6, Vision Care - Lenses...
10. Acupuncture services as specified in Title 22, CCR, Section 51308.5.
11. Chiropractic services as specified in Title 22, CCR, Section 51308.
12. Prayer or spiritual healing as specified in Title 22, CCR, Section 51312.
13. Local Education Agency (LEA) assessment services...
14. Any LEA services as specified in Title 22, CCR, Section 51360 provided pursuant to an Individualized Education Plan (IEP)... or an Individualized Family Service Plan (IFSP)... or LEA services provided under an Individualized Health and Support Plan (IHSP)...
16. Adult Day Health Care...
18. Childhood lead poisoning case management provided by County health departments…" California Contract, pages 2-5.
"F1. Minor Consent Services means those Covered Services of a sensitive nature which minors do not need parental consent to access, related to:
1. Sexual assault, including rape.
2.Drug or alcohol abuse for children 12 years of age or older.
3.Pregnancy.
4.Family planning.
5.Sexually transmitted diseases (STDs), designated by the Director, in children 12 years of age or older.
6.Outpatient mental health care for children 12 years of age or older who are mature enough to participate intelligently and where either (1) there is a danger of serious physical or mental harm to the minor or others or (2) the children are the alleged victims of incest or child abuse.
State law provides minors the right to obtain an abortion without parental consent...
N1. Pediatric Subacute Care means health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of vital bodily function. Medical necessity criteria are described in the Physician's Manual of Criteria for Medi-Cal Authorization...
T1. Preventive Care means health care designed to prevent disease and /or its consequences. There are three levels of Preventive Care; primary, such as immunizations, aimed at preventing disease; secondary, such as disease screening programs, aimed at early detection of disease; and tertiary, such as physical therapy, aimed at restoring function after the disease has occurred." California Contract, pages 9-11.
"6.5.7.8 Sensitive
Services
Contractor
shall implement and maintain procedures to ensure confidentiality and ready
access to Sensitive Services for all Members, including minors. Members
shall be able to access Sensitive Services in a timely manner and without
barriers such as Prior Authorization requirements. Access to abortion
services for Members who are minors shall be subject to applicable State
and federal law." California Contract, page 98.
"6.6.22 Vision
Care Services
Contractor
will ensure a vision care services system, consistent with good professional
practice, which provides that a Member may be seen initially by either
of the following:
A. An optometrist
or an ophthalmologist.
B. A Primary
Care Physician before referral to an optometrist or an ophthalmologist.
Contractor will provide ophthalmic lenses in accordance with Section 6.7.3.6...
6.7.2 EXCLUDED
SERVICES: CIRCUMSTANCES UNDER WHICH MEMBER DISENROLLED
6.7.2.1 Major
Organ Transplants
Major organ
transplant procedures are not covered under the Contract...
6.7.2.2 Waiver
Programs
Contractor
shall maintain systems for identifying and referring Members to the appropriate
waiver program, including the In-Home Medical Care Waiver Program, the
Skilled Nursing Facility Waiver Program, the Model Waiver Program, and
the Acquired Immune Deficiency (AIDS) and AIDS Related Conditions Waiver
Program...
6.7.2.3 Long
Term Care (LTC)
Contractor
will ensure that Members, other than Members requesting hospice services,
in need of nursing Facility services are placed in Facilities providing
the appropriate level of care commensurate with the Member's medical needs...
If the Member will require long term care, care in the Facility for longer than the month of admission plus one month, the Contractor will submit a Disenrollment request for the Member to DHS for approval...
Admission to a nursing Facility of a Member who has elected hospice services as described in Title 22, CCR, Section 51349, does not affect the Member's eligibility for Enrollment under this Contract. Hospice services are Covered Services under this Contract and are not long term care services regardless of the Member's expected or actual length of stay in a nursing Facility.
6.7.3 EXCLUDED
SERVICES: CIRCUMSTANCES UNDER WHICH MEMBER ENROLLED WITH SERVICE CARVE
OUT
6.7.3.1 Miscellaneous
Service Carve Outs
Acupuncture
services, adult day health care services, chiropractic services, and healing
by prayer or spiritual means are not Covered Services under this Contract.
Contractor may, upon request, refer Members to these services.
Local Education Agency (LEA) assessment services provided to any student and any LEA services provided pursuant to an Individual Education Plan (IEP) or Individual Family Service Plan (IFSP) or Individualized Health and Support Plan (IHSP) are not covered under the Contract.
Childhood lead poisoning case management is not a Covered Service under this Contract...
6.7.3.2 California
Children Services (CCS)...
C. Contractor
shall continue to provide all Medically Necessary Covered Services and
case management services for Member children referred to CCS until eligibility
for the CCS program is established...
D. Once eligibility
for the CCS program is established for a Member child:
1. Contractor
shall continue to provide Primary Care and other Medically Necessary Covered
Services unrelated to the CCS-eligible condition and will ensure the coordination
of services between its Primary Care providers, the CCS specialty providers,
and the local CCS program." California Contract, pages 110-114.
"6.7.3.6 Vision
Care - Lenses
The Contractor
will order the fabrication of optical lenses for Members from Prison Industry
Authority (PIA) optical laboratories... The Contractor will provide
all other Covered Services described in Title 22, CCR, Section 51317, including
contact lenses and eyeglass frames...
6.7.3.8 Department
of Developmental Services Administered Medicaid Home
and Community
Based Services Waiver
The HCBS waiver services are not covered under this Contract. The Contractor will maintain systems for identifying developmentally disabled Members who are at risk for institutional placement and refer these Members to the HCBS waiver administered by DDS... The Contractor will continue to provide all Primary Care and other Medically Necessary Covered Services to a plan Member who is receiving HCBS waiver services." California Contract, pages 118-119.
"6.7.4.11 Services
for Persons with Developmental Disabilities
The Contractor
will provide all screening, preventive, and Medically Necessary and therapeutic
services covered by the Contract to Members with developmental disabilities.
The Contractor will coordinate all medical services rendered to the Members,
including the determination of medical necessity. The Contractor
will refer enrollees with developmental disabilities to the regional centers
for those nonmedical services such as respite, out-of-home placement, supportive
living, etc. for persons with substantial disabilities if such services
are needed." California Contract, page 123.
"6.7.6.7 Adults
Contractor
will implement and maintain The Guide to Clinical Preventive Services,
a report of the U.S. Preventive Service Task Force (USPSTF) as the minimum
acceptable standard for Adult Preventive Health Services. The following
are a core set of preventive services that will be provided to all asymptomatic,
healthy adult Members (age 21 and older):...
A. History and physical examination - an initial complete history and physical examination will be performed on each adult Member within 120 days of Enrollment. Targeted history and physical examination focusing on the needs and risk factors of each Member will be done every one to three years for adults age 21 to 64 years; and annually for individuals age 65 and older.
B. Blood pressure - persons who are normotensive will have blood pressure measurements at least every 2 years.
C. Cholesterol - total cholesterol will be measured at least once every 5 years for adults age 20 and older.
D. Clinical breast examination - women over age 40 will have annual clinical breast examination.
E. Mammogram - all women over age 50 will have a screening mammogram every 1 to 2 years, concluding at age 75 unless pathology has been demonstrated.
F. Pap Smear - beginning at the age of first sexual intercourse, pap smears will be performed every one to three years, depending on the presence or absence of risk factors.
G. Tuberculosis (Tb) screening - all adults will be screened for TB risk factors upon Enrollment and Mantoux skin test will be performed on all persons at increased risk of developing Tb...
6.7.7 HEALTH
EDUCATION
6.7.7.1 General
Requirements
The Contractor
will implement and maintain a system for providing Member health education
services, clinical preventive services, health education and promotion
and patient education and counseling... The Contractor will maintain
a health education system which includes, at a minimum, the following services:
A. Member Education
1. Use of Clinical
Preventive Services.
2. Promote
Appropriate Use of Managed Care Plan Services.
3. Availability
of Local Social and Health Care Programs.
B. Clinical
Preventive Services, Education and Counseling:
1. Nutrition
2. Tobacco
Prevention and Cessation
3. HIV/STD
Prevention
4. Family Planning."
California Contract, pages 127-128.
"I. DEFINITIONS
The following
terms as used in this Contract shall be construed and interpreted as follows
unless the context otherwise expressly requires a different construction
and interpretation: …
F. 'Ambulance Service' shall mean the transportation by a vehicle especially equipped for conveyance of persons who are sick, injured, infirm or living with Disabilities; and, operated, and equipped in accordance with applicable local, State or Federal statutes or regulations to operate as a professional Ambulance Service. Ambulance Service does not include transportation of Members by passenger car, taxi cab, or other forms of private or public conveyance, or when the Ambulance Service is not Medically Necessary." Colorado Contract, page 2.
"XIV.
SERVICE DELIVERY…
D. Preventive
Health Services
1. The Contractor
shall establish and maintain a comprehensive program of preventive health
services for Members that is used to minimize the risk of preventable illness
and Secondary Disability and promote the highest level of wellness and
appropriate self-care among Members...
2. The program
of preventive health services shall include, but is not limited to:
a.
risk assessment by a Member’s Primary Care Provider or other qualified
professionals specializing in risk prevention who are part of the Contractor’s
provider network or under contract to provide such services, to identify
Members with chronic/high risk illnesses, Disabilities, or the potential
for such conditions;
b. targeted health education and promotion programs, including the development of appropriate preventive services for Members with Disabilities to prevent further deterioration and Secondary Disability, and the distribution of information to Members to encourage Member responsibility for following guidelines for preventive health;
c. evaluation of the effectiveness of health preventive services, including monitoring and evaluation of the use of select preventive health services by at-risk Members;
d. procedures to identify priorities and develop guidelines for appropriate preventive services;
e. integration of preventive health programs into the Contractor’s Quality Assurance program and describing specific preventive care priorities, services, accomplishments, and goals as part of required reporting under Section XVII of the contract; and,
f. processes to inform and educate Participating Providers about preventive services, involve Participating Providers in the development of programs, and evaluate the effectiveness of Participating Providers in providing such services." Colorado Contract, pages 46, 51-52.
"EXHIBIT A
COVERED SERVICES…
A.02 Skilled
Nursing Facility Services
Required coverage
during a Client's admission to a nursing facility for extended skilled
nursing services includes the supplies, accommodations, and services as
listed in the following section. Clients must require skilled nursing
services or skilled rehabilitation, i.e., services that must be performed
by or under the supervision of professional or technical personnel on a
daily basis. Coverage is limited to a maximum of thirty (30) days
per Contract...
A.04 Medical
Services
For specific
procedures and indications of basic Medicaid coverage, the Medicaid Master
Procedure File shall be considered the prevailing guide. The following
is a general overview of such services.
PROCEDURE/SERVICE
(REQUIRED COVERAGE)
Direct physical
examination of the patient's body and/or mental or cognitive status…
Manual manipulation
Diagnosis and
treatment of eye disease or injury
Foot care services
Administration
of injectables and allergens...
Medically necessary
diet and/or nutritional counseling, when the diagnosis indicates or includes
a clinical problem that is or could be impacted by obesity.
Medically necessary
treatment for ear or hearing problems.
Medically necessary
treatment for disease or injuries of the eye...
A.05 Vision
and Hearing Services
PROCEDURE/SERVICE
ADULTS:
* Eye
exams
* Vision
correction...
A.06 Preventive
Health Services...
PROCEDURES/SERVICE
(REQUIRED COVERAGE)...
ADULTS:
Preventive
physical exams...
Women's health
*
Routine yearly breast and pelvic, with PAP, hematocrit and urinalysis;
* Routine
mammograms as required by statute...
Men's Health:
Screening for early detection of prostate cancer in men 50 years of age...
Health education
services...
A.07 Consultation
Covered services
include medical services rendered by a participating provider whose opinion
or advice is requested by a Client's primary care provider or the medical
director when further evaluation of an illness or injury is indicated...
A.08 Anesthesia
Services
Administration
of anesthetics to achieve general, regional, supplementation of local anesthesia,
related resuscitative and supportive procedures...
ORGAN TRANSPLANTS...
A.12 Ambulance
Services...
PROCEDURES/SERVICE
(REQUIRED COVERAGE)
Emergency
Non-emergency
Air ambulance...
A.14 Outpatient
Rehabilitation Services...
PROCEDURE/SERVICE
(REQUIRED COVERAGE)
Speech therapy
Occupational
and physical therapy
Pulmonary rehabilitation
Cardiac rehabilitation...
A.17 Exclusions
The following
services are excluded from coverage hereunder:
PROCEDURE/SERVICE...
Biofeedback,
stress management, behavioral testing and training, and counseling for
sexual dysfunction
Services provided
by a chiropractor unless Medicare has paid as primary and the condition
is radiologically shown to be subluxation.
Cosmetic procedures
or corrective plastic surgery performed solely to improve appearance.
Counseling
for the care or treatment of marital or family problems...
a.
Wheelchair lifts for vans or automobiles
b.
Hot tubs, jacuzzis...
Examination
or treatment ordered by a court.
Experimental
or Investigational treatment, procedures or devices as determined by Medicaid...
Government-sponsored
care
Hearing evaluations,
except as otherwise specified.
High colonics.
Holistic or
homeopathic care including drugs and ecological or environmental medicine.
Home delivery
Hospice services...
Institutional
care
Isometric exercise
Expenses for
medical reports, including presentation and preparation.
Personal comfort
or convenience items.
Services not
provided, referred, or authorized by a Client's Primary Care Provider,
except Emergency Services and Urgently Needed Services
Procedures,
services and supplies relating to sex change or transformation...
Third party
physical examinations for employment, licensing, marriage, insurance, school,
camp, sports, or adoption purposes.
Travel, whether
or not recommended or prescribed by a Physician or other medical practitioner.
Services not
provided, arranged, or authorized by a client's primary care provider,
except emergency and/or urgently needed services, as provided for in A.11,
Emergency Care." Colorado Contract, Exhibit A, pages 8-35.
"SUMMARY DESCRIPTION
OF BENEFITS
A. Covered
Services Included in the Capitation Payment
1...
b.
Organ transplants are covered if they are of demonstrated therapeutic value,
medically necessary and medically appropriate, and likely to result in
the prolongation and the improvement in the quality of life of the applicant...
5. Nursing Facility (Skilled Nursing and Intermediate Care) Inpatient Care - Such medically necessary care is covered while the patient remains in a managed care coverage group. For coverage in nursing homes which are characterized as 'institutions for mental disease' see Section C.1 of this summary overview.
6. Intermediate Care Facility (Mentally Retarded) Inpatient Care - Such medically necessary care is covered while the patient remains in a managed care coverage group.
7. Christian Science Sanitoria Service - Such medically necessary care is covered while the patient remains in a managed care coverage group...
13. Chiropractor
Services - Manual manipulation of the spine performed by a licensed chiropractor
within the scope of chiropractic practice. Noncovered services:
a.
Prescription or administration of any medicine or drug or the performance
of any surgery;
b.
X-rays furnished by a chiropractor;
c.
Manipulation of other parts of the body (e.g., shoulder, arm, knee, etc.)
even when for subluxation of the spine; and
d.
Lab work ordered by a chiropractor.
14. Natureopathic Services - Services provided by a licensed natureopath which conform to accepted methods of diagnosis and treatment and which are within the scope of natureopathic practice.
15. Podiatrist
Services - Services provided by a licensed podiatrist which conform to
accepted methods of diagnosis and treatment and which are within the scope
of podiatric practice.
a.
Limitations of Coverage
i.
Orthotic and/or corrective arch supports for recipients under five years
of age; and
ii.
Orthotic and/or corrective arch supports only one every two (2) years.
b.
Noncovered Services
i.
Services of assistants at surgery;
ii.
Simplified tests requiring minimal time or equipment and employing materials
nominal in cost such as Clinitest, Testape, Hematest, Bumintest, Dextrostix,
nonphotolitric homoglobin, etc.;
iii.
Simple foot hygiene; and
iv.
Repairs to devices judged to be necessitated by willful or malicious abuse
on the part of the patient...
17. Outpatient Medical Rehabilitation Service - Medically necessary and medically appropriate outpatient rehabilitation services provided by a licensed or certified practitioner. Such services include: physical therapy, occupational therapy, speech therapy, audiology, inhalation therapy, social services, psychological services, traumatic brain injury (T.B.I.) day treatment, neuropsychological evaluation, electonystagmography, and early childhood intervention services...
18. Vision Care - Services performed by a licensed ophthalmologist, optometrist, or optician which conform to accepted methods of diagnosis and treatment...
23. Respiratory Therapy - services include: intermittent positive pressure breathing, ultrasonography, aerosol, sputum induction, percussion and postural drainage, arterial puncture, and withdrawal of blood for diagnosis.
24. Dialysis - hemodialysis and peritoneal dialysis services are covered, including the treatment of end stage renal disease.
25. School-Based
Clinics - services provided at a facility: a) located on the grounds
of a public school; b) serving enrolled participants on a scheduled basis
or for an emergency situation; and c) licensed as an outpatient medical
facility to provide comprehensive care.
a.
Covered services include: health assessments; family planning services;
diagnosis and/or treatment of illness or injuries; laboratory testing (performed
by the School-Based Health Clinic); follow-up visits; EPSDT services; one-on-one
health education, medical social work services, and nutritional counseling;
and mental health and substance abuse services including diagnostic assessments,
individual, group, and family therapy or counseling.
b.
Noncovered services include: mandated school health screenings, simple
intervention of a health problem such as nonmedical personnel could render,
visits where the presenting health problem does not require a health or
mental health assessment/evaluation, visits for the sole purpose of administering
or monitoring medications, services which are not part of the written individual
plan of care, and visits for mental health or substance abuse determined
by the clinic to be beyond the scope of the clinic...
27. Ambulatory Surgery - Services include preoperative examinations, operating and recovery room services, and all required drugs and medicine…
32. Medical
Transportation Services
a.
Emergency and Nonemergency Ambulance Service is covered when: i) the patient's
condition indicates that the patient's condition might deteriorate in transit
to the point where medical attention would be needed; or iii) the patient's
condition requires hand and/or feet restraints; or iv) the ambulance is
responding to an emergency; or v) no alternative less expensive means of
transportation is available.
b.
Air Transportation - when a medical condition or time constraint dictates
its use.
c.
Critical Care Helicopter - when a medical condition or time constraint
dictates its use.
d.
Other Nonambulance Transportation [Livery, Invalid Coach, Commercial Carrier,
Taxi, Private Transportation, Service bus ('Dial-a-Ride' type service),
etc.] - when needed to obtain necessary medical services covered by Medicaid,
and when it is not available from volunteer organizations, other agencies,
personal resources, etc. To administer the benefit, DSS currently
employs the following limitations on services:
i.
Requirement of prior authorization...
e.
Transportation for relatives or foster parents of a Medicaid recipient...
f.
Out-of-State Transportation Services - when out-of-state- medical services
are needed because of the following:
i.
a medical emergency;
ii.
the patient's health would be endangered if required to travel to Connecticut;
and
iii.
needed medical services are not available in Connecticut.
33. Medical Surgical Supplies - those items which are prescribed by a physician to meet the needs or requirements of a specific medical and/or surgical treatment. They are generally disposable and not reusable...
C. Noncovered
Services
1. Institutions
for Mental Disease (IMD) - The federal definition of an IMD is '…a hospital,
nursing facility, freestanding alcohol treatment center, or other institution
of more than sixteen (16) beds that is primarily engaged in providing diagnosis,
treatment, or care of persons with mental diseases…'
a.
IMD Exclusion - Medicaid does not cover IMD services (i.e., these services
are excluded)…" Connecticut Contract, Appendix A, pages 3-17.
"6.3 Excluded
Services
6.3.1 Federally
Excluded Services
Under federal
law, Medicaid does not receive federal matching funds (called federal financial
participation, or FFP) for certain services. Some of these excluded services
are optional services which the State has elected not to cover. Therefore,
MCOs will not be reimbursed to cover the following services:
(a) All
non-medically necessary services
(b) Abortion unless by rape or incest, or if necessary to save the life of the mother
(c) Sterilization
of a mentally incompetent or institutionalized individual. FFP for sterilization's
are only available if:
1. The
individual is at least twenty-one (21) years old at the time consent is
obtained, and
2. The
individual is mentally competent, and
3. The
individual has voluntarily given informed consent in accordance with all
the requirements prescribed, and
4. At
least thirty (30) calendar days, but not more than one hundred and eighty
(180) calendar days, have passed between the date of informed consent and
the date of the sterilization, except in the case of premature delivery
or emergency abdominal surgery
(d) Single-antigen vaccines and their administration in any case in which the administration of the combined antigen vaccine was medically appropriate
(e) Except in an emergency, inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practices, who is responsible for the diagnosis or treatment of a particular patient's condition
(f) Organ
transplants do not receive FFP unless the State plan includes written standards
for the coverage of those procedures, and those standards provide that:
1. similarly
situated individuals are treated alike, and
2. Any
restriction of the practitioners or facilities that may provide organ transplant
procedures is consistent with the accessibility of high quality care to
individuals eligible for the procedures under the plan.
(g) Treatments for infertility
(h) Sex transformation procedures and hormone therapy
(i) Cosmetic services
(j) Christian Science nurses and sanitariums
MCOs must expect to have on file information to prove to HCFA that abortions were performed only by Federal guidelines.
6.3.2 Other
Excluded Services
While excluded
from the basic benefits package, the following services may be provided
by the MCO if deemed cost effective, medically necessary care: personal
care, chiropractic services, adult dental services, and routine eye care
and glasses for adults; capitation rates will not reflect utilization of
these services by the DSHP population...
6.4.2 Home Visiting
Program
Also included
in the standard benefit package will be a home visit for first time mothers
or mothers sent home under early hospital discharge. See Appendix M for
a description of the program...
6.5 Wrap-Around
Services
Diamond State
Health Plan, Medicaid members only, enrolled in the DHSSHP are also entitled
to a number of services not included in the Basic Benefit Package. Services
not covered under the managed care program include:
(a) Long-term
care services after a thirty (30)-day minimum per calendar year under a
MCO
(b) Pharmacy
benefits
(c) Transportation
except for ambulances in case of medical necessity
(d) Medically
necessary behavioral health services in excess of prepaid plan limits listed
in Appendix H.
(e) Day
treatment by continuous treatment teams for mental illness or substance
abuse
The services listed above are currently covered under the Delaware Medicaid program. For these wrap-around services, the State will continue to reimburse the billing provider directly. Although MCOs are not responsible for directly furnishing wrap-around services, they are responsible for coordinating the overall delivery of care with out-of-network providers whenever one of their patients requires wrap-around services. The major types of out-of-plan services with which MCOs must coordinate are described below…" Delaware RFP, pages II.35-II.39.
"Appendix H
Overview Medicaid
Covered Services
SERVICE TYPE/
BASIC BENEFIT PACKAGE...
Medical
Primary/Preventive
Routine Visit/
Covered
Well Baby/
Covered...
Special Care
Office Visit/
Covered...
Newborn*/ Covered
Home visit/first
time moms* / Covered...
*Covered under
Title XXI when Mother and/or baby are not Medicaid eligible.
Non-invasive diagnostic tests/Covered...
Other
Private Duty
Nursing/ Covered
Ambulance/
Covered for Emergency Service…
Skilled Nursing
Facility/ Covered, 30 days of Skilled nursing when authorized
Therapies (Physical/Speech/Occupational)/
Covered…
Dialysis/ Covered
Transplants/
Covered...
Hospice/ Covered…"
Delaware RFP, Appendix H, page 1.
"3.1 Describe the methods of delivery of the child health assistance using Title XXI funds to target low-income children: (Section 2102(a)(4))
Delaware SCHIP (SCHIP) program is targeted to children under age 19 with income at or below 200% of the Federal Poverty Level (FPL). The service package will include all of those basic benefit services provided under the State's Diamond State Health Plan (DSHP) (as it was structured during 1998) through the fully capitated managed care organizations (MCOs) participating with the DSHP. In addition, participants in the SCHIP will receive pharmacy services comparable to the Medicaid population. They will also receive 31 days of mental health and substance abuse treatment services (any treatment modality) in a calendar year in addition to the basic MCO benefit of inpatient care, children will become eligible for Medicaid long-term care services. Thus the SCHIP program will provide very high quality mental health and substance abuse coverage - coverage which is better by far than most private sector coverage. Services will be provided statewide with no variations based on geography.
Delaware assures that it will spend no more than 10% of actual or estimated Federal expenditures for outreach and administrative costs in accordance with Section 2105(a)(2)). The plan does not currently include any initiative to provide services through any options other than through MCO capitated arrangements with the two 'wrap-around' services listed above…" Delaware RFP, Appendix A (SCHIP), page A.7.
"6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations)
The following services marked with an 'X' are covered by the State Child Health Insurance Program as part of a basic MCO benefit package when medically necessary with exceptions/limitations noted: ...
6.2.4.
'X' Surgical services (Section 2110(a)(4))
6.2.5.
'X' Clinic services (including health center services) and other
ambulatory health care services (Section 2110(a)(5))….
6.2.7.
'X' Over-the-counter medications (Section 2110(a)(7))…
6.2.12.
'X' Durable medical equipment and other medically-related or remedial
devices (such as prosthetic devices, implants, eyeglasses, hearing aids,
dental devices, and adaptive devices) (Section 2110(a)(12)) - dental
devices are not provided as part of the basic benefit or wrap-around services...
6.2.15.
'X' Nursing care services (See instructions) (Section
2110(a)(15)) - there is a limit of 28 hours of Private Duty Nursing Services
per week in the basic benefit; no additional hours available...
6.2.21.
'X' Care coordination services (Section 2110(a)(21))
6.2.22.
'X' Physical therapy, occupational therapy, and services for individuals
with speech, hearing, and language disorders (Section 2110(a)(22))
6.2.23.
'X' Hospice care (Section 2110)(a)(23))
6.2.24.
'X' Any other medical, diagnostic, screening, preventive, restorative,
remedial, therapeutic, or rehabilitative services. (See instructions)
(Section 2110(a)(24))...
6.2.26.
'X' Medical transportation (Section 2110(a)(26)) Emergency
transportation only as provided in the basic benefit package…" Delaware
RFP, Appendix A (SCHIP), page A.18-A.20.
"H. COVERAGE
AND BENEFITS
1.
Covered services
a.
This contract provide for coverage and provision by Provider of all medical
assistance benefits and services that are listed in Attachment I,
which is incorporated herein as part of this contract…
4.
Mental Illness and Addiction Disorder Treatment Services
a.
Services needed to treat mental illness or addiction disorders other than
pharmaceuticals are excluded from the provision and coverage requirement
of this contract.
b.
Provider is responsible for arranging for mental illness or addiction disorder
services if such assistance is requested by the enrollee or by the enrollee's
PCP. Provider shall document the provision of such services in enrollees'
medical records.
c.
Provider shall make available to the member a directory of mental health
and substance abuse providers in the District. The District shall
furnish a copy of the directory to the Provider. Provider shall
assist the member in selecting a mental health and substance abuse provider
and making an appointment, when requested and necessary.
6.
Services for Children with Developmental Disabilities
a.
Provider is responsible for coverage and provision of services other than
services necessary for the diagnosis and treatment of mental illness and
addiction disorders in the case of children with developmental disabilities,
as defined in Article XXII.
b.
In making coverage determinations in the case of children with developmental
disabilities, Provider shall provide coverage if, taking into consideration
the clinical evidence as well as the opinion of health, educational and
social service professional furnishing care to such children, Provider
determines that the care is necessary to correct or ameliorate the effects
of a developmental disability.
c.
Provider shall coordinate with District agencies, including the Public
School system and the District's Early Intervention Program that are responsible
for services for infants, toddlers, preschool and school age children it
developmental disabilities to develop a comprehensive plan of care.
7.
Services for Persons with HIV or AIDS
a.
Provider is responsible for coverage and provision of services necessary
to the diagnosis and treatment of persons with HIV and AIDS other than
services for mental illness or addictive disorders. ...
11.
Transplant Surgery
a.
Provider is responsible for the coverage of all transplant surgery services,
except for those services provided during the inpatient stay in which the
transplant surgery takes place.
b.
Provider is responsible for arranging for the transplant surgery and obtaining
authorization for the transplant surgery from the District. Provider
shall be responsible for transplant surgeries when Provider fails to seek
authorization for the transplant surgery…" District of Columbia Contract,
pages 21, 25-27.
"Attachment
I
Covered Services
A. General
Classes of Covered Benefits
Coverage of
all benefits by Provide shall conform to the definition of the benefit
set forth in federal statute and regulation. The following
general categories of benefits are included in the state plan and are not
otherwise exempt under this contract. ...
8. Podiatrists services excluding routine for care for a symptomatic individuals.
9. Optometrist services including contact lenses and special eyeglasses and are sunglasses when authorized as medically necessary. Eyeglasses or contacts limited to one pair every 24 months except for person under age 21, person experiencing a change of more that plus or minus one half diopter and to replace broken or lost eyeglasses. In these exception cases, eyeglasses or contacts are limited to one pair every six months.
11. Private duty nursing services limited to individuals who require more individual and continuous care than is routinely provided by home health agencies, a nursing facility, or a hospital.
12.
Physical therapy and related services including physical and occupational
therapy and services for individuals with speech, language and hearing
disorders furnished under the supervision of a speech pathologist or audiologist.
Services for speech, language and hearing disorders are limited to children
under 21 and include services furnished by the District's school
system...
14. Prosthetic devices including items listed in the program's Medical Equipment/Medical Supplies Procedure Code and Price List as well as other devices as authorized for medical necessity. ...
18. Personal care services not to exceed 1040 hours annually except as authorized for medical necessity.
19. Abortions as permitted under federal law.
20. Adult day treatment services for persons with mental retardation to prepare for independent living." District of Columbia Contract, Attachment I, pages 1, 2.
"ATTACHMENT
I
A. Services
To Be Provided
1. Services.
The plan shall insure the provision of the following covered services as
defined and specified in Attachment II:
Mandatory...Covered...
Therapy Services...X
Visual Services...X
Hearing Services...
X
Nursing Facility
Services...X" Florida Contract, page 5.
"2. Ancillary Services Provided at the Hospital. Ancillary services which are provided by the hospital include, but are not limited to...neurology, neonatology and anesthesiology. When the plan or plan's authorized physician authorizes these services (either inpatient or outpatient), the plan must reimburse the professional component of the service at the Medicaid line item rate, unless another reimbursement rate has been negotiated. This is also required for emergency services rendered by non-plan physicians for ancillary services provided in a hospital setting." Florida Contract, page 56.
"10. Therapy Services. Medicaid therapy services provide physical, speech-language (including augmentative and alternative communication systems), occupational and respiratory therapies. Medicaid pays only for therapy services that are medically necessary for the provision of therapy evaluations and individual therapy treatment. Therapy services are limited to children and young people who are under the age of 21, and to adults whose therapy services are covered by Medicaid as specified in the Medicaid coverage and limitations handbooks...
b. Members must be offered scheduling assistance in making treatment appointments and obtaining transportation.
c. This service includes the maintenance of a coordinated system to follow the member through the entire range of screening and treatment.
d. The agency shall reimburse schools participating in the certified school match program... for school-based therapy services rendered to members..." Florida Contract, pages 83-84.
"15. Nursing Facility Services. Skilled nursing facility services are those services furnished in a health care facility licensed under Chapter 400, Florida Statutes, according to physician orders that the patient requires the skills or technical and professional personnel...
The contractor is responsible for care in skilled nursing facilities that is considered to be a downward substitution for inpatient hospital services and is not considered to be custodial care." Florida Contract, page 85.
"30.410
Required Providers...
*Ambulance
services...
*Physical,
occupational, audiology and speech and language therapy services...
*Other practitioner
services such as optometry, registered nursing...
*Transportation
services including emergency ground and air
*Lodging and
meals associated with obtaining necessary medical care" Hawaii RFP, page
9.
"30.710
Medical Services
One of the
primary focuses of Quest is preventive care; therefore, preventive and
diagnostic services are important benefits of the basic health plan.
The services include all medically necessary and preventive services.
The health plan shall provide, at a minimum, whatever services are currently
covered by the Hawaii Medicaid program...
* Preventive
services including:
- Initial
and interval histories, comprehensive physical examinations and developmental
assessments...
* Other
practitioner services including:
- Optometry...
-
Other medically necessary practitioner services provided by licensed and/or
certified health care providers
* Therapeutic
services including:
- Physical
therapy
- Occupational
therapy
- Speech
therapy
- Audiology
services
- Other
medically necessary therapeutic services including services which would
prevent institutionalization...
* Hospice
services
* Long-term
care services (SNF or ICF or waitlisted for SNF/ICF bed in an acute hospital
for a maximum of 60 days)
* Cornea
and kidney transplants and bone graft services (other covered transplants
provided under 'carve-out')
* Transportation
services...
Specifically
excluded from the basic health plan are services excluded by federal Medicaid
requirements including:
* Experimental
or investigational services, supplies, equipment, devices and drugs...
* Treatment
of Hansen's Disease after a definite diagnosis has been made except for
surgical or rehabilitative procedures to restore useful function…" Hawaii
RFP, pages 16-20.
"30.740
Appropriate Levels of Care...
For a recipient
with documented medical needs which cannot be provided in his/her home
and who does not qualify for care home residence, medically necessary long
term care services shall be provided. Cost of these services for
a period up to maximum of 60 days, shall be included in the capitation
rate.
The plan shall arrange for the placement of qualified recipients into appropriate nursing facilities, and shall be responsible for meeting all documentation requirements for admission into LTC facilities...
30.770
Craniofacial Review Panel Recommendations...
Unless the
medical and dental plan can demonstrate alternative appropriate treatment,
the recommendations of the Panel are binding on the plans, subject to the
approval of the parent(s) or legal guardian(s) and the member. As
the work is highly specialized, the recommendations may also include the
names of the providers who are qualified to perform the procedures.
Minor changes by a provider may be acceptable, but major changes must involve
the member's treatment team and if the proposed treatment deviates significantly
from that recommended by the Panel may require additional discussion by
the Panel…" Hawaii RFP, pages 26-28.
"33.100
Other Services to be Provided...
* Transportation
services...
Transportation
for a child under the Children with Special Health Ends Branch for medically
necessary evaluations required by the Craniofacial Review Panel and to
attend case presentations by the Panel shall be borne by the health plan.
* Recipient
education
The health
plan shall educate its members on the importance of good health and how
to achieve and maintain good health...
* Certification
of Physical or mental impairment...
The plans shall
provide these evaluations and certifications to continue the recipient's
eligibility for public assistance…" Hawaii RFP, pages 31-32.
"40.720
Transplant Program
The health
plan is responsible for kidney and cornea transplants and bone grafts...
In all cases, the children and adults will be required to meet the specific
medical conditions for the transplants. The DHS does not cover other
transplants. The State and the transplant facility will determine
whether a transplant will take place" Hawaii RFP, pages 51-52.
"APPENDIX D
HEALTH INTERVENTIONS
1. Health
plans are required to cover health interventions within the specified categories
that meet the following criteria:
a.
The intervention must be used for a medical condition.
b.
There is sufficient evidence to draw conclusions about the intervention's
effects on health outcomes.
c.
The evidence demonstrates that the intervention can be expected to produce
its intended effects on health outcomes.
d.
The intervention's beneficial effects on health outcomes outweigh its expected
harmful effects.
e.
The health intervention is the most cost-effective method available to
address the medical condition." Hawaii RFP, Appendix D, page 1.
"APPENDIX E
COVERED PREVENTIVE
SERVICES FOR ADULTS AND CHILDREN
The following
is a listing of preventive services for which payments will be made by
the health plans.
For Adults:
The following
are services for which payment will be made by health plans as separate
medical services, as components of separate medical services, or as components
of the 'evaluation and management' services rendered by the health plans'
providers. The services and periodicity are adapted from the 1996
U.S. Preventive Services Task Force.
Screening:
1. Blood
Pressure Measurement: ...
2. Weight/Height
Measurement: ...
3. Total
Cholesterol Measurement: …
4. Breast
Cancer Screening: ...
5. Cervical
Cancer Screening: ...
6. Colorectal
Cancer Screening: ...
7. Prostate
Cancer Screening: ...
8. Rubella
serology or vaccination history: ...
9 Tuberculin
Skin Testing...
10. Health
Education and Counseling...
Immunizations:
...
Chemoprophylaxis:
...
For the high risk population the required preventive interventions are an Adult Health Regimen which includes the prior listed preventive interventions in addition to the following:
Risk Factor/
Intervention
1) low income;
immigrants, alcoholics TB contacts/ 1) PPD
2) certain
chronic medical conditions, institutionalized persons/ 2) PPD; pneumococcal
vaccine influenza vaccine
3) health care,
lab workers/ 3) PPD; hepatitis B and hepatitis A influenza vaccine
4) family h/o
skin cancer; fair skin/ 4) avoid sun exposure
5) blood product
recipients/ 5) HIV screen; hepatitis B vaccine
6) susceptible
to measles, mumps, or varicella/ 6) MMR; varicella vaccine
7) previous
pregnancy with neutral tube defect/ 7) folic acid 4.0 mg
8) injection
or street drug use/ 8) RFR/VDRL; PPD; HIV screen hepatitis B &
A vaccine
9) high risk
sexual behavior/ 9) STD screens; hepatitis B & A vaccines." Hawaii
RFP, Appendix E, page 1-3.
"Other Practitioner
Services
A. For
adults
1. Other
practitioner services are included if these services are provided by certified
and/or licensed practitioners of health care within their legal scope or
practice in the State or Hawaii and if these services are allowable under
Federal Medicaid rules and regulations...
Physical Therapy,
Occupational Therapy, Speech Therapy, and Audiology Services
A. For
adults
1. Physical
therapy, occupational therapy, speech therapy, and audiology services are
included if medically necessary, prescribed by a licensed physician, and
provided by or under the direction of a licensed/certified physical therapist,
occupational therapist, speech therapist or pathologist or audiologist….
Rehabilitative
Services
A. For
adults
1. Services
include but are not limited to corrective surgery, physical therapy, speech
therapy, occupational therapy, drugs, prosthesis and orthoses, durable
medical equipment, medical supplies, and respiratory services prescribed
or performed by licensed physician to maximally reduce medical physical
or mental disabilities and restore a member to optimal functional level….
Hysterectomies
A. For
Adults
1. The
medical procedure or operation to remove the uterus performed by a licensed
physician is included only when medically necessary and when strict federal
criteria are met...
Organ and Tissue
Transplantation
A. For
Adults
1. Covered
transplantations are limited to the following:
a.
Cadeveric corneal transplants.
b.
Bone grafts
c.
Allogenic or cadaveric kidney transplants.
2. Covered transplants must be medically necessary for the recipient...
Transportation
A. For
Adults
1. Transportation
services are travel, lodging and meals, for the member and (if needed)
an attendant in order for the member to obtain medically necessary diagnosis
and treatment services. Hawaii RFP, Appendix H, pages 8-13.
"APPENDIX I
SERVICES AND
MISCELLANEOUS ITEMS NOT COVERED BY THE HAWAII QUEST PROGRAM
1.
Personal care items such as shampoos, toothpaste, toothbrushes, mouth washes,
denture cleansers, shoes, slippers, clothing, laundry serves, baby oil
and powder, sanitary napkins, soaps, lip balm, band aids
2. Non-medical
items such as books, telephones, beepers, radios, lines, clothing, television
sets, computers, air conditioners, air purifiers, fans, household items
or furnishings
3. Experimental
and/or investigational services, procedures, drugs, devices, and treatments;
drugs not approved by the FDA, brand name drugs except single source drug
and brand name drugs when required by statute required
4. Gender
reassignment - all medical, surgical, and/or psychiatric services
and drugs, including hormones, needed for changing the sex of an individual.
5. In
vitro fertilization, reversal or sterilization, artificial insemination,
sperm making procedures; procedures and drugs to treat infertility or enhance
fertilization.
6. Biofeedback,
acupuncture, naturopathic services, faith healing, Christian Science services,
hypnosis, massage treatment (by masseurs)
7. Obesity
treatment, weight loss programs; food, food supplements including prepared
formulas, health foods
8. Cosmetic
surgery or treatment - cosmetic rhinoplasties, reconstructive, or plastic
surgery to improve appearance and not bodily function, piercing or ears
and other body areas, electrolysis, hair transplantation, reduction and
augmentation mammoplasties, paniculectomies and other body sculpturing
procedures, excision or destruction of benign skin or subcutaneous lesions
without medical justification
9. Tuberculosis
services when provided free to the general public
10. Hansen's
Disease treatment or follow-up
11. Treatment
of persons confined to public institutions
12. Penile
and testicular prostheses and related services
13. Psychiatric
care and treatment for sex and marriage problem, weigh control employment
counseling, primal therapy, long term character analysis, marathon group
therapy, and/or consortium
14. Routine
foot care; treatment of flat feet
15. Swimming
lesson, summer camp, gym membership, weight control classes, smoking cessation
classes and drugs
16. Stand-by
services by stand-by physician, telephone consultations, telephone calls,
writing or prescription, stat changes.
17. All
medical and surgical procedures, therapies, supplies, drugs, equipment
for the treatment of sexual dysfunction.
18. Beds
- lounge beds, bead beds, water beds, day beds; over bed table, bed lifters,
bed boards, bed side rails in not an integral part of a hospital bed
19. Topical
application of oxygen
20. Contact
lenses for cosmetic purposes; bifocal contact lenses
21. Oversized
lessen, blended or progressive bifocal lenses, tinted or absorptive lenses
(except for aphasia, albinism, glaucoma, medical photophobia), trifocal
lenses (except as a specific job requirement), spare glasses
22. Orthopedic
training
23. Physical
exams for employment when the patient is self-employed or as a requirement
for continuing employment (i.e. truck and taxi drivers' licensing, other
P.E.s as a requirement for continual employment by the State or Federal
Government, or by private business
24. Physical
exams and immunizations for travel - domestic or foreign
25. Physical
exams, psychological evaluation and/or immunization as a requirement for
Hawaii or other states' drivers' licenses or for the purpose of securing
life and other insurance policies or plans.
26. Organ
transplants not meeting the guidelines established by the Medicaid program
and organ transplants not specifically identified as a Medicaid benefit"
Hawaii RFP, Appendix I, pages 1-2.
"APPENDIX K
LONG TERMCARE
FACILITY SERVICES
The types or
long-term care faulty levels currently recognized by the Hawaii Medicaid
Program are as follows:
*Skilled Nursing
Facilities (SNFs) or Nursing Facilities (NFs) - Level 'C'
*Intermediate
Care Facilities (ICFs) or Nursing Facilities (NFs) - 'A'
*Intermediate
Care Facilities for the Mentally Retarded (ICF-MRs) or Nursing Facilities
(NFs) -Level 'B'…" Hawaii RFP, Appendix K, page 1.
"Prior to presentation of a case to the Craniofacial Review panel, diagnostic workshops, consultations and so forth may be required. Who will be financially responsible for these services?
ANSWER:
The diagnostic
workshops and consultations are often made by the Craniofacial Review Panel
as part of the initial case review. If these services are covered
benefits of QUEST, the QUEST medical and/or dental plans are responsible."
Hawaii RFP, Q&A, page 16.
"Does skilled nursing carve out require the Plan to be responsible for the first 60 days of skilled nursing care or if the State moves quickly on transition of members, can this obligation be less?
ANSWER:
The obligation
may be less. The 60 days reflects a maximum." Hawaii RFP, Q&A,
page 35.
"a) Is
the plan required to cover services required as a result of a gender reassignment
procedure complication
b) Is
the plan required to cover complication arising from cosmetic surgery or
other procedures?
ANSWER:
The plan is
not required to cover complications that occur during surgery or in the
immediate post-operative period. However, if the complications are
delayed in onset or if they are not direct outcomes of the procedure itself,
these should be covered if medically necessary. Examples of services
which should be covered: renal failure after gender reassignment
urological complications should be covered: orbital cellulitis after
cosmetic septoplasty, autoimmune disease after silicone breast implant."
Hawaii RFP, Q&A, pages 53-54.
"APPENDIX E
SERVICES AND
MISCELLANEOUS ITEMS NOT COVERED BY THE HAWAII QUEST PROGRAM
1. Personal
care items such as shampoos, toothpaste, toothbrushes...
2. Non-medical
items such as books, telephones, beepers...
3. Experimental
and/or investigational services, procedures, drugs, devices, and treatments;
drugs not approved by the FDA, brand name drugs except single source drugs
and brand name drugs when required by statute required
4. Gender
reassignment - all medical, surgical, and/or psychiatric services and drugs,
including hormones, needed for changing the sex of an individual...
6. Biofeedback,
acupuncture, naturopathic services, faith healing, Christian Science services,
hypnosis, massage treatment (by masseurs)
7. Obesity
treatment, weight loss programs; food, food supplements including prepared
formulas, health foods
8. Cosmetic
surgery or treatment...
10. Hansen's
Disease treatment or follow-up
11. Treatment
of persons confined to public institutions
12. Penile
and testicular prostheses and related services
13. Psychiatric
care and treatment for sex and marriage problems, weight control...
14. Routine
foot care...
15. Swimming
lessons, summer camp...
16. Stand-by
services by stand-by physicians, telephone consultations, telephone calls,
writing of prescriptions, state charges
17. All
medical and surgical procedures, therapies, suppliers, drugs, equipment
for the treatment of sexual dysfunction
18. Beds
- lounge beds, bead beds, water beds...
19. Topical
application of oxygen
20. Contact
lenses for cosmetic purposes; bifocal contact lenses
21. Oversized
lenses, blended or progressive bifocal lenses, tinted or absorptive lenses...
22. Orthopedic
training
23. Physical
exams for employment when the patient is self-employed or as a requirement
for continuing employment...
24. Physical
exams and immunizations for travel - domestic or foreign
25. Physical
exams, psychological evaluations and/or immunizations as a requirement
for Hawaii or other states' drivers' licenses or for the purpose of securing
life and other insurance policies or plans.
26. Organ
transplants not meeting the guidelines established by the Medicaid program…"
Hawaii Mental Health RFP, pages E1-E2.
"(b) Covered
Services...
(2) Medically
Necessary Covered Services
The following
services and benefits shall be included as Covered Services under this
Contract and will be provided to Beneficiaries whenever medically necessary:
...
• Nursing
facility services for the first ninety (90) days;* [* Contractors will
be responsible for covering up to a maximum of ninety (90) days skilled
and intermediate care annually per Beneficiary. Periods in excess of ninety
(90) days annually will be paid by the Department according to its prevailing
reimbursement system.]...
• Private duty
nursing services;
• Clinic services...
• Orthotic/prosthetic
devices, including prosthetic devices or reconstructive surgery incident
to a mastectomy;
• Physical,
occupational and speech therapies;
• Assistive/augmentative
communication devices...
• Transportation
to secure medical services...
• Blood, blood
components and the administration thereof;
• Podiatric
services for enrollees age 20 and under if determined necessary by EPSDT
screens;
• Chiropractic
services for enrollees age 20 and under if determined necessary by EPSDT
screens...
• Certified
hospice services.
(3) Services
to Prevent Illness and Promote Health
In addition,
the Contractor shall exercise reasonable efforts to provide initial health
screenings and a preventive care program to maximize the effectiveness
of a prepaid health care system. The Contractor shall provide the following
Covered Services to all Beneficiaries, as appropriate, to prevent illness
and promote health:
(4) Other
Medical Assistance Services
All services
not specifically excluded in this Article V(b) but listed in 89111. Adm.
Code 140 as amended from time to time, shall be provided to all Beneficiaries.
(5) Exclusion
from Covered Services
The following
services and benefits shall NOT be included as Covered Services: ...
(B) Optometric
services as follows. The Contractor shall refer Beneficiaries eligible
for refractions, eyeglasses, and other devices to correct vision to Providers
participating in the Medical Assistance Program and able to provide such
services;
(C) Nursing
facility services beginning on the ninety-first (91st) day;
(D) Intermediate
Care facilities for the Mentally Retarded;
(E) Early
intervention services, including case management, provided pursuant to
the Early Intervention Services System Act [325 ILCS 20 et seq.];
(F) Services
provided through school-based clinics as such clinics are defined by the
Department;
(G) Services
provided through local education agencies that participate in the Special
Education Medicaid Matching Fund Program;
(H) Services
provided under Section 1915(c) home and community-based waivers; and
(I) Audiology
services, physical therapy, occupational therapy and speech therapy provided
to Beneficiaries under twenty-one (21) years of age.
(6) Limited
Covered Services
The following
services and benefits shall be limited as Covered Services:
(A) Termination
of pregnancy shall be provided only as allowed by applicable State and
federal law (42 C.F.R. Part 441, Subpart E). In any such case, the requirements
of such laws must be fully complied with and DPA Form 2390 must be completed
and filed in the Beneficiary's medical record.
(B) Sterilization
services may be provided only as allowed by State and federal law (see
42 C.F.R. Part 441, Subpart F). In any such case, the requirements of such
laws must be fully complied with and the DPA Form 2189 must be completed
and filed in the Beneficiary's medical record.
(C) If
a hysterectomy is provided, the DPA Form 1977 must be completed and filed
in the Beneficiary's medical record…" Illinois HMO Contract, pages
19-22.
"3.1.3 Medicaid Covered Services
The Indiana
Medicaid program covers the following services for all eligible recipients.
The specific services covered under the managed care initiative are specified
in Section 4.4 of this RFP...
*
Long-term care
- Nursing homes
- Intermediate care facility for the mentally retarded (ICF/MR)
- Mental hospital care for recipients under 21 years or over 65 years
- Community residential centers for the developmentally disabled (CRF/DD)
*
Transportation/ambulance services
*
Podiatry services...
*
Physical therapy services
*
Occupational therapy services
*
Respiratory therapy services
*
Speech therapy services
*
Chiropractic services
*
Optometric services and eye glasses
*
Audiological services and hearing aids...
*
Medical supplies...
*
Preventive health services...
*
Food supplements approved by the FDA...
*
Hospice services
In addition, the Indiana Medicaid program covers certain waiver services for a limited number of qualified recipients under one of four Home-and Community-Based Services Waiver Programs.
All Medicaid
coverage is subject to certain limitations that may be defined by the State
in terms of:
*
Specific services excluded from coverage (e.g. cosmetic surgery)
*
Limits on the frequency of services provided
*
Services provided only under certain conditions (e.g. prior-authorized
services)
*
Coverage available only to certain age groups of recipients
The Indiana Administrative Code, 405 IAC 5, which is available in the Procurement Library, details the amount, scope and duration of covered services...
4.4 Description
Of Managed Care Services
4.4.1
Hoosier Healthwise RBMC Covered Services
Covered services
under Hoosier Healthwise RBMC include all Medicaid covered services with
the exception of mental health, dental care, long-term institutional care,
services provided as part of an Individualized Education Plan (IEP) pursuant
to the Individuals with Disabilities Education Act (IDEA) at 20 U.S.C.
1400 et seq., substance abuse and chemical dependency services, and hospice
services. The MCO must arrange and assure the provision of all RBMC covered
services except self-referral services. For additional information about
self-referral services, refer to Section 4.4.2.4 of this RFP. Detailed
explanations of covered services and limitations are cited in Title 405,
Article 5 of the Indiana Administrative Code that is on file in the Procurement
Library. The Procurement Library also contains a copy of the Indiana
Medicaid over-the-counter (OTC) drug formulary.
The following
is a general list of covered services under the RBMC program, listed by
general categories; an abbreviated list of covered services within each
category also is provided...
*
Primary care services
*
Preventive health services
*
Therapeutic and rehabilitative services
*
Specialty care services
*
Nursing services...
*
Therapy services...
*
Diagnostic studies
*
Sterilization, hysterectomy services...
*
Initial and periodic screenings
*
Diagnosis and treatment...
*
Physical, occupational and respiratory therapy
*
Speech pathology
*
Renal dialysis...
*
Non-legend drugs (selected over-the-counter drugs) as identified in OMPP’s
over-the-counter formulary
*
Medical supplies and equipment...
*
Braces and orthopedic shoes
*
Prosthetic devices
*
Hearing aids
*
Preventive and diagnostic services
*
Transportation services
*
Emergency transportation
*
Non-emergency transportation
*
Transportation to and from excluded but covered services
*
HIV/AIDS targeted case management
*
Diabetes self-management training
4.4.2
Special Provisions
Specific coverage
and payment policies apply to certain types of services and providers,
including the following:
*
Emergency room services
*
Out-of-area services
*
Out-of-plan providers
*
Self-referral services
*
Federally Qualified Health Centers (FQHCs)
*
Rural Health Clinics (RHCs)
*
Short-term placements in a long-term care facility
*
Copayments...
4.4.3
MCO Excluded, But Medicaid Covered Services
Under Hoosier
Healthwise RBMC, services excluded from the capitated payment amount, but
still covered by Medicaid, include:
*
Long-term institutional care
*
Hospice care
*
Substance abuse and chemical dependency services
*
Mental health services rendered by providers enrolled in Indiana Medicaid
with a mental health specialty; those provider specialties are listed in
Section 4.4.2.4
*
Dental services rendered by providers enrolled in Medicaid in a dental
specialty; the dental specialties are: endondontist, general dentistry
practitioner, oral surgeon, orthodontist, pediatric dentist, periodontist,
pedodontist, and prosthodontist
*
Services provided by a school as part of a student’s Individualized Education
Plan (IEP).
4.4.4
Enhanced Services
In conjunction
with the provision of covered services, strong emphasis will also be placed
on programs to enhance the general health and well-being of Medicaid recipients,
including programs that specifically address preventive health and preventive
risk factors. Wellness programs available to the MCO's commercial
population should be made available to Medicaid enrollees. The MCO
should provide a list and description of the available wellness programs.
Additionally, the MCO is encouraged to provide enhanced services, such
as health education classes which target the Medicaid population specifically.
In addition to wellness and education services, it is appropriate for an
MCO to provide non-Medicaid covered services to enrollees that are more
clinically appropriate or cost-effective than Medicaid covered services.
The MCO must inform OMPP at least four (4) weeks prior to implementing
or providing any enhanced services. Enhanced services must comply with
the education/outreach and other relevant guidelines set forth in this
RFP." Indiana RFP, pages 3-3 - 3-5, 4-4 - 4-11.
"CHIP Benefit Package
Service: Podiatrists
Indiana Medicaid Benefits: No more than 6 routine foot care visits per year are covered.
CHIP Benefit Package: Surgical procedures involving the foot, laboratory or x-ray services, and hospital stays are covered when medically necessary Coverage is subject to the same limitations as Medicaid...
Service: Chiropractors*
Indiana Medicaid Benefits: Reimbursement is available for covered services provided by a licensed chiropractor, enrolled as an Indiana Medicaid provider, when rendered within the scope of the practice of chiropractic. Limited to 5 visits and 50 therapeutic physical medicine treatments per recipient per year.
CHIP Benefit Package: Reimbursement is available for covered services provided by a licensed chiropractor, enrolled as an Indiana Medicaid provider, when rendered within the scope of the practice of chiropractic. Limited to 5 visits and 14 therapeutic physical medicine treatments per recipient per year. Additional treatments will be covered if prior approval is obtained based on medical necessity...
Service: Physical Therapy**
Indiana Medicaid Benefits: Must be ordered by M.D. or D.O. and provided by qualified therapist or assistant. Covered for no longer than two years. No more than one hour per day per type of therapy. Not to exceed twelve hours per 30 calendar days.
CHIP Benefit Package: Must be ordered by M.D. or D.O. and provided by qualified therapist or assistant. Maximum of 50 visits per year per type of therapy.
Service: Speech, Hearing and Language Disorders*
Indiana Medicaid Benefits: Prior authorization not required for initial evaluations. Evaluations and reevaluations limited to three hours of service per evaluation.
CHIP Benefit Package: Must be ordered by M.D. or D.O. and provided by qualified therapist or assistant. Maximum of 50 visits per year per type of therapy.
Service: Occupational Therapy**
Indiana Medicaid Benefits: Must be performed by registered occupational therapist or assistant under direct supervision. Evaluations and reevaluations limited to three hours of service per evaluation. May continue for a period not to exceed twelve hours in thirty calendar days.
CHIP Benefit Package: Must be ordered by M.D. or D.O. and provided by qualified therapist or assistant. Maximum of 50 visits per year per type of therapy.
Service: Respiratory therapy*
Indiana Medicaid Benefits: Prior authorization not required for inpatient or outpatient hospital, emergency, oxygen in nursing facility, thirty days following discharge from hospital when ordered by physician prior to discharge.
CHIP Benefit Package: Must be ordered by M.D. or D.O. and provided by qualified therapist or assistant. Maximum of 50 visits per year per type of therapy...
Service: Inpatient Rehabilitative Services**
Indiana Medicaid Benefits: Prior authorization is required. Educational services not covered.
CHIP Benefit Package: Covered up to 50 days per calendar year. Prior authorization is required. Educational services not covered...
Service: Hospice care**
Indiana Medicaid Benefits: Must be expected to die from illness within six months. Coverage of two consecutive periods of 90 days followed by an unlimited number of periods of 60 days.
CHIP Benefit Package: Must be expected to die from illness within six months. Coverage of two consecutive periods of 90 days followed by an unlimited number of periods of 60 days….
Service: Diabetes Self Management Training Services*
Indiana Medicaid Benefits: Limited to 16 units per recipient per year. Additional units may be prior authorized.
CHIP Benefit Package: Limited to 16 units per recipient per year. Additional units may be prior authorized.
Service: Out-of-state Medical Services**
Indiana Medicaid Benefits: Covers acute general hospital care; physician services; dental services; pharmacy services; transportation services; therapy services; podiatry services; chiropractic services; durable medical equipment and supplies.
CHIP Benefit Package: Covers acute general hospital care; physician services; dental services; pharmacy services; transportation services; therapy services; podiatry services; chiropractic services; durable medical equipment and supplies. Coverage is subject to any limitations included in the CHIP benefit package...
Service: Food Supplements, Nutritional Supplements, and Infant Formulas**
Indiana Medicaid Benefits: Covered only when no other means of nutrition is feasible or reasonable. Not available in cases of routine or ordinary nutritional needs.
CHIP Benefit Package: Covered only when no other means of nutrition is feasible or reasonable. Not available in cases of routine or ordinary nutritional needs…
**Prior Approval
Always Required
*Prior Approval
Required Under Certain Circumstances
+Federally
Required CHIP Benefits." Indiana SCHIP Amendment, Attachment C-1,
pages 2-5.
"1.3 Definitions...
- Personal
Care Services - are any medically necessary services provided to an individual
who is not an inpatient or resident of a hospital, nursing facility, intermediate
care facility for the mentally retarded, or institution for mental disease
that are not related to the mental health and substanc e abuse and are
(A) authorized for the individual by a Provider in accordance with a plan
of treatment, (B) provided by an individual who is adequately qualified
to provide authorized services and who is not a member of individual's
family, and (C) furnished in a home or other location as deemed appropriate
by the HMO." Iowa Contract, pages 6, 9.
"4.2.1
Covered Services
The HMO must
promptly provide or arrange for the provision of all medically necessary
services required under Chapters 78, 79 and 84 of the Iowa Administrative
Code 441, as further clarified in all Iowa Medicaid Program Provider Handbooks
and Bulletins, or as otherwise specified in this Contract.
Following service
categories shall be covered under this Contract: ...
- Clinical
services...
- Ambulance...
- Optometric
services
- Podiatric
services
- Other practitioners
The HMO may
provide services in addition to those identified above, as further defined
in Medicaid Provider Manuals. Any services proposed by the HMO shall
require approval of the Department and shall be subject to quality assurance
and utilization management guidelines as may be required by the Department...
The HMO shall provide or pay for medically appropriate second opinions, within the HMO's Provider network. If there is no alternate Provider within the HMO's network to provide the second opinions the HMO shall provide or pay for medically appropriate second opinions by a Non-Participating Provider." Iowa Contract, pages 17-19.
"4.2.2
Optional Services
The HMO may
elect to provide as Covered Services the following:
- Chiropractic
as outlined in 441 Iowa Administrative Code --78.8...
4.2.3
Services Not Covered Under This Contract
The following
services are not Covered Services:
- Medical Transportation
by common carrier or private motor vehicle as outlined in 441 Iowa Administrative
Code--78.13
- Services
by Nursing Facilities (SNF, ICF, ICF/MR) as outlined in 441 Iowa Administrative
Code Chapters 81 and 82
- Home and
Community Based Waiver Services as outlined in 441 Iowa Administrative
Code Chapter 83
- Services
in Psychiatric Institutions as outlined in 441 Iowa Administrative Code
Chapter 85
- Services
by Area Educational Agencies as outlined in 441 Iowa Administrative Code
-- 78.32
- Rehabilitative
Treatment Services as outlined in 441 Iowa Administrative Code--78.42
- Family Preservation
- Family Foster
Care
- Family Centered
- Group Care."
Iowa Contract, page 23.
"B. MEDICAL
SERVICES NOT INCLUDED IN THE CONTRACT
The following
services are non-covered under the terms of this contract, but are covered
under Fee-For-Service in the Medicaid Program: ...
• Long
Term Care Services…
• State
Institution Services…
• Community
Developmental Disability Organizations (CDDOs)
• Inpatient
hospital costs of heart, liver and bone marrow transplants
• School-based
and Early Intervention Services ordered through an Individual Education
Plan (IEP) or Independent Family Services Plan (IFSP) (Local Education
Agencies (LEAs), Head Start Facilities, Part H of The Individuals With
Disabilities Education Act)...
C. MEDICAL
SERVICES INCLUDED IN THE CONTRACT...
The following
services and scope of these services as described in each specific Medicaid
Provider Manual are reflective of current SRS Fee-For-Service limitations
and must be covered, at a minimum, under the terms of this contract: ...
o
Physical therapy services when restorative for each injury or acute episode
for a maximum of six months from the date of the first therapy...
o
Occupational therapy services when restorative for each injury or acute
episode for a maximum of six months from the date of the first therapy….
o
Speech therapy services when restorative for each injury or acute episode
for a maximum of six months from the date of the first therapy…
o
Life sustaining therapies (such as chemotherapy, radiation, inhalation
therapy or renal dialysis) as ordered by a qualified health plan provider...
o
Blood transfusions...
• Medical
Transportation...
o
Emergency ambulance transportation.
o
Non-emergency ambulance services from the member's home to the nearest
medical facility, or transportation from one facility to another if the
first facility is inadequate for treatment.
o
Non-ambulance transportation to all medical services for KAN Be Healthy
Program Participants and pregnant women; 24-hour access to this service
is not required.
o
Non-ambulance transportation for Non-KAN Be Healthy members shall be available
to ensure access; 24-hour access to this service is not required for non-emergent
situations.
• Audiology
and hearing services...
• One
chiropractic history and physical per calendar year for KAN Be Healthy
participants...
• Vision
Services...
• Hospice
services when ordered by a qualified health plan provider...
• Podiatric
services...
• Newborn
Services - One home visit per member within 28 days after the birth date
of the newborn...
• Dietary
services as medically necessary.
• Kidney
and corneal transplants…" Kansas Contract, page 3-9.
"J. SERVICES
FOR SPECIAL DISORDERS
Treatment services
for chronic renal disease, also referred to as 'endstage renal disease'
(ESRD), meaning the stage of renal impairment that appears to be irreversible
and permanent, and requires a regular course of dialysis or kidney transplantation
to maintain life, must be covered by the HMO...
If the member is eligible for Medicare, the HMO shall provide renal dialysis before Medicare eligibility begins. If the member is ineligible for Medicare (example: not having worked enough quarters under Social Security), the HMO will provide for renal dialysis until such time as the member may become Medicare eligible." Kansas Contract, pages 12-13.
"O. LIMITATION
ON COVERAGE: Contract Section IIB, Medical Services Not Included
In The Contract, shall be amended by adding the following language.
MCO shall not
cover or fund the following:
1. Organ
transplant unless the State plan has written standards meeting coverage
guidelines specified...
4. Any
activities/services in violation of the Assisted Suicide Funding Restriction
Act of 1997." Kansas Contract, Amendment One.
"D. Services
to Be Provided.
1. Covered
Services
The
Contractor shall provide Covered Services in accordance with Section 7.9.1
and Attachment VIII of the RFA...
8. Outreach
to Homeless
The
Contractor shall implement and maintain outreach to the homeless as specified
in Section 7.9.E of the RFA.
9. Advance
Medical Directives
The
Contractor shall comply with requirements regarding Advance Directives
as specified in Section 7.9.8 of the RFA.
10. Referrals
for Noncovered Services
The
Contractor shall refer Members for Noncovered Services in accordance with
Section 7.9.10 of the RFA." Kentucky Contract, pages 21-22.
"The Managed Care Organization (MCO) under the BBA is required to coordinate post-stabilization care established under Medicare Part C (Medicare + Choice)…It is the responsibility of the Partnership to make the necessary arrangements for the provision of this care and it is responsible under these conditions to make payment for these post-stabilization services.
Post-stabilization services are services subsequent to an emergency that a treating physician views as medically necessary AFTER an emergency medical condition has been stabilized. They are NOT 'emergency services', which MCOs are obligated to cover in-or-out of plan according to the 'prudent layperson' standard. Rather, they are NON-emergency services that the MCO could choose NOT to cover out-of-plan EXCEPT in the circumstances described above." Kentucky RFA, page 69.
"Covered Services
Alternative
Birthing Center Services
Ambulatory
Surgical Center Services
Behavioral
Health Visits (Provided by the Assigned Primary Care Provider)...
End Stage Renal
Dialysis Services
Family Planning
Clinic Services in accordance with federal and state law and judicial opinion
Hearing Services,
including Hearing Aids for Members Under age 21...
Hospice Services...
Meals and Lodging
for Appropriate Escort of Members
Medical Detoxification
as defined in 907 KAR 1:705...
Organ Transplant
Services not considered Investigational by FDA...
Podiatry Services...
Therapeutic
Evaluation and Treatment, including Physical Therapy, Speech Therapy, Occupational
Therapy
Transportation
to Covered Services, including Emergency and Non emergency Ambulance and
other Transportation Services
Urgent and
Emergency Care Services
Vision Care,
including Vision Examinations, Services of Opticians, Optometrists and
Ophthalmologists, including eyeglasses for Members Under age 21."
Kentucky RFA, Attachment VIII, page 57.
"The Partnership shall provide any Covered Services ordered to be provided to a Member by a Court, to the extent not in conflict with federal laws…The Partnership shall additionally cover forensic pediatric and adult sexual abuse examinations performed by health care professional(s) credentialed to perform such examinations and any physical and sexual abuse examination(s) for any Member when the Department for Community Based Services is conducting an investigation and determines that the examination(s) is necessary." Kentucky RFA, Attachment VIII, page 58.
"B. COVERED
SERVICES...
Covered Services:
...
• Ambulance
Services (defined as Ambulance Services in the MMAM, Chapter II, Section
5)...
• Podiatry
Services...
• Therapy Services
Physical
Occupational
Speech/Language
Audiology
• Hearing Services...
• Early Intervention
Services
• Developmental
and Behavioral Clinic Services
• Nursing Facility
Services - limited to 30 calendar days per year of skilled nursing facility
care
• Ambulatory
Care Clinics...
• Private Duty
Nursing and Personal Care Services...
• Prenatal
Care
• Vision Care
- annual eye examinations may be self referred..." Maine Contract,
pages 20-21.
"9. Vision Care. The Contractor must submit requests for eyeglasses to the Department's vision care volume purchase contractor." Maine Contract, page 25.
"Dear State
Medicaid Director: ...
Each MCO must
cover the following services without requiring authorization, and regardless
of whether the enrollee obtains the services within or outside the MCO:
Post-stabilization care services that were preapproved by the entity; or were not preapproved by the entity because the entity did not respond to the provider of post-stabilization care services' request for pre-approval within 1 hour after being requested to approve such care, or could not be contacted for pre-approval.
Post-stabilization services are services subsequent to an emergency that a treating physician views as medically necessary AFTER an emergency medical condition has been stabilized. They are NOT 'emergency services', which MCOs are obligated to cover in-or-out of plan according to the 'prudent layperson' standard. Rather, they are NON-emergency services that the MCO could choose NOT to cover out-of-plan EXCEPT in the circumstances described above. The intent of the regulation is to promote efficient and timely coordination of appropriate care of a managed care enrollee after the enrollee's condition has been determined to be stable." Maryland Contract, HCFA Letter, 8/5/98.
"Chapter 62
Maryland Medicaid Managed Care Program: Definitions
.01 Definitions...
B. Terms
Defined...
(4) 'Adult
day care' means, in the context of COMAR 10.09.69, services furnished 4
or more hours per day on a regularly scheduled basis, for 1 or more days
per week, in an outpatient setting, and includes:
(a) Health
and social services needed to ensure the optimal functioning of the client;
(b) Meals,
but not constituting a full nutritional regimen of three meals per day;
and
(c) Physical,
occupational, and speech therapies indicated in the recipients' plans of
care...
(9) 'Ancillary services' means diagnostic and somatic therapeutic services, including but not limited to radiology, laboratory services, cardiac diagnostics, neurology diagnostics, occupational therapy, physical therapy, durable medical equipment, disposable medical supplies, audiology, speech therapy, and cardiac rehabilitation therapy...
(28) 'Community supported living arrangement-type services (CSLA)' means, in the context of COMAR 10.09.69, on or more of the following services which are intended to assist eligible individuals, regardless of the nature or severity of their disability, to live independently and successfully in the community...
(29) 'Companion services' means, in the context of COMAR 10.09.69, nonmedical care, supervision, and socialization provided to a functionally impaired adult...
(30) 'Convalescent care' means, in the context of COMAR 10.09.69, services provided to an individual who requires bed rest and assistance with the activities of everyday living...
(35) 'Day habilitation' means, in the context of COMAR 10.09.69, assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills which takes place in a non-residential setting, separate from the home or facility in which the recipient resides…
(75) 'In-home infusion therapy' means, in the context of COMAR 10.09.69, the administration of fluids and medication intravenously or subcutaneously and includes the use of appropriate medications, supplies, equipment, and professional health care services.
(76) 'In home parenteral therapy' means, in the context of COMAR 10.09.69, the administration of nutrients intravenously, and includes the use of appropriate formulae, supplies, equipment, and professional health care services.
(77) 'Initial health screen' means the comprehensive evaluation performed by the PCP, that includes a comprehensive history and physical examination to determine the new enrollee's baseline health status and health needs." Maryland COMAR 10.09.62.01.
"10.09.64.07...
.07 Access
and Capacity: Contracts and Provider Applications.
An MCO applicant
shall include in its application the following information or descriptions:
...
E. Written
evidence of the applicant's organizational capacity to provide special
programs adequate to meet the individual needs of all enrollees, including:
(1) Outreach...
(3) Home
visiting...
(5) Prevention
and wellness education…" Maryland COMAR 10.09.64.07.
"10.09.65.04...
.04 Special
Needs Populations.
A. An
MCO shall provide health care services to enrollees who are members of
special needs populations.
B. Special
needs populations consist of the following non-mutually exclusive populations:
(1) Children
with special health care needs;
(2) Individuals
with a physical disability;
(3) Individuals
with a developmental disability;
(4) Pregnant
and postpartum women;
(5) Individuals
who are homeless;
(6) Individuals
with HIV/AIDS; and
(7) Individuals
with a need for substance abuse treatment." Maryland COMAR 10.09.65.04.
"10.09.67.09...
.09 Benefits-Transplants
An MCO shall
provide to its enrollees medically necessary and appropriate transplants."
Maryland COMAR 10.09.67.09.
"10.09.67.12...
.12 Benefits-Nursing
Facility Services.
A. An
MCO shall provide to its enrollees medically necessary and appropriate
nursing facility services for:
(1) The
first 30 continuous days following the enrollee's admission; and
(2) Any
days following the first 30 continuous days of an admission until the date
the MCO has obtained the Department's determination that the admission
is medically necessary and appropriate as specified in §B of this
regulation...
.14 Benefits-Vision
Care Services.
A. An
MCO shall provide to its enrollees medically necessary and appropriate
vision care services as specified in this regulation.
B. For enrollees who are 21 years old or older, the MCO is responsible for providing at least one eye examination every 2 years.
C. For
its enrollees who are younger than 21 years old, the MCO is responsible
for providing medically necessary and appropriate vision services, including
but not limited to:
(1) At
least one eye examination every year in addition to any vision screen performed
as part of an EPSDT screen;
(2) Eyeglasses,
limited to one pair per year unless lost, stolen, broken, or no longer
vision appropriate; and
(3) Contact
lenses, if medically necessary and appropriate and if eyeglasses are not
medically appropriate for the condition.
.15 Benefits-Podiatry
Services.
An MCO shall
provide to its enrollees medically necessary and appropriate outpatient
rehabilitative services, including but not limited to physical therapy,
occupational therapy, and speech therapy...
.18 Benefits-Dialysis
Services.
An MCO shall
provide to its enrollees medically necessary and appropriate dialysis services."
Maryland COMAR 10.09.67.12-.18.
"10.09.67.23...
.23 Benefits-Hospice
Care Services.
An MCO shall
include in its benefits package medically necessary and appropriate hospice
care services to enrollees who are terminally ill, when appropriately requested
by the enrollee.
.24 Benefits-Diabetes
Care Services.
A. An
MCO shall provide to its qualifying enrollees medically necessary and appropriate
diabetes care services as specified in this regulation...
.25 Benefits-Blood
and Blood Products.
An MCO shall
provide to its enrollees medically necessary and appropriate blood, blood
products, derivatives, components, biologics, and serums to include autologous
services, whole blood, red blood cells, platelets, plasma, immunoglobulin,
and albumin...
.27 Benefits-Limitations.
A. An
MCO is not required to provide any of the benefits or services listed in
§B of this regulation.
B. The
benefits or services not required to be provided under §A of this
regulation are as follows:
(1) Experimental
or investigational services, including organ transplants determined by
Medicare to be experimental...
(6) Long-term
care services;
(7) ICF-MR
services;
(8) Personal
care services;
(9) Medical
day care services, for either adults or children;
(10)
Transportation services provided through grants to local governments pursuant
to COMAR 10.09.19, other than:
(a) Assisting
enrollees to access nonemergency transportation services through their
local transportation grantee agency; and
(b) Nonemergency
transportation to access a covered service if the MCO chooses to provide
the service at a location that is outside of the closest county in which
the service is available...
(13) Autopsies...
(15)
Services received while the enrollee is outside of the United States...
(17)
Diet and exercise programs for the loss of weight except when medically
necessary and appropriate...
(21)
Surgery or related services for cosmetic purposes to improve appearance,
but not to restore bodily function or correct deformity resulting from
disease, trauma, or congenital or developmental anomalies;
(22)
Lifestyle improvements, including smoking cessation, nutrition counseling,
or physical fitness programs, unless specifically included as a covered
service;
(23)
Nonmedical ancillary services such as vocational rehabilitation, employment
counseling, or educational therapy;
(24)
Private hospital room, unless medically necessary;
(25)
Private duty nursing for adults 21 years old or older...
(28)
Orthodontic care except when:
(a) The
enrollee is younger than 21 years old;
(b) The
case scores at least 15 points on the Handicapping Labio-Lingual Deviations
index No. 4; and
(c) The
condition causes dysfunction...
(30) Piped-in
oxygen or oxygen prescribed for standby purposes or on an as-needed basis;
(31)
Arch supports, orthotic devices, in-shoe supports, orthopedic shoes, elastic
supports, or examinations for their prescription or fitting, except when
the enrollee qualifies for diabetes care services under Regulation .24
of this chapter or is younger than 21 years old.
(32)
Routine foot care, except for visits for continued or chronic podiatric
care for enrollees who are diabetic or who have a vascular disease affecting
the lower extremities or are younger than 21 years old…" Maryland
COMAR 10.09.67.25-.27.
"10.09.69.06…
.08 Covered
Services-Nutritional Supplements.
Covered services
include nutritional supplements or enteral feeding when medically indicated,
other than those administered by tube.
.09 Covered
Waiver Services-Assisted Living Services…
B. These
services are rendered by a qualified individual as indicated below:
(1) Chore
services...
(2) Nutritional
counseling for adults, including family education, which is provided by
a licensed nutritionist, dietician, or registered nurse;
(3) Private
duty nursing for adults; and
(4) Home
health aide services: ...
.10 Covered
Waiver Services-Community Support...
B. The
following services are covered:
(1) Convalescent
care which is provided in an appropriate home or community-based setting…
if the following conditions are met: ...
(2) Respite
care services, as approved by the Department, that are provided by a licensed
nursing home or intermediate care facility, licensed home care agency,
licensed hospice agency, or licensed community program;
(3) Services
for medically complex patients in nursing facilities which include but
are not limited to intensive suctioning and intensive therapy;
(4) CARF-accredited
community rehabilitation program that includes residential and support
services for individuals with traumatic brain injury.
.11 Covered
Waiver Services-Assistive Equipment...
B. The
following services are covered:
(1) Emergency
call system or electronic device; and
(2) Specialized
medical equipment and supplies not covered under COMAR 10.09.12.
.12 Covered
Waiver Services-Environmental Modifications...
B. Environmental
Accessibility Modification.
(1) Adaptations
or improvements to the home are covered:
(a) If
of direct medical or remedial benefit to the waiver client; and
(b) If
provided in accordance with applicable State or local building codes.
(2) Covered
adaptations or improvements to the home may include:
(a) Installation
of ramps and grab bars;
(b) Widening
of doorways;
(c) Modification
of bathroom facilities; and
(d) Installation
of specialized electric and plumbing systems that are necessary to accommodate
the medical equipment and supplies that are necessary for the welfare of
the participant...
.13
Covered Waiver Services-Transportation.
B. Transportation
services not covered under COMAR 10.09.19 are covered if necessary in order
to enable participants to gain access to waiver and other community services
and resources required by the plan of care." Maryland COMAR 10.09.69.06-.13.
"10.09.67
Maryland Medicaid Managed Care Program: Benefits
.27 Benefits-Limitations...
B. The
benefits or services not required to be provided under §A of this
regulation are as follows: ...
(39)
Physical therapy, speech therapy, occupational therapy, and audiology services
when:
(a) The
enrollee is younger than 21 years old; and
(b) The
services are not part of an inpatient hospital stay." Maryland COMAR
10.09.67.27, Proposed Regulation.
"APPENDIX C:
MCO COVERED SERVICES
Exhibit 1:
MCO Covered Services for MassHealth Standard Enrollees...
Ambulatory Surgery -- all outpatient surgical, and related diagnostic and medical, services.
Audiologist -- audiologist exams and evaluations. See related hearing aid services...
Chiropractic Services -- Effective January 1, 1999, the Contractor is responsible for providing chiropractic manipulative treatment, office visits, and radiology services. The Contractor may establish a per Enrollee per Contract Year service limit of 20 office visits or chiropractic manipulative treatments, or any combination of office visits and chiropractic manipulative treatments...
Hospice -- a package of services such as nursing; medical social services; physician; counseling, including bereavement, dietary, spiritual, or other types of counseling; physical, occupational, and speech language therapy; homemaker/home health aid service; medical supplies, drugs, biological supplies; and short term inpatient care services.
Institutional Care -- services provided at either a nursing facility, chronic or rehabilitation hospital, or any combination thereof, up to 100 days per Contract Year per Enrollee...
Orthotics -- braces (non dental) and other mechanical or molded devices to support or correct any defect or form or unction of the human body.
Oxygen and Respiratory Therapy Equipment -- ambulatory liquid oxygen systems and refills; aspirators; compressor-driven nebulizers; intermittent positive pressure breather (IPPB); oxygen; oxygen gas; oxygen-generating devices; and oxygen therapy equipment rental...
Podiatry - Effective January 1, 1999, the Contractor is responsible for providing services necessary for the life and safety of the enrollee as certified by a physician, including medical, radiological, surgical, and laboratory care.
Prosthetic Services and Devices -- evaluation, fabrication, fitting, and the provision of a prosthesis...
Therapy -- individual treatment, (including the design, fabrication, fitting of an orthotic, prosthetic, or other assertive technology device); comprehensive evaluation; and group therapy...
Transportation (emergent) -- ambulance (air and land) transport that generally is not scheduled, but is needed on an emergency basis.
Vision Care (medical component) -- eye examinations at a minimum of (a) once per 12 month period for Enrollees under the age of 21 and (b) once per 24 month period for Enrollees 21 and over, and, for all Enrollees, whenever medically necessary; and vision training...
Exhibit 3:
Standard Non-MCO Covered Services
(non-capitated
services)
The Contractor need not provide but shall coordinate for each Enrollee the delivery of all MassHealth services… for which such Enrollee is eligible… but which are not currently MCO Covered Services.
The following list includes non-MCO covered services, chiropractic, hearing aids, and podiatry, that will become MCO covered services effective January 1, 1999. Other non-MCO Covered Services may become MCO covered services in future Contract Years of the Contract (e.g., Private Duty Nursing, Personal Care Attendant). Until such time that such services become MCO covered services, the Contractor shall coordinate said services for each Enrollee, including providing a referral where necessary.
Administrative
Day...
Adult Day Health...
Adult Foster
Care/Adult Group Care...
Chiropractic
Services...
Day Habilitation...
Hearing Aids...
Institutional
Care...
Personal Care
Attendant...
Podiatry...
Private Duty
Nursing...
Transportation
(non-emergent)...
Vision Care
(non-medical component)...
Exhibit 4:
MCO Covered Services for MassHealth Basic Enrollees...
Ambulatory
Surgery...
Audiology...
Chiropractic
Services...
Dialysis...
Hearing Aids...
Orthotics...
Oxygen and
Respiratory Therapy Equipment...
Podiatry...
Prosthetic
Services and Devices...
Therapy...
Transportation
(emergent)...
Vision Care
(medical component)...
Exhibit 5:
Basic Non-MCO Covered Services
(non-capitated
services)...
Administrative
Day...
Behavioral
Health Services...
Chiropractic
Services...
Hearing Aids...
Podiatry...
Vision Care
(non-medical component)...
Exhibit 6: MassHealth Excluded Services
Except as otherwise
noted, the following services are not covered under MassHealth and as such
are not required to be provided or coordinated by the Contractor.
1. Cosmetic
surgery, except as determined by the Contractor to be necessary for:
- correction
or repair of damage following an injury or illness which occurred while
an enrollee of the Contractor's Plan;
- mammoplasty
following a mastectomy which took place while an enrollee in the Contractor'
plan;
- repair of
congenital deformity; or
- any other
medical necessity as determined by the Contractor...
3. Experimental
treatment...
Exhibit 7:
Additional MCO Covered Services for Special Populations...
Adult Day Health...
Adult Foster
Care/Adult Group Care...
Private Duty
Nursing...
Exhibit 8:
MCO Covered Services for MassHealth Family Assistance Enrollees...
Ambulatory
Surgery...
Audiologist...
Chiropractic
Services...
Dialysis...
Hearing Aids...
Hospice...
Institutional
Care...
Orthotics...
Oxygen and
Respiratory Therapy Equipment...
Podiatry...
Prosthetic
Services and Devices...
Therapy...
Transportation
(emergent)...
Vision Care
(medical component)...
Exhibit 9:
Family Assistance Non-MCO Covered Services
(non-capitated
services)...
Administrative
Day...
Chiropractic
Services...
Hearing Aids...
Institutional
Care...
Podiatry...
Vision Care
(non-medical component)…" Massachusetts Contract, Appendix C, pages
1-26.
"II-H
SCOPE OF COMPREHENSIVE BENEFIT PACKAGE
1. Services
Included...
The services
provided to Enrollees under this Contract include, but are not limited
to. The following: …
*Chiropractic
services
*Podiatry services...
*Transplant
services...
*Prosthetics
& orthotics...
*Hospice service
(if requested by the Enrollee)
*Transportation
*Ambulance and other emergency medical transportation
*Vision services
*Hearing &
speech services, including hearing aids
*Therapies,
(speech, language, physical, occupational)...
*Health education...
*Intermittent
or short-term restorative or rehabilitative nursing care (in or out of
a facility)...
*End Stage
Renal Disease services...
*Out-of-state
services authorized by the Contractor…" Michigan Contract, pages
20-21.
"II-I Special
Coverage Provision...
11. Transportation
The Contractor
must ensure transportation and travel expenses determined to be necessary
for Enrollees to secure medically necessary medical examinations and treatment...
12. Transplant
Services
The Contractor
agrees to cover all costs associated with transplant surgery and care Related
care may include but is not limited to organ procurement, donor searching
and typing, harvesting or organs, related donor medical costs. Cornea
and kidney transplants and related procedures are covered services.
External organ transplants (heart, lung, heart-lung, liver, pancreas, bone
marrow including allegoric, autologous and peripheral stem cell harvesting,
and small bowel) must be covered on a patient-specific basis when determining
medically necessary according to currently accepted standards of care..."
Michigan Contract, pages 22, 28.
"Section 4.7.
Skilled Nursing Facility/Nursing Facility Liability.
Section 4.7.1.
90-Day SNFINNF Liability Period.
A. Beginning July 1, 1999, for any Recipient who is over the age of 65, is non-institutionalized and who enrolls in the HEALTH PLAN's MA product while in a community setting, the HEALTH PLAN shall have financial responsibility for Nursing Facility services for 90 days…" Minnesota Contract, page 42.
"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 6.1.4. Chiropractic Services.
Section 6.1.5. Clinic Services...
Section 6.1.9. Hospice Services. Services provided by a Medicare certified hospice agency or, when a Medicare certified hospice agency is not available, services that are equivalent to those provided in a Medicare certified hospice agency...
Section 6.1.18. Nursing Facility Services. Beginning July 1, 1999, the HEALTH PLAN shall provide Nursing Facility services for those MA Enrollees age 65 and over who are not residing in a Nursing Facility at the time of enrollment into PMAP...
Section 6.1.21. Personal Care Attendant (PCA) Services...
Section 6.1.23. Podiatric Services...
Section 6.1.26. Public Health Services. Public health clinic services and public health nursing clinic services as they are described in Chapter 8 of the Provider Manual which is incorporated herein by reference...
Section 6.1.27. Rehabilitation and Therapeutic Services...
Section 6.1.28. Transplants...
Section 6.1.31. Vision Care Services. Vision care services includes vision examinations, eyeglasses, and optician, optometrist, and opthalmologist services..." Minnesota Contract, pages 48-49, 51, 53, 57-59.
"Section 6.2. GAMC Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to 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 6.2.3. Chiropractic Services...
Section 6.2.8. Interpreter Services, as specified in Section 6.1.11...
Section 6.2.12. Medical Transportation services, as specified in Section 6.1.15, except that 6.1.15.B is covered only for Enrollees who reside in an IMD...
Section 6.2.17. Public Health Nursing Clinic Services. Services of a certified public health nurse or a registered nurse practicing in a Public Health Nursing Clinic as they are described in Chapter 8 of the Provider Manual which is incorporated herein by reference.
Section 6.2.18. Rehabilitative Services by a Medicare-certified agency.
Section 6.2.19. Vision Care Services, specified in Section 6.1.31." Minnesota Contract, pages 59-60.
"Section 6.3.2.
MinnesotaCare Enrollees. The HEALTH PLAN shall provide, or arrange to have
provided to MinnesotaCare Enrollees the same services described in Section
6.1. above with the following modifications...
F. Non-emergency
medical transportation is not covered.
G. Nursing
Facility services are not covered." Minnesota Contract, page 61.
"Section 6.4. Alternative Services Permitted. To the extent consistent with Minnesota Statutes, Chapter 256B and Sections 256L.03, et seq., and 256D.03, Subdivision 4(b), the HEALTH PLAN shall have the right, in its discretion, to pay for or provide alternative health services if such services are, in the judgement of the HEALTH PLAN, medically appropriate and cost-effective; provided, however, that it is understood that the provision of any such services shall not affect the calculation of capitation rates pursuant to Article 4.
Section 6.5. Additional Services Permitted. The HEALTH PLAN may provide or arrange to have provided services in addition to the services described in Article 6, Sections 6.1., 6.2., and 6.3., as permitted through waivers granted by the U.S. Department of Health and Human Services-Health Care Financing Administration under Title XI, Section 1115 of the Social Security Act, for Enrollees… provided, however, that it is understood that the provision of any such services shall not affect the calculation of capitation rates pursuant to Article 4." Minnesota Contract, pages 61-62.
"Section 6.11. Services Not Covered By This Contract. Although the HEALTH PLAN may provide the following services, the prepaid capitation rate does not include payment for the following services, and therefore the HEALTH PLAN is not required to provide them...
Section 6.11.2. Cosmetic Procedures or Treatment. Cosmetic procedures or treatment are not covered, except that the following services are not considered cosmetic and therefore must be covered: services necessary as the result of injury, illness or disease, or for the treatment or repair of birth anomalies.
Section 6.11.3. Incidental Services. Incidental services are not covered, including but not limited to rental of television or telephone, barber and beauty services, and guest services that are not Medically Necessary...
Section 6.11.5. Waivered Services. Waivered services provided under home-based and community-based waivers authorized under 42 U.S.C., Section 1396 are not covered, except as provided in Section 6.1.8...
Section 6.11.7. Gender Reassignment Surgery. Gender reassignment surgery and other gender reassignment medical procedures including drug therapy are not covered unless the Enrollee began receiving such services prior to July 1, 1998...
Section 6.11.8. Other. All other exclusions set forth in Minnesota Statutes, Section 25613.0625, Minnesota Statutes, Section 256B.69, Minnesota Rules, Part 9505.0170 to 9505.0475, and Minnesota Rules, Part 9500.1450 to 9500.1464 are not covered." Minnesota Contract, pages 65-66.
"Section 6.15.10. Children and Adolescents. Including Severely and Emotionally Disturbed (SED) Children and Children Involved in the Child Protection System: service specific to the needs of these groups, including day treatment, home-based mental health services, and inpatient services. The services which the HEALTH PLAN delivers must be provided in the least restrictive clinical setting, individualized to meet the specific needs of each child, and designed to provide early identification and treatment of mental illness. The HEALTH PLAN must coordinate services with the child's county case manager(s)." Minnesota Contract, page 67.
"Services for adults in expanded eligibility of groups will include a package of benefits equivalent to that offered State of Missouri employees." Missouri RFP, page 6.
"b. Covered
Services
Children will
receive the MC+ Medicaid package of medically necessary health services.
Non-emergent medical transportation will not be a covered service."
Missouri RFP, page 7.
"b. Covered
Services...
3) Emergency
room services
4) Ambulatory
surgical center, birthing center" Missouri RFP, page 8.
"b. Covered
Services...
11) Preventative
care...
13) Hearing
aids and related services
14) Eye
exams and services to treat trauma or disease (one pair of glasses after
cataract surgery only)...
16) Emergent
(ground or air) transportation...
18) Services
of other providers when referred by the health plan's primary care provider.
19) Hospice
services...
21) Diabetic
supplies, equipment and self management training for persons with gestational,
Type I or Type II diabetes…" Missouri RFP, page 9.
"c. The health plan is not obligated to provide or pay for any non-plan, non-capitated services. However, it must agree to establish processes to coordinate in-plan service delivery with service delivered outside of the health plan to the same degree and specifications as for the other populations covered by the contract.
The major types
of out-of-plan services with which it must coordinate are described below:
...
2) Organ
and bone marrow transplant services are not included in the capitated benefit
package. Any services for pre-transplant and post-transplant care
are the responsibility of the health plan...
2.1.5
Services shall include: ...
d. Ambulatory
surgical center, birthing center…
m. Hearing
aids and related services
n. Optical
services...
p. Adult
day health care services
q. Personal
care services
r. Comprehensive
Say Rehabilitation (for certain persons with disabling impairments as the
result of a traumatic head injury)
s. Emergent
(ground and air) and non-emergent transportation...
u. Services
of other providers when referred by the health plan's primary care provider"
Missouri RFP, page 10.
"2.1.5
Services Shall Include...
v. Hospice
services...
x. Podiatry
y. Diabetic
supplies, equipment and self management training for persons with gestational,
Type I, or Type II diabetes." Missouri RFP, page 19.
"The comprehensive
benefit package includes: ...
d. Ambulatory
surgical center, birthing center...
k. Preventive
care...
m. Optical
services
n. Hearing
aids and related services...
p. Adult
day health care
q. Personal
care services
r. Comprehensive
Day Rehabilitation
s. Emergent
(ground or air) and non-emergent transportation
v. Hospice
services...
x. Podiatry
y. Diabetic
supplies, equipment and self management training for persons with gestational
Type I or Type II diabetes
z. Services
provided by local health agencies…" Missouri RFP, pages 48-49.
"2.6.3 Transportation: The health plan must provide emergency transportation for its embers. Non-emergency transportation must be provided to members who do not have the ability to provide their own transportation (such as their own vehicle, friends or relatives) to and from services covered by the contract.
2.6.4 Transplant Related services: Any inpatient, outpatient, physician and related support services including presurgery assessment/evaluation prior to date of the actual transplant surgery must be permitted and authorized by the health plan and are the financial responsibility of the health plan…" Missouri RFP, page 54.
"Second Opinion:
Members have
a right to second opinions, and health plans shall have policies and procedures
for rendering second opinions both in-plan and out-of-plan when requested
by a member…" Missouri RFP, page 66.
"Federally Qualified
Health Centers/Rural Health Clinics
Category of
Service
Covered Services...
Pneumococcal
vaccine and its administration and influenza vaccine and its administration
Physician assistant
services...
Clinical psychologist
services
Clinical social
work services
Services and
supplies incident to clinical psychologist and clinical social worker services
as would otherwise be covered if furnished by or incident to physician
services
Part-time or intermittent nursing care and related medical supplies to a homebound individual (in the case of those Federally Qualified Health Centers or Rural Health Clinics that are located in an area that has a shortage of home health agencies)…" Missouri RFP, Attachment Two.
"MANAGED CARE
POLICIES GOVERNING MC+ SERVICES
The following
are brief descriptions of the services included in the standard benefit
package ad the various programs and policies governing delivery of services
for MC+...
ADULT HEALTH
CARE BENEFITS...
AMBULATORY
SURGICAL CENTER SERVICES...
ANESTHESIA
SERVICES...
AUGUMENTATIVE
COMMUNICATION EVALUATIONS & DEVICES...
COMPREHENSIVE
DAY REHABILITATION...
DIABETIC SUPPLIES,
EQUIPMENT AND SELF MANAGEMENT TRAINING...
GENERIC DRUG
REIMBURSEMENT OVERRIDE POLICY...
HEARING AID...
HOSPICE...
HYSTERECTOMY
SERVICES...
MEDICAID CHILDREN
WITH SPECIAL HEALTH CARE NEEDS...
OPTICAL...
OPTIOCAL (HCY)...
PERSONAL CARE
AND ADVANCED PERSONAL CARE
PERSONAL CARE
AND ADVANCED PERSONAL CARE (HCY)...
PHYSICAL, OCCUPATIONAL
AND SPEECH THERAPY SERVICE (HCY)...
PHYSICIAN INJECTIONS...
PODIATRY SERVICES...
PRIVATE DUTY
NURSING (HCY)...
PSYCHOLOGY/COUNSELING...
SAFE/CARE EXAMS...
SECOND OPINION
SERVICES...
TRANSPLANTS...
TRANSPORTATION…"
Missouri RFP, Attachment Five.
"2.4.4 Coordination
with PROVIDERS of Non-COVERED SERVICES:
The CONTRACTOR
must follow established Medicaid procedures and provide referrals and assistance
in scheduling appointments to ENROLLEES in need of Medicaid covered services
outside of the scope of this contract as defined in Appendix 2, 2.5.2 of
Attachment 1. These services include transportation, vision care...which
are not COVERED SERVICES…
2.5 PROVISION
OF SERVICES
2.5.1 COVERED
SERVICES
HMO COVERED
SERVICE/ DESCRIPTION
Ambulance Service
(all persons)/ambulance and air transport; ARM 46.12.1201 & 1022...
County Public Health Clinics (all persons)/all Medicaid covered services are covered at publicly funded clinics that provide routine care; ARM 46.12.570 & 571…
Hospice Services (all persons)/nursing, social work and counseling; ARM 46.12.1819 & 1823q...
Mid-level Practitioner (all persons)/ physician assistant, nurse anesthetist, nurse practitioner, and nurse mid-wife services as allowed by State law; ARM 46.12.2010 & 2011
Occupational Therapy Services [outpatient] (all persons)/outpatient occupational therapy services ordered by a physician; ARM 46.12.545 & 546
Optometric/Ophthalmic Services (all persons)/medical conditions of the eye with one of the following ICD-9 codes: ...
Physical Therapy
Services [outpatient] (all persons)/outpatient physical therapy ordered
by a
physician;
Arm 46.12.545 & 546...
Podiatry Services/cutting or removing corns and calluses, trimming nails, applying skin creams, measuring and fitting foot and ankle devices, and lab services and supplies; ARM 46.12.520 & 521
Private Duty Nursing * children (see EPSDT) adults/ covered for adults only to assist with an inpatient stay requiring substantial nursing services; ARM 46.12.565 & 566...
Speech Therapy Services (all persons)/outpatient speech therapy ordered by a physician; ARM 46.12.530 & 531
Transplants
no experimental transplants are covered ARM 46.12.583 & 584
- Children
are covered for all medically necessary, non-experimental, transplants
- Adults are
limited to kidney,cornea, and bone marrow transplants for certain conditions
2.5.2 Non-Covered
Services:
HMO NON-COVERED
SERVICES/DESCRIPTION
Audiology
Services and Hearing Aids...
Diagnosis-Prevention-Screening-Rehabilitation/a
state plan amendment category which is not included in Montana Medicaid
state plan...
Eye
Exams and Eyeglasses/...
Freestanding
Dialysis Clinics and Home/...
Dialysis
Attendants/...
Indian
Health Service Clinic Services/...
Intermediate
Care Facility for the Mentally Retarded/...
Medical
and Surgical Services provided by a Dentist/...
Medical
Transportation/ by common carrier or private motor vehicle...
Nursing Home and Swing Bed Services and Home and Community Based Waiver Services/...
Optometric Services/ Except for the following ICD 9 codes: ...
Personal Care Attendant/..." Montana Contract, pages 46-47.
"4.1 Applicable
Definitions: The following definitions apply under this contract: ...
4.1.3 The term
'Basic Benefits Package,' means the following medical/surgical services,
representing a minimum benefits package, as defined in this contract and
471 Nebraska Administrative Code (NAC), that shall be provided by the plan
to clients enrolled in the NHC: ...
(i) Therapy
services, including physical therapy, occupational therapy, and speech
pathology and audiology. (See 471 NAC 17-000, 22-000 and 23-000)...
(k) Podiatry
services (See 471 NAC 19-000);
(l) Chiropractic
services (See 471 NAC 5-000);
(m) Ambulance
services (See 471 NAC 4-000);
(n) Medical
transportation services (See 471 NAC 27-000);
(o) Visual
services (See 471 NAC 24-000);
(u) Skilled/Rehabilitative
and Transitional Nursing Facility services (See 471 NAC 12-000, 13-000
and Section 9.20 of this contract);
(v) Transitional
Hospitalization services (See 471 NAC 10-000, Section 9.13, 9.17, 9.18,
and 9.19 of this contract); and
(w) Transitional
Transplantation services (See 471 NAC 10-000 and Section 9.18 of this contract)…"
Nebraska Contract, pages 6-7.
"4.1.19 The term 'Enrollment Broker Services (EBS)' means a contracted entity that is responsible for the following NHC functions: initial client marketing, education, and outreach; enrollment activities; health assessments; health services coordination; public health nursing: Helpline; client advocacy; and EBS satisfaction surveys." Nebraska Contract, page 9.
"9.20 Admission
to Nursing Facility Care
9.20.1 Nursing
Facility Admission-Skilled/Rehabilitative Level of Care:
Admission to
a nursing facility for skilled/rehabilitative care may affect the client’s
enrollment in NHC. The following rules apply:
(a) When a
NHC client is admitted to a nursing facility, the plan shall determine
the level of care the client requires skilled/rehabilitative or custodial/maintenance
- using Medicare’s definition for skilled care; and
(b) When the
level of care the client requires is skilled/rehabilitative, the client
shall not be disenrolled from NHC. The plan shall be responsible for the
client while in skilled level of care.
9.20.2 Nursing
Facility Admission-Custodial Level of Care: Admission to a nursing facility
for custodial care may affect the client’s enrollment in NHC. The following
rules apply:
(a) When the
client is admitted to a nursing facility for custodial care, the Department
shall assume financial responsibility for the facility charges. The plan
shall continue responsibility for all related services included in the
Basic Benefits Package until disenrollment of the client from NHC; and
(b) Disenrollment
from NHC shall occur the first month possible, given system cutoff, or
first of the month the Department and the plan agree that the client’s
level of care is custodial, whichever is earlier.
9.20.3 Plan Responsibility for PCP Coverage: ...The plan shall make arrangements to ensure reimbursement of PCP services provided by the client’s nursing facility physician, for referrals, and for all services included in the Basic Benefits Package until the client is disenrolled from NHC, or effective with the first of the month the Department and plan agree that the client’s level of care is custodial, which is earlier.
9.20.4 Transportation Needs While in the Nursing Facility: Transportation services are included in the nursing facility’s per diem for most medical services." Nebraska Contract, page 46.
"11.1 Overview of Enrollment Broker Services: The EBS is a contracted entity that completes the following NHC functions: initial client marketing, education, and outreach; enrollment activities; health assessment; health services coordination; public health nursing; Helpline services; client advocacy; and EBS satisfaction surveys. The EBS is required by contract to develop protocols, plans, and procedures to implement these functions…" Nebraska Contract, page 60.
"11.4 Enrollment Outreach: The EBS shall be responsible for the activities and associated marketing, informational, and educational materials which precede selection or assignment of a client to a PCP/plan. Enrollment outreach activities include, but are not limited to, mailings, follow-up, and orientations, conducted by telephone or in person, as appropriate to meet the needs of the client...
11.5 Health Assessment: The Health Assessment is designed to establish the client’s basic health status and assist the EBS in identifying administrative enrollment, health and social issues...
11.6 Public Health Nursing (PHN): A major component of the NHC is Public Health Nursing (PHN). PHN shall provide a client-centered approach to achieve the maximum health status possible for each client enrolled in NHC and to ensure that the client experiences a seamless integrated health care delivery system that includes a variety of community resources known to affect health status outcomes...
11.7 Reasons for Referral: The EBS shall be responsible for promoting effective utilization of health resources to enable clients to better manage their own health care and to build community support systems by encouraging health, wellness, and a positive relationship with the PCP/plan...
11.8 PHN Outreach: When determined necessary, the EBS shall schedule visits with the client/family...
11.9 PHN Needs
Assessment: The EBS shall conduct an assessment of needs for each referral
which shall include, but is not limited to:
(a) Medical
conditions(s), illness and treatment history, current medications and treatment
plans, assessment of compliance with prescribed treatments, and family
medical histories;
(b) Previous
medical providers and hospitalizations, both for assessment purposes and
to ensure that appropriate records and information are transferred to a
new provider and that proper client authorization for the transfer is obtained;
(c) The specific
community and/or public services with which the client had existing or
recent relationships; the existence of case manager(s) and/or recent relationships;
and/or service case workers;
(d) A detailed
family/individual assessment of medical, supportive, social needs, and
behaviors which place the client at risk for disease, injury, or other
barriers to health care, employment, or daily living requirements; and
(e) Provide
specific follow-up education and referral/service planning regarding the
specific issues, if any, which were raised by the PCP/plan at the time
of the referral to the EBS." Nebraska Contract, pages 63-65.
"13.45 Services
in the Basic Benefits Package: Pursuant to this contract, services included
in the Basic Benefits Package are...
(h) Private
duty nursing services (471 NAC 13-000);
(i) Therapy
services (physical therapy -471 NAC 17-000, occupational therapy-471 NAC
14-000, and speech pathology and audiology-471 NAC 23-000)...
(k) Podiatry
services (471 NAC 19-000);
(l) Chiropractic
services (471 NAC 5-000)...
(o) Visual
services (471 NAC 24-000)...
(u) Skilled/Rehabilitative
and Transitional Nursing Facility services (See 471 NAC 12-000 and 13-000,
and Section 9.20 of this contract)...
(x) Transitional
Transplantation services (See 471 NAC 10-000 and Section 9.18 of this contract)...
13.46 NHC Excluded
Services: The following Medicaid-coverable services are excluded from the
NHC Basic Benefits Package and are not the responsibility of the plan:
...
(b) Nursing
Facility Services - custodial level of care (See 471 NAC 12-000 and 9.20
of this contract);
(c) ICF/MR services
(See 471 NAC 31-000);
(d) Home and
community based waiver services (See Title 480 NAC);
(e) School-based
services covered under Medicaid in Public Schools (See 471 NAC 25-000)…
(j) Non-Home
Health Agency Approved Personal Care Aide Services (471 NAC
15-000)."
Nebraska Contract, pages 94-96.
"CONTRACTOR
DUTIES AND RESPONSIBILITIES
I. Medical
Services
A. Contractor
Mandatory Managed Care Benefit Package. Except as otherwise provided
for in this contract, each Contractor must provide a comprehensive managed
care benefit package to Medicaid participants. No participant should
receive fewer services in the Mandatory managed care program than they
would receive in the current State Medicaid Plan except for excluded services
in paragraph C. Thus, a Medicaid eligible enrolled with the Contractor
may be entitled to a number of services which may not be included in the
Contractor's commercial benefit package.
Any new services
added or deleted from a Medicaid benefit package will be analyzed for inclusion
or exclusion in the Contractor benefit package.
B. Contractor
Covered Services. At a minimum, the Contractor must provide directly
or by subcontract all medical services listed below: ...
4.
Chiropractor;
5.
Disposable Medical Supplies...
8.
Emergency Transportation (air or ground ambulance);
9.
End Stage Renal Disease Facilities...
11.
Hearing Aid Dispenser and Related Supplies;
12.
Home Health Agency...
15.
Inpatient Medical Rehabilitation Center or Specialty Hospital;
16.
Intravenous Therapy (TPN);
18.
Medical Rehabilitation Center or Specialty Hospital...
20.
Nurse Anesthetist...
22.
Opticians/Optometrists; (includes eyeglasses per current Medicaid policy)
23.
Outpatient Surgery;
24.
Personal Care Aide (home care)...
27.
Physician Assistants;
28.
Podiatrist;
29.
Prosthetics...
32.
Skilled Nursing Facility, Intermediate Care Facility and Swing Beds; (Acute
Hospital) (first 45 days);
33.
Special Clinics;
34.
Therapy: Audiology;
/ Occupational;
/ Physical;
/ Respiratory;
/ Speech; and
35.
Transitional Rehabilitative Center.
C. Excluded
Services
1.
The Contractor is not required to cover the following services for Medicaid
participants
a) All Services Provided at Indian Health Service Facilities and
Tribal Clinics;
b) Non-emergency transportation;
c) Nursing facility stays over 45 days;
d) Swing bed stays in acute hospitals over 45 days;
e) School Based Services; and
f) Dental services (includes dentists, physicians, anesthesiologists,
facility costs and pharmacy related to a dental service)
2.
The Contractor is not required to cover the following services because
Medicaid recipients receiving these services are not eligible to enroll
in the Managed Care Program.
a) Adult Day Health Care;
b) Adult Group Care Waiver;
c) Home and Community Based Waiver services;
d) ICF/MR;
e) Physically Disabled Waiver;
f) Pre-admission Screening and Annual Resident Review (PAASARR);
g) Residential Treatment Centers;
h) Senior Waiver Services; and
i) Hospice.
The Contractor is required to notify DHCFP of any Medicaid participant receiving any services listed in this section." Nevada Contract, pages 21-22.
"Covered Services
I. Covered
Services - General
A. Outpatient
Services...
4.
Preventive medical care...
E. Ambulance
Service
F. Facility
Based Skilled Care Nursing...
H. Human
Organ Transplants...
J. Rehabilitation
Services
N. Care
Outside the Contractors Service Area." New Hampshire General Service
Agreement, Exhibit A.3, pages 3-4.
"ARTICLE 10
COVERED HEALTH
CARE SERVICES
10.1 For enrollees
who are Medicaid-eligible through Title XIX or the NJ KidCare Plan A program,
the contractor shall provide or shall arrange to have provided comprehensive,
preventive, diagnostic, rehabilitative, and therapeutic health care services
to enrollees that include all services that Medicaid recipients are entitled
to receive pursuant to Medicaid, subject to any limitations and/or excluded
services as specified in Appendix A of this contract. DMAHS shall assure
the continued availability and accessibility of Medicaid covered services
not covered under this contract. All services provided shall be in accordance
with the New Jersey State Plan for Medical Assistance, the New Jersey Medicaid
Managed Care Plan, and all applicable statutes, rules, and regulations.
10.1.1 For beneficiaries eligible solely through NJ KidCare Plan B and Plan C, the contractor shall provide the same managed care services and products provided to enrollees who are eligible through Title XIX. However, non-HMO covered services (i.e., services that continue to be provided fee-for-service) will be limited to certain services for the NJ KidCare Plan B and C populations as indicated in Appendix A.
10.1.2 For beneficiaries eligible solely through NJ KidCare Plan D, the contractor shall provide the managed care services and products as delineated in Appendix S. Non-HMO covered services (i.e., services that will be provided fee-for-service by the Division of Medical Assistance and Health Services) will be limited to the services delineated in Appendix S.
10.2 The contractor hereby agrees that no distinctions shall be made with regard to the provision of services to Medicaid enrollees and the provision of services provided to the contractor's other non-Medicaid members unless required by this contract.
10.3 The scope of services to which an enrollee is entitled from the contractor, while deemed eligible for enrollment in the contractor's plan, is those services included in the benefits package. The remaining services to which enrollees are entitled under the Medicaid program but are not included in the contractor's benefits package will continue to be covered by Medicaid under its fee-for-service program." New Jersey Contract, page 51.
"APPENDIX
A
BENEFITS PACKAGE-INCLUSIONS
AND EXCLUSIONS MEDICAID
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 equal in amount, duration, and scope
as established by the Medicaid program, in accordance with medical necessity
without any predetermined limits, unless specifically stated...
SERVICES INCLUDED
IN THE CONTRACTOR'S BENEFITS PACKAGE
The following
services must be provided and case managed by the contractor...
2.
Preventive health care and counseling and health promotion...
11.
Outpatient Rehabilitative Services - Physical Therapy, Occupational Therapy,
Speech-Language and Audiology Services--60 days per therapy per contract
year.
12.
Podiatrist services: Medicaid coverage of podiatry excludes routine
hygienic care of the feet, including the treatment of corns and calluses,
the trimming of nails, and other hygienic care such as cleaning or soaking
feet, in the absence of pathological condition.
13.
Chiropractor Services
14.
Optometrist Services
15.
Optical Appliances
16.
Hearing Aid Services...
18.
Hospice Services: Provided by an agency that meets Medicare certification
requirements...
20.
Medical Supplies
21.
Prosthetics and Orthotics
23.
Organ Transplants - including liver, lung, heart, heart-lung, kidney, cornea,
intestine, and bone marrow including autologous bone marrow transplants.
Donor and recipient inpatient hospital costs are excluded.
24.
Transportation Services including ambulance, medical intensive care units
(MICUs), and invalid coach…" New Jersey Contract, Appendix A, pages
166-168.
"INSTITUTIONAL
FEE-FOR-SERVICE BENEFITS
NO CASE MANAGEMENT
BY THE CONTRACTOR
The following
institutional services will remain in the fee-for-service program without
requiring case management by the contractor and are not covered for NJ
KidCare Plans B &C. Medicaid recipients participating in a waiver or
demonstration program or admitted for long term care treatment in one of
the following shall be disenrolled from the contractor's plan on the date
of admission to institutionalized care.
-
Nursing Facility care
-
Residential Treatment Center care
-
Psychiatric hospital
-
Intermediate Care Facility/Mental Retardation
-
Waiver and demonstration program services
EXCLUSIONS
All services
not medically necessary, provided, approved or arranged by a plan physician
except emergency services.
-
Cost of methadone and its administration are excluded. The contractor will
remain responsible for the medical care of members requiring substance
abuse treatment.
-
Cosmetic surgery except when medically necessary and approved.
-
Experimental organ transplants.
-
Elective/induced abortions are not covered under this contract, but will
continue to be paid on a fee-for-service (FFS) basis by the Medicaid program.
-
Family Planning services rendered by non-participating providers of the
contractor's network will be paid on a FFS basis by the Medicaid FFS program.
-
Infertility treatment services are not covered.
-
Rest cures, personal comfort and convenience items, services and supplies
not directly related to the care of the patient, including but not limited
to, guest meals and accommodations, telephone charges, travel expenses
other than those services not in Appendix A of this contract, take home
supplies and similar cost.
-
Services involving the use of equipment in facilities, the purchase, rental
or construction of which has not been approved by applicable laws of the
State of New Jersey and regulations issued pursuant thereof.
-
All claims arising directly from services provided by or in institutions
owned or operated by the federal government.
-
Services provided in an inpatient psychiatric institution, that is not
an acute care hospital, to individuals under 65 years of age and over 21
years of age... " New Jersey Contract, Appendix A, pages 170-171.
"APPENDIX R
COST-SHARING
REQUIREMENTS FOR NJ KIDCARE PLAN C BENEFICIARIES...
PERSONAL CONTRIBUTION TO CARE (PCC) FOR NJ KIDCARE - PLAN C...
SERVICE*****AMOUNT
OF PCC
4. Independent
Clinic Servics*****$5 PCC for each practitioner visit (except for preventive
care services); 5. Podiatrist Services*****$5 PCC for each visit;
6. Optometrist Services*****$5 PCC for each visit; 7. Chiropractor
Services*****$5 PCC for each visit..." New Jersey Contract, Appendix
R, pages 231-232.
“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…
SERVICES INCLUDED
IN THE CONTRACTOR'S BENEFITS PACKAGE
The following
services must be provided and case managed by the contractor: ...
5. Hospice Services...
10. Optometrist Services -- including one routine eye examination per year
11. Optical appliances -- limited to one pair of glasses (or contact lenses) per 24 month period or as medically necessary
12. Organ transplant services which are non-experimental or non-investigation, excluding inpatient hospital services, which are covered fee-for-service...
15. Podiatrist Services: Excludes routine hygienic care of the feet, including the treatment of corns and calluses, the trimming of nails, and other hygienic care such as cleaning or soaking feet, in the absence of a pathological condition.
16. Prosthetic appliances: Limited to the initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect. Repair and replacement services are covered when due to congenital growth.
17. Private duty nursing: Only when authorized by the contractor.
18. Outpatient Rehabilitation Services -- Physical therapy, Occupational therapy, and Speech therapy for non-chronic conditions and acute illnesses and injuries. Limited to treatment for a 60-day consecutive period per incident. of illness or injury beginning with the first day of treatment per contract year. Speech therapy services rendered for treatment of delays in speech development, unless resulting from disease, injury or congenital defects are not covered.
19. Transportation Services -- Limited to ambulance for medical emergency only
22. Diabetic supplies and equipment
SERVICES AVAILABLE TO NJ KIDCARE – PLAN D UNDER FEE-FOR SERVICE
1. Organ transplants -- Donor and beneficiary inpatient hospital services for organ transplants that are non-experimental or non- investigation.
2. Elective/induced abortion services
3. Skilled nursing facility services...
EXCLUSIONS
Services not
covered for NJ KidCare - Plan D participants include, but are not limited
to: ...
3. Private
duty nursing unless authorized by the HMO
3. Personal
Care Assistant Services
4. Medical
Day Care Services
5. Chiropractic
Services...
7. Orthotic
devices...
10. Christian
Science Santeria care and services...
13. Transportation
Services, including non-emergency ambulance, invalid coach, and lower mode
transportation
14. Hearing
Aid Services
15. Blood
and Blood Plasma, except administration of blood, processing of blood,
processing fees and fees related to autologous blood donations are covered.
16. Cosmetic
Services
17. Custodial
Care
18. Special
Remedial and Educational Services
19. Experimental
and Investigational Services
20. Medical
Supplies (except diabetic supplies)
23. Weight
reduction programs or dietary supplements, except surgical operations,
procedures or treatment of obesity when approved by the HMO
24. Acupuncture
and acupuncture therapy, except when performed as a form of anesthesia
in connection with covered surgery
25. Temporomandibular
joint disorder treatment, including treatment performed by prosthesis placed
directly in the teeth
26. Recreational
therapy
27. Orthotics
28. Sleep
therapy...
30. Thermograms
and thermography
31. Biofeedback
32. Radial
kerototomy." New Jersey Contract, Appendix S, pages 233-237.
“APPENDIX T
COST-SHARING
REQUIREMENTS FOR NJ KIDCARE PLAN D BENEFICIARIES...
COPAYMENTS FOR
NJ KID CARE - PLAN D…
Below is listed
the services requiring copayments and the amount of each copayment.
SERVICE*****AMOUNT
OF COPAYMENT
7. Podiatrist
Services*****$5 copayment for each visit
8. Optometrist
Services*****$5 copayment for each visit, except for newborns covered under
fee-for-service
9. Outpatient
Rehabilitation Services, $5 copayment for each visit including Physical
Therapy, Occupational Therapy, and Speech Therapy*****$5 copayment for
each visit…" New Jersey Contract, Appendix T, pages 238-239.
"2.D.2 Transplant
Services:
The benefit
package includes transplantation services. The following transplants
are covered in the benefit package: heart transplants, lung transplants,
heart-lung transplants, liver transplants, kidney transplants, autologous
bone marrow transplants, allogeneic bone marrow transplants and corneal
transplants, as detailed in medical Assistance Division Program manual
Section MAD-764, TRANSPLANT SERVICES. Section MAD-765, EXPERIMENTAL
OR INVESTIGATIONAL PROCEDURES, TECHNOLOGIES, OR NON-DRUG THERAPIES...
2.D.9 Anesthesia
Services:
The benefit
package includes anesthesia and monitoring services necessary for performance
or surgical or diagnostic procedures as set forth in Medical Assistance
Division Program Manual Section MAD-714, ANESTHESIA SERVICES.
2.D.10
Vision Services:
The benefit
package includes vision services as set forth in Medical Assistance Division
Program Manual Section MAD-715, VISION CARE SERVICES.
2.D.11
Audiology Services:
The benefit
package includes audiology services as set forth in medical Assistance
Division Program manual Section MAD-755, HEARING AIDS AND RELATED EVALUATION...
2.D.13
Dialysis Services:
The benefit
package includes medically necessary dialysis services as set forth in
Medical Assistance Division Program manual Section MAD-761, DIALYSIS SERVICES.
Dialysis providers shall assist members in applying for and pursuing final
Medicare eligibility determination...
2.D.18 Services
Provided in Schools:
The benefit
package includes services provided in schools excluding those specified
in the Individual Education Plan (IEP) or the Individualized Family Services
Plan (IFSP) as set forth in the Medical Assistance Division Program Manual
Section MAD-747, SCHOOL-BASED SERVICES FOR RECIPIENTS UNDER TWENTY-ONE
YEARS OF AGE.
2.D.19
Nutritional Services:
The benefit
package includes nutritional services furnished to pregnant women and children
as set forth in Medical Assistance Division Program manual Section MAD
758, NUTRITIONAL SERVICES...
2.D.20 Home
Health Services:
The MCO shall
coordinate Home Health and the Home and Community-Based Waiver programs
if a member is eligible for both Home Health and Waiver Services.
2.D.21 HOSPICE
SERVICES:
The benefit
package includes hospice services as set forth in Medical Assistance Division
Program Manual Section MAD-763, HOSPICE CARE SERVICES...
2.D.23
Rehabilitation Services:
The benefit
package includes inpatient and outpatient hospital and outpatient physical,
occupational, and speech therapy services as set forth in Medical Assistance
division Program manual Section MAD-767, REHABILITATION SERVICES and licensed
speech and language pathology services furnished under the EPSDT program
as set forth in medical Assistance division Program manual Section MAD-746.4,
LICENSED SPEECH AND LANGUAGE PATHOLOGISTS. The MCO shall coordinate
rehabilitation services and Home and Community-Based Waiver programs if
a member is eligible for rehabilitation services and Waiver Services.
2.D.26
Emergency and Non-Emergency Transportation Services
The benefit
package includes transportation service such as ground ambulance, air ambulance,
taxicab and/or handivan, commercial bus, commercial air, meal, and lodging
services as indicated for medically necessary physical and behavioral health
services as set forth in Medical Assistance division Program Manual Section
MAD-756, TRANSPORTATION SERVICES. Non-emergency transportation is
covered only when a member does not have a source of transportation available
and when the member does not have access to alternative free sources.
Pursuant to NMSA Section 65-2-97.F and State Corporation commission rule
221.07.A., and interpretations of these laws and rules by the State Corporation
commission, rates paid by the CONTRACTOR to transportation providers are
not subject to and are exempt from New Mexico State corporation commission
approved tariffs." New Mexico Contract, pages 36-42.
"2.D.32
Health Education and Preventive Care
The CONTRACTOR
shall provide a continuous program of health education without cost to
members. such a program may include publications(e.g., brochures,
newsletters), media (e.g., films, videotapes), presentations (seminars,
lunch-and-learn sessions) and classroom instruction.
2.D.32.a
The CONTRACTOR shall provide programs of wellness education. Additional
programs may be provided which address the social and physical consequences
of high-risk behaviors.
2.D.32.b
The CONTRACTOR shall make preventive services available to members.
The MCO shall periodically remind and encourage their members to use benefits
including physical examinations which are available and designed to prevent
illness (e.g. HIV counseling and testing for pregnant women)…
2.D.34
Experimental Technology
The CONTRACTOR
shall not deem a technology or its application experimental, investigational
or unproven and deny coverage unless that technology or its application
fulfills the definition of ‘experimental, investigational or unproven'
contained in the New Mexico Medical Assistance Program Policy manual, Section
765." New Mexico Contract, pages 45-46.
"2.D.35.b
Screens
The CONTRACTOR
shall insure that, to the extent possible, within six months of enrollment
or within six months of a change in standard, asymptomatic members receive
and are current for at least the following preventive screening services
Current is defined as no more that four months overdue. The CONTRACTOR
shall perform the appropriate interventions based on the results of the
screening.
2.D.35.b.i
Screening for Breast Cancer. Females aged 50-69 years who are not
at high risk for breast cancer shall be screened annually with mammography
and a clinical breast examination.
2.d.35.b.ii
Screening for Cervical Cancer...
2.d.35.b.iii
Screening for Colorectal Cancer...
2.D.35.b.iv
Blood Pressure Measurement...
2.d.35.b.v
Serum Cholesterol Measurement...
2.d.35.b.vi
Screening for Obesity...
2.D.35.b.vii
Screening for Elevated Lead levels...
2.D.35.b.viii
Screening for Diabetes...
2.D.35.b.ix
Screening for Tuberculosis...
2.D.35.b.x
Screening for Rubella...
2.D.35.b.xi
Screening for Visual Impairment...
2.D.35.b.xi
Screening for Hearing Impairment...
2.D.35.b.xiii
Screening for Problem Drinking and Substance Abuse...
2.D.35.b.xiv
Prenatal Screening...
2.D.35.b.xv
Newborn Screening...
2.D.35.b.xvi
During an encounter with a primary care provider, a behavioral health screen
shall occur…
2.D.35.d The CONTRACTOR shall provide to applicable asymptomatic members counseling on the following unless recipient refusal is documented: to prevent tobacco use, to promote physical activity, to promote a health diet, to present osteoporosis and heart disease in menopausal women siting the advantages and disadvantages of calcium and hormonal supplementation, to prevent motor vehicle injuries, to prevent household and recreational injuries, to prevent dental and periodontal disease, to prevent HIV infection and other sexually transmitted diseases, and to prevent unintended pregnancies…
2.D.36
Services Excluded from the Benefit package
The following
services are not included in the benefit package. Reimbursement for
these services shall be made on a fee-for- service basis:
2.D.36.a
Services provided in nursing facilities or hospital swing beds to clients
residing over thirty (30) continuous days or on a permanent basis as set
forth in Medical Assistance Division Program Manual Section MAD-731, NURSING
FACILITIES, and MAD-723, SWING BED HOSPITAL SERVICES.
2.D.36.b
Services provided in intermediate care facilities for the mentally retarded
as set forth in Medical Assistance Division Program Manual...
2D.36.c
Services provided pursuant to the Home and community- based Services Waiver
programs as set forth in Medical Assistance division Program manual Sections
MAD- 733-736, HOME AND COMMUNITY -BASED SERVICES WAIVERS...
2.d.36.e Experimental
or investigational procedures, technologies or non-drug therapies as set
forth in Medical Assistance Division Program manual Section MAD-765, EXPERIMENTAL
OR INVESTIGATIONAL PROCEDURES, TECHNOLOGIES OR NON-DRUG THERAPIES...
2.d.36.j
Services provided in the schools and specified in the Individual Education
Plan (IEP) or Individualized Family Services Plan (IFSP) as detailed in
the Medical Assistance Division Program Manual..." New Mexico Contract,
pages 49-52.
"APPENDIX K-1
MANAGED CARE
PLAN PREPAID BENEFIT PACKAGE
Covered Services
Preventive
Health Services
Managed Care
Plan Scope of Benefit
Care
or service to avert disease/illness and/or its consequences. Preventive
care includes primary care, secondary care and tertiary care. Coverage
includes general health education classes, smoking cessation classes, childbirth
education classes, parenting classes and nutrition counseling (with targeted
outreach to persons with diabetes and pregnant women). HIV counseling
and testing is a covered service for all Enrollees…
Covered Services
Private
Duty Nursing Services
Managed Care
Plan Scope of Benefit
covered
service when medically necessary in accordance with the ordering physician,
physician assistant or nurse practitioner's written treatment plan…
Covered Services
Foot
Care Services
Managed Care
Plan Scope of Benefit
Foot
care when the Enrollee's (any age) physical condition poses a hazard due
to the presence of localized illness, injury or symptoms involving the
foot, or when performed as a necessary and integral part of otherwise covered
services such as the diagnosis and treatment of diabetes, ulcers, and infections…
Covered Services
Eye
Care and Low Vision Services
Managed Care
Plan Scope of Benefit
Eye
care includes the services of an optometrist and an opthalmic dispenser
and coverage for contact lenses, polycarbonate lenses, artificial eyes
and replacement of lost or destroyed glasses (including repairs) when medically
necessary
Artificial
eyes are covered as ordered by a Contractor's Participating Provider.
Covered Services
Hearing
Aids Services
Managed Care
Plan Scope of Benefit
Provided
when medically necessary to alleviate disability caused by the loss or
impairment of hearing. Hearing aid products include hearing aids,
earmolds, special fittings, and replacement parts. Coverage excludes
hearing aid batteries…
Covered Services
Transportation
Services
Managed Care
Plan Scope of Benefit
Non-Emergency
Transportation:
Transportation expenses are covered when transportation is essential in
order for an Enrollee to obtain necessary medical care and services which
are covered under this benefit package (or by fee-for-service Medicaid
for carved-out services). Non-emergent transportation guidelines
may be developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan
Transportation services means transportation by ambulance, ambulette or
invalid coach, taxicab, livery, public transportation, or other means appropriate
to the Enrollee's medical condition; and a transportation attendant to
accompany the Enrollee, if necessary. Such services may include the
transportation attendant's transportation, meals, lodging and salary; however,
no salary will be paid to a transportation attendant who is a member of
the Enrollee's family.
For Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of
the disability
Emergency
Transportation
Emergency transportation can only be provided by an ambulance service.
Emergency transportation is covered for Enrollees suffering from severe,
life-threatening or potentially disabling conditions which require the
provision of emergency medical services while the Enrollee is being transported.
Covered by
Medicaid Fee-For-Service
For
MCOs that do not cover Transportation services, these services are paid
for fee for services. Non-emergent transportation requests should
be referred to the LDSS…
Covered Services
Prosthetic/Orthotic
Services/Orthopedic Footwear
Managed Care
Plan Scope of Benefit
Covered
when medically necessary as ordered by the a managed care plan qualified
medical professional.
Covered Services
Experimental
and/or Investigational Treatment
Managed Care
Plan Scope of Benefit
Covered
on a case by case basis in accordance with the provisions of Section 4910
of the New York State P.H.L…" 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
Private
Duty Nursing Services
Managed Care
Plan Scope of Benefit
covered
service when medically necessary in accordance with the ordering physician,
physician assistant or nurse practitioner's written treatment plan…
Covered Services
Foot
Care Services
Managed Care
Plan Scope of Benefit
Foot
care when the Enrollee's (of any age) physical condition poses a hazard
due to the presence of localized illness, injury or symptoms involving
the foot, or when performed as a necessary and integral part of otherwise
covered services such as the diagnosis and treatment of diabetes, ulcers,
and infections…
Covered Services
Eye
Care and Low Vision Services
Managed Care
Plan Scope of Benefit
Eye
care includes the services of an optometrist and an opthalmic dispenser
and coverage for contact lenses, polycarbonate lenses, artificial eyes
and replacement of lost or destroyed glasses (including repairs) when medically
necessary
Artificial
eyes are covered as ordered by a Contractor's Participating Provider.
Covered Services
Transportation
Services
Managed Care
Plan Scope of Benefit
Non-Emergency
Transportation:
Transportation expenses are covered when transportation is essential in
order for an Enrollee to obtain necessary medical care and services which
are covered under this benefit package (or by fee-for-service Medicaid
for carved-out services). Non-emergent transportation guidelines
may be developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan
Transportation services means transportation by ambulance, ambulette or
invalid coach, taxicab, livery, public transportation, or other means appropriate
to the Enrollee's medical condition; and a transportation attendant to
accompany the Enrollee, if necessary. Such services may include the
transportation attendant's transportation, meals, lodging and salary; however,
no salary will be paid to a transportation attendant who is a member of
the Enrollee's family.
For Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of
the disability
Emergency
Transportation
Emergency transportation can only be provided by an ambulance service.
Emergency transportation is covered for Enrollees suffering from severe,
life-threatening or potentially disabling conditions which require the
provision of emergency medical services while the Enrollee is being transported.
Covered by
Medicaid Fee-For-Service
For
MCOs that do not cover Transportation services, these services are paid
for fee for services. Non-emergent transportation requests should
be referred to the LDSS…
Covered Services
Hearing
Aids Services
Managed Care
Plan Scope of Benefit
Provided
when medically necessary to alleviate disability caused by the loss or
impairment of hearing. Hearing aid products include hearing aids,
earmolds, special fittings, and replacement parts. Coverage excludes
hearing aid batteries.
Covered by
MA Fee for Service
Covered
for excluded services, such as hearing aid batteries with a provider's
order...
Covered Services
Prosthetic/Orthotic
Services/Orthopedic Footwear
Managed Care
Plan Scope of Benefit
Covered
when medically necessary as ordered by the a managed care plan qualified
medical professional.
Covered Services
Experimental
and/or Investigational Treatment
Managed Care
Plan Scope of Benefit
Covered
on a case by case basis in accordance with the provisions of Section 4910
of the New York State P.H.L…" New York Contract, Appendix K, pages
K-9-K12.
"Appendix III
Schedule of
Benefits
In-Plan Benefits...
*
Adult Health Screening
*
Ambulance
*
Chiropractic Services…
*
Diagnostic Services
*
Dialysis…
*
Emergency Room…
*
Home Infusion Therapy
*
Hospice...
*
Midwife
*
Occupational Therapy...
*
Podiatry...
*
Speech Therapy
*
Sterilization…" North Carolina Contract, Appendix III, Amendment.
"2.14
Health Education and Prevention
Each Contractor
shall be encountered to provide a continuous program of general health
education or disease prevention and identification without additional cost
to the enrollee...
Programs of
wellness education including stress management, smoking cessation, nutritional
education, and physical fitness programs may be offered to enrollees on
a voluntary basis. These programs shall be conducted by qualified
personnel." North Dakota Contract, Attachment C, page 16.
"ATTACHMENT
L: COVERED SERVICES
1. Ambulance
Services - includes emergency ambulance and air transport. Non-emergency
ambulance services may be approved if medically necessary. Transportation
payment is governed by N.D. Admin. Code 75-02-02-13.1...
3. Chiropractor
- services limited to medically necessary manual manipulation of the spine
and x-rays limited to the spinal area...
8. Hospice
- includes all authorized services provided by a licensed hospice agency...
15. Nutrition
Services - includes evaluation and dietary counseling for diabetes, eating
disorders including morbid obesity, cardiovascular diseases, phenylketonuria,
and renal failure. Prior authorization is necessary for treatment
of other conditions.
16. Occupational
therapy - includes therapy ordered by a physician and provided by a licensed
therapist...
19. Podiatry
- includes all necessary services of a licensed podiatrist for the treatment
of the foot or ankle...
21. Public
Health Units - includes all Medicaid eligible services that are covered
at publicly funded health units...
23. Speech
therapy - includes therapy referred by a physician and provided by a qualified
therapist. Also includes any necessary hearing devices including
hearing aides and batteries.
24. Transplants
- includes all covered transplants as described in the Medicaid State Plan.
Experimental transplants are not covered.
25. Transportation
- includes necessary transportation in order for a receipt to secure medical
examinations and treatment. Available free transportation services
should be used before incurring any transportation expenses. Transportation
expenses include cost of transportation, (common carrier, taxi, other appropriate
means) meals and lodging en route to and from medical care and while receiving
care and the cost of an attendant if necessary. Transportation payment
is governed by N.D. Admin. Code 75-02-02-13.1." North Dakota Contract,
Attachment L, pages 1-3.
"ATTACHMENT
M: NON-COVERED SERVICES
The following
services are NOT COVERED SERVICES under this contract: ...
2.
Home and Community-Based Care for the Elderly, Disabled, Traumatic Brain
Injure and Developmentally Disabled.
3.
Intermediate Care Facilities for the developmentally disabled (ICF-MR).
4.
Nursing facility and swing-bed services...
6.
Optometric services, included eyewear...
8.
School based special education related services included in a child's Individual
Education Plan...
10. Indian
Health Service hospital or clinic services.
11. Treatment
services for children in private facilities.
12. Private
duty nursing services.
The following
are NOT COVERED SERVICES under Medicaid:
1. Acupuncture.
2. Cosmetic
surgery.
3. Experimental
services and procedures...
6. Care
by physicians and hospitals who are not Participating Providers with the
Contractor (except in emergencies or upon prior approval by the Contractor's
Medical Director).
7. Services
that are the responsibility of Workers Compensation." North Dakota
Contract, Attachment M.
"D. Benefit
Package
Pursuant to
the provisions of Ohio Administrative Code (OAC) rule 5101:3-26-03 and
the provider agreement, MCPs must cover at a minimum all medically-necessary
services included in the Ohio Medicaid program as summarized in Appendix
A...
D.1. Exclusions
2. Community
Alternative Funding Services (CAFS)
MCPs are responsible
for covering all medically-necessary, Medicaid-covered services to its
enrollees, including those with mental retardation/developmental disabilities.
MCPs are not responsible for the payment of services provided through Community
Alternative Funding Services (CAFS) providers." Ohio RFP, page 12.
"APPENDIX A
BASIC BENEFIT
PACKAGE BY SERVICE TYPE
The following
types of services must be provided to covered persons by participating
health plans and at least to the extent such services are covered by Ohio
Medicaid. Additional covered services required under this contract
are outlined in the RFP...
8. Medical
care and any other type of remedial care recognized under state law, furnished
by licensed practitioners within the scope of their practice as defined
by state law...
10. Private
duty nursing services...
12. Physical
therapy, occupational therapy, and services for covered persons with speech,
hearing, and language disorders...
14. Ambulance
and ambulette transportation...
17. Podiatric
services.
18. Chiropractic
services.
19. Physical
medicine services...
21. Vision
care services...
23. Nursing
facility services provided as part of a plan of care for the rehabilitation
of any injury or illness.
24. Other
limited practitioner services.
25. Hospice
care services provided by Medicare-certified hospices…" Ohio RFP,
Appendix A, pages 1-2.
"5101:3-26-03
Managed care plan: Covered services...
(B) MCPs
must cover annual examinations for adults." Ohio RFP, Appendix E,
OAC 5101:3-26-03, page 1.
"3. STATEMENT
OF WORK
A. Subject
to the provisions of this Section and Section 4, COVERED SERVICES, with
the exception of services for physician assisted suicide under the Oregon
Death with Dignity Act, ORS 127.800-127.897 and therapeutic abortions,
Contractor shall:
(1) (a) Ensure provision of Medically Appropriate Covered Services consistent with OAR 410-141-0120, including Emergency Services and preventive care services, in all those categories listed below as Mandatory and in those Optional categories that are listed below (hereinafter referred to as Capitated Services) for all OMAP Members: …
FCHP Mandatory
Exceptional
needs Care Coordination...
Private Duty
Nursing/Hospice
Post Hospital
Extended Care
Tobacco Cessation
Transportation
- Ambulance
Vision Exams,
Therapy, Materials…" Oregon Contract, pages 2-3.
"G. Preventive
Care Services
Contractor
shall provide Preventive Care Services for OMAP Members in compliance with
OAR 410-141-0520, Prioritized List of Health Services. Screening and counseling
content is based on age and risk factors determined by a comprehensive
patient history. All necessary diagnosis and treatment services identified
as a result of such screening must be provided by Contractor to the extent
such services are Capitated Services. To the extent such services are not
Capitated Services, but are Medical Case Management Services, Contractor
must refer the OMAP Member to an appropriate provider and manage and coordinate
the services...
H. Transportation
Ambulance Services
Contractor
is required to pay for Emergency ambulance and Services provided for evaluation
and treatment, including transport, in accordance with the standard identified
under Section 3.F. Emergency Services, specifically subsections (1), (2),
(3), (5) and (10).
Contractor is not responsible for non-emergency transports that do not comply with the plans authorization requirements, Contractor is not required to pay for transportation to a specific provider based solely on client or client/family preference or convenience…" Oregon Contract, page 9.
"4. COVERED
SERVICES...
A. ...Covered
Services are those Medically Appropriate services specified in OAR 410-141-0480,
Oregon Health Plan Benefit Package of Covered Services, which shall include:
...
(1) Diagnostic services which are medically appropriate regardless of whether or not the final diagnosis is covered
(2) Treatment, including ancillary services, that is included in or supports the condition/treatment pairs on the prioritized list of health services reported to the Oregon Legislative Assembly by the Health Services Commission, to the extent such condition/treatment pairs are currently funded by the Legislative Assembly...
(4) Such treatment, including ancillary services, are covered subject to the service limitations of the Medical Assistance program and provider guides, when the services are Medically Appropriate for the treatment of a covered condition-treatment pair. In addition to the coverage, the OMAP Member may be eligible to receive services for treatments which are below the funded line or not otherwise excluded from coverage as cited i n OAR 410-141-0480.
(5) Contractor is required to notify OMAP's Transplant Coordinator of all transplant prior authorizations…" Oregon Contract, pages 15-16.
"F. IN-PLAN
SERVICES...
2. Description
of Comprehensive Benefit Package
a. General
The HMO must
agree to make available the comprehensive benefit package to program eligibles.
The comprehensive benefit package includes…emergent transportation…"
Pennsylvania RFP, pages 37-38.
"F. IN-PLAN
SERVICES
6. Organ
Transplants
To the extent
that the FFS Program pays for transplants, the HMO will be responsible
for transplants. However, the HMO will not be responsible for organ
transplants determined by the Department to be experimental. Currently,
Kidney, cornea, heart/lung, single lung, double lung, liver, bone marrow,
pancreas transplants, and liver-bowel transplants for children are covered
by the FFS program, if the Department agrees that the procedure is medically
necessary and in accordance with customary standards of medical practice
to treat the specific diagnosis…" Pennsylvania RFP, pages 37-49.
"2.06.02.01
General...
The comprehensive
benefit package includes… other diagnostic services, and preventive care.
The comprehensive benefit package places a special emphasis on preventive
care…" Rhode Island RFP, page 21.
"SCHEDULE OF
IN-PLAN BENEFITS...
Non-Prescription
Drugs
Covered when
prescribed by a Health Plan physician/provider; limited to non-prescription
drugs covered by the Rhode Island Medical Assistance Program...
Diagnostic Services
Covered when
ordered by a Health Plan physician/provider (or other physician for SED
and SPMI)…
School-Based
Clinic Services
Covered as
medically necessary at four designated sites…
Podiatry Services
Covered as
ordered by Health Plan physician
Optometry Services
For adults
21 and older, benefit is limited to examinations that include refraction's
and provision of eyeglasses if needed once every two years, and other medically
necessary treatment visits for illness or injury to the eye. For
children under 21, covered as medically necessary with no other limits…"
Rhode Island RFP, Attachment A, pages 1-6.
"Post-stabilization services - Services subsequent to an emergency that a treating physician views as medically necessary AFTER an emergency medical condition has been stabilized. They are NOT 'emergency services', which HMOs are obligated to cover in-or-out of plan according to the 'prudent layperson' standard. Rather, they are NON-emergency services that the HMO could choose NOT to cover out-of-plan EXCEPT in the circumstances described above." South Carolina Contract, Appendix A, page 7.
"4.1 Core
Benefits For The South Carolina Medicaid HMO Program
Core benefits
must be available to each Medicaid HMO Program member within the Contractor's
service area and the Contractor must provide a mechanism to reduce inappropriate
and duplicative use of health care services...
A summary listing
of the core benefits is as follows: ...
Podiatry Services
Emergency Transportation...
Institutional
Long Term Care Facilities/Nursing Homes, swing bed and administrative days
(First thirty (30) days)…" South Carolina Contract, page 15.
"4.7 Medical
Services for Special Populations
Individuals
with Sickle Cell Disease, children with chronic/complex health care needs,
and pregnant women determined to be at high medical risk based on the SCDHHS
Pregnancy and Risk Assessment Form 204P/2041 and SCDHHS Infant Risk Assessment
Form 204P/2041 Appendix D, Tab 5, screening criteria and all infants of
high risk mothers are defined as special populations in the Title XIX SC
State Medicaid Plan. The special populations are identified as individuals
which may require additional health care services which should be incorporated
into a health management plan which guarantees that the most appropriate
level of care is provided for these individuals.
4.6 Expanded
Services
The Contractor
may offer expanded services to enrolled Medicaid HMO Program members in
addition to those covered services specified in Appendix C, Tab 1 of this
Contract. These expanded services may include health care services which
are currently non-covered services by the Title XIX SC State Medicaid Plan
and/or which are in excess of the amount, duration, and scope of those
listed in Appendix C, Tab 1. These services must be specifically
defined by the Contractor in regard to amount, duration and scope.
SCDHHS will not provide any additional reimbursement of these services.
The Contractor shall provide SCDHHS a description of the expanded services
to be offered by the Contractor for approval, which shall be included and
incorporated as a part hereof to the Contract and included in the Contractor's
marketing information." South Carolina Contract, page 17.
"PREVENTIVE
AND REHABILITATIVE SERVICES FOR PRIMARY CARE ENHANCEMENT (PSPCE/RSPCE)
Other services,
which were previously limited to high risk women, are now available through
PSPCE/RSPCE to any Medicaid recipient determined to have medical risk factors...
SICKLE CELL
ANEMIA SERVICES
To receive
services recipients must be diagnosed through laboratory testing as having
Sickle Cell disease or Sickle Cell Trait. Recipients of all ages
are eligible...
DIABETES EDUCATION...
Description:
The Ambulatory
(outpatient) Diabetes Education program is one that (a) provides medically
necessary comprehensive diabetes education and counseling services to any
newly diagnosed diabetics; pregnant diabetics; diabetics admitted with
a primary diagnosis of one of the following complications: diabetic
ketoacidosis or diabetic acidosis or coma, hyperosmolar non-ketotic coma,
lactic acidosis , hypoglycemia, or any other diabetic the physician determines
will benefit from an education intervention; and (b) deliver educational
and counseling services that meet the goals of diabetes as described by
the American Diabetes Association and have a current curriculum in the
fifteen content areas…" South Carolina Contract, Appendix B, pages
3, 5-6.
"PODIATRY SERVICES
Podiatry services
are those services responsible and necessary for the diagnosis and treatment
of foot conditions. Services are limited to specialized care of the
foot as outlined under the laws of the State of South Carolina…
INSTITUTIONAL
LONG TERM CARE FACILITIES/NURSING HOMES
HMO plans are
responsible for the first 30 days of confinement in a long term care facility/nursing
home/hospital who provides swing bed or administrative days. Services
include nursing facility and rehabilitative services at the skilled or
sub-acute intermediate level of care. After the first 30 days, payment
for services will be reimbursed fee-for-service by the Medicaid program
for Medicaid enrolled providers…" South Carolina Contract, Appendix C,
Tab 1, page 6.
"SERVICES OUTSIDE CORE BENEFITS TO BE REIMBURSED BY MEDICAID FEE-FOR-SERVICE...
INSTITUTIONAL
LONG TERM CARE FACILITIES/NURSING HOMES...
After the first
30 days, payment for services will be reimbursed fee-for-service by the
Medicaid program for Medicaid enrolled providers...
NON-EMERGENCY
TRANSPORTATION
It may be necessary
for a Medicaid HMO member to require non-emergency transportation to receive
medical services from a provider located in a county other than the member's
county of residence if the HMO does not have that provider type as part
of its network. Since prior approval for non-emergency transportation
is required by DSS, the HMO will be responsible for faxing or telephoning
the request for transportation and authorization for services to the DSS
county office...
If the HMO authorizes out-of-state referral services and the referral service is available in-state as determined by Department of Health and Human Services (DHHS), the HMO is responsible for all Medicaid covered services related to the referral, including transportation and lodging…
VISION CARE
Vision care
includes one vision test for members during a 12 month period. Eyeglasses
for recipients under the age of 21 are limited to one pair and one replacement
during a 12 month period. Eyeglasses for recipients 21 and over are
covered only following cataract or detached retina surgery...
CHIROPRACTIC
SERVICES
Chiropractic
services are available to all recipients. Chiropractic services are
limited to manual manipulation of the spine to correct a subluxation…Medicaid
recipients are limited to a maximum of one visit per day and up to 12 visits
within a calendar year...
THERAPIES FOR
CHILDREN WITH CHRONIC/COMPOLEX HEALTH CARE NEEDS
The Title XIX
SC State Medicaid Plan provides for a wide range or therapeutic services
available to individuals under the age of twenty-one (21) who have sensory
impairments, mental retardation, physical disabilities, and/or developmental
disabilities or delays, as well as to individuals of any age who are in
the Mental Retardation/Related Disabilities Waiver or the Head and Spinal
Cord Injury Waiver programs...
Rehabilitative therapy services include: speech-language pathology, audiology, physical and occupational therapies...
HOME AND COMMUNITY
BASED WAIVER SERVICES
Home and community-based
waiver services target persons with long term care needs and provide recipients
access to services that enable them to remain at home rather than in a
institutional setting. An array of home and community based services
provides enhanced coordination in the delivery of medical care for long
term care populations…
PREGNANCY PREVENTION
SERVICES - TARGETED POPULATIONS
The Medicaid
program provides reimbursement for pregnancy prevention services for targeted
populations through state and community providers…The HMO should ensure
that Medicaid HMO program members continue to have access to these programs,
which include but are not limited to:
Teen Companion
Program (SCDSS): ...
The program
takes a holistic approach to making adolescents self-sufficient before
becoming parents. Services under this program are defined as follows:
referrals, home visits, counseling, community outreach, and health education...
Socialization
training, Education and Parenting (DDSN): ...
Services provided
under this program are: needs assessment, intervention plan development,
record maintenance/administration, and pregnancy prevention counseling…"
South Carolina Contract, Appendix C, Tab 2, pages 1-4.
"2-3.
Benefits/Service Requirements and Limitations
a. Covered
Services...
SERVICE/BENEFIT…
Vision Services/Preventive,
diagnostic and treatment services (including eyeglasses) for enrollees
under age 21. The first pair of cataract glasses or contact lens/lenses
following cataract surgery is covered for adults.
Emergency Ambulance Transportation/As medically necessary.
Non-Emergency Ambulance Transportation/As medically necessary.
Non-Emergency Transportation/As necessary for enrollees lacking accessible transportation for covered services
Community Health Services/As medically necessary.
Renal Dialysis Services/As medically necessary.
Rehabilitation Services/As medically necessary when determined cost effective by the MCO.
Chiropractic Services/When determined cost effective by the MCO.
Private Duty Nursing/As medically necessary and when prescribed by an attending physician for treatment and services rendered by registered nurse (R.N.) or a licensed practical nurse (L.P.N.), who is not an immediate relative.
Speech Therapy/As medically necessary, by a Licensed Speech Therapist to restore speech (as long as there is continued medical progress) after a loss or impairment. The loss or impairment must not be caused by a mental, psychoneurotic or personality disorder…
Sitter/As medically necessary, a sitter who is not a relative may be used where an enrollee is confined to a hospital as a bed patient and certification is made by a network physician that R.N. or L.P.N. is needed and neither is available.
Convalescent Care/Upon receipt of proof that a Covered Person has incurred Medically Necessary expenses related to convalescent care, the Plan shall pay for up to and including the one-hundredth (100th) day of confinement during any calendar year for convalescent facility(ies) room, board and general nursing care, provided: (1.) a Physician recommends confinement for convalescence; (2.) the enrollee is under the continuous care of a Physician during the entire period of confinement; and (3) the confinement is required for other than custodial care.
Donor Organ Procurement/As medically necessary for a covered organ transplant…" Tennessee Contract, pages 7-11.
"2-3.
Benefit/Services Requirements and Limitations...
c. Specialized
Services
The
following specialized services shall be provided according to the following
provisions:
1.
HIGH COST CHRONIC CONDITIONS (HCCC) SERVICES
Effective
January 1, 1994, the following will be implemented:
(a)
Persons in this population are those with certain diagnoses that typically
involve exceptional medical expenditures…" Tennessee Contract, pages
7-14.
"2-3.
Benefit/Services Requirements and Limitations...
s. Coverage
of Organ Transplants
The CONTRACTOR shall cover at a minimum the following transplants:
Renal, Heart, Liver, Corneal and Bone Marrow, when medically necessary
and consistent with the accepted mode of treatment for which the transplant
procedure is performed. The CONTRACTOR shall not be required to cover
transplants or procedures which are not medically necessary nor performed
for a purpose inconsistent with acceptable modes of treatment. Besides
the minimally required transplants, the CONTRACTOR may cover other transplants
which are not considered investigational or experimental by the National
Institutes of Health and the Tennessee Department of Health. For
purposes of this Section, investigational or experimental shall mean those
transplants and/or procedures which are not considered medically necessary
and which have not been approved by the Health Care Financing Administration
and published in the Federal Register...
Exceptions to the above list of transplants must be made for other non-investigational/non-experimental transplants if the transplant and/or procedure is found to be medically necessary, performed within the accepted mode of treatment for which it is intended, and is found to be cost effective as determined by the CONTRACTOR…" Tennessee Contract, pages 7-27.
"ARTICLE VI
SCOPE OF SERVICES
6.1 SCOPE
OF SERVICES
HMO is paid
capitation for all services included in the State of Texas Title XIX State
Plan and the 1915(b) waiver application for the SDA currently filed and
approved by HCFA, except those services which are specifically excluded
and listed in Article 6.1.8 (non-capitated services)...
6.1.6 Value-added Services. Value-added services that are approved by TDH during the contracting process are included in the Scope of Services under this contract. Value-added services are listed in Appendix C...
6.1.6.3 Value-added services must be offered to all mandatory HMO Members, as indicated in Article 6.1.6.1.2, unless the contract is amended or the contract terminates.
6.1.7 HMO may offer additional benefits that are outside the scope of services of this contract to individual Members on a case-by-case basis, based on medical necessity, cost-effectiveness, and satisfaction and improved health/behavioral health status of the Member/Member family.
6.1.8
Non-Capitated Services. The following Texas Medicaid program services
have been excluded from the services included in the calculation of HMO
capitation rate: ...
Texas
School Health and Related Services
Medical
Transportation
TDHS
Hospice Services...
Although HMO is not responsible for paying or reimbursing for these non-capitated services, HMO remains responsible for providing appropriate referrals for Members to obtain or access these services." Texas Contract, pages 33-35.
"6.14
HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS
6.14.2
Wellness Promotion Programs. HMO must conduct wellness promotion
programs to improve the health status of its Members. HMO may cooperatively
conduct Health Education classes for all enrolled STAR Members with one
or more HMOs also contracting with TDH in the service area to provide services
to Medicaid recipients in all counties of the service area. Providers
and HMO staff must integrate health education, wellness and prevention
training into the care of each Member..." Texas Contract, page 50.
"2. Care
Provided in Skilled Nursing Facilities
a.
In General: Stays Lasting 30 Days or Less
The
CONTRACTOR may provide long term care for Enrollees in skilled nursing
facilities and then
reimburse such
facilities when the plan of care includes a prognosis of recovery and discharge
within 30 days...
b.
Process for Stays Longer than 30 Days
When
the prognosis of an Enrollee indicates that all long term care greater
than 30 days will be required, the following process will occur:
1)
The CONTRACTOR will notify the Enrollee, hospital discharge planner, and
nursing facility that the CONTRACTOR will not be responsible for the services
provided for the Enrollee during the stay at the skilled nursing facility...
c.
Process of Stays Less than 30 Days
When
the prognosis of skilled nursing facility services is anticipated to be
less than 30 days, but during the 30-day period the CONTRACTOR determines
that the Enrollee will require skilled nursing facility services for greater
than 30 days, the following process will be in effect: ...
(5)
The CONTRACTOR will be responsible for payment for three working days after
the CONTRACTOR has notified the nursing facility that skilled nursing care
will be required for more than 30 days..." Utah Contract, pages 15-16.
"8. Speech
and Hearing Services
Services
and appliances, including hearing aids and hearing aid batteries, provided
by a licensed medical professional to test and treat speech defects and
hearing loss.
1.
Podiatry Services
Services
provided by a licensed podiatrist.
10.
End Stage Renal Disease - Dialysis
Treatment
of end stage renal dialysis for kidney failure. Dialysis is to be
rendered by a Medicare-certified Dialysis facility...
12.
Hospice Services
Services
delivered to terminally ill patients (six months life expectancy) who elect
palliative versus aggressive care. Hospice care is to be rendered
by a Medicare-certified hospice.
M. Private
Duty Nursing
Services
provided by licensed nurses for ventilator-dependent children and technology-dependent
adults in their home in lieu of hospitalization if Medically Necessary,
feasible, and safe to provided in the patient's home. Requests for
continuous care will be evaluated on a case by case basis and must be approved
by the CONTRACTOR..." Utah Contract, Attachment B, page 3.
"7. Organ
Transplantation's
a.
In General
All
organ transplantation services are the responsibility of the CONTRACTOR
for all Enrollees in accordance with the criteria set forth in Rule R414-10A
of the Utah Administrative Code, ...
b.
Specific Organ Transplantation's Covered.
The
following transplantation's are covered... Kidney, liver, corneal,
bone marrow, heart, intestine, lung, pancreas, small bowel, combination
heart/lung, combination intestine/liver, combination kidney/pancreas, combination
liver/kidney, multi visceral, and combination liver/small bowel.
c.
Psychosocial Assessment Required
Medicaid
requires that Medicaid eligible who have applied for organ transplantation's
undergo a psychosocial assessment... This psychosocial evaluation
is a Covered Service under this Contract...
d.
Out-of-State Transplantations
When
the CONTRACTOR arranges the transplantation to be performed out-of-state,
the CONTRACTOR is responsible for coverage of food, lodging, transportation
and airfare expenses for the Enrollee and attendant..." Utah Contract,
Attachment B, pages 21-22.
"E. Vision
Care
Services
provided by licensed ophthalmologists or licensed optometrists, and opticians
within their scope of practice. Eyeglasses will be provided to eligible
recipients based on medical necessity. Services include, but are
not limited to, the following:
1. Eye
refractions, examinations
2. Laboratory
work
3. Lenses
4. Eyeglass
Frames
5. Repair
of Frames
6. Repair
or Replacement of Lenses
7. Contact
Lenses (when Medically Necessary)...
G. Physical
and Occupational Therapy
1.
Physical Therapy
Treatment
and services provided by a licensed physical therapist. Treatment
and services must be authorized by a physician and include services prescribed
by a physician or other licensed practitioner of the healing arts within
the scope of his or her practice under State law and provided to an Enrollee
by or under the direction of a qualified physical therapist...
2. Occupational
Therapy
Treatment
of services provided by a licensed occupational therapist. Treatment
and services must to authorized by a physician and include services prescribed
by a physician or other licensed practitioner of he healing arts within
the scope of his or her practice under State law and provided to an Enrollee
by or under the direction of a qualified occupational therapist..."
Utah Contract, Attachment C, page 2.
"O. Abortions
and Sterilizations
These
services are provided to the extent permitted by Federal and State law
and must meet the documentation requirement of 42 CFR 441, Subparts E and
F. These requirements must be met regardless of whether Medicaid
is primary or secondary payer...
17. Organ
Transplants
The
following transplantations are covered for all Enrollees: Kidney,
liver, cornea, bone marrow, heart, intestine, lung, pancreas, small bowel,
combination heart/lung, combination intestine/liver, combination kidney/pancreas,
combination liver/kidney, multi visceral, and combination liver/small bowel...
R. Other
Outside Medical Services
The
CONTRACTOR, as its discretion and without compromising quality of care,
may choose to provide services in Freestanding Emergency Centers, Surgical
Centers and Birthing Centers.
S. Long
Term Care
The
CONTRACTOR may provide long term care for Enrollees in skilled nursing
facilities requiring such care as a continuum of a medical plan when the
plan includes a prognosis of recovery and discharge within thirty (30)
days or less. When the prognosis of an Enrollee indicates that long
term care (over 30 days) will be required, the CONTRACTOR will notify the
DEPARTMENT and the skilled nursing facility of the prognosis determination
and will initiate disenrollment to be effective on the first day of the
month following the prognosis determination. Skilled nursing care
is to be rendered in a skilled nursing facility which meets federal regulation
of participation.
T. Transportation
Services
Ambulance
(ground and air) service for medical emergencies. The CONTRACTOR
is also responsible to pay for authorized emergency transportation for
an illness or accident episode which, upon subsequent medical evaluation
at the hospital, is determined to be psychiatric-related... The CONTRACTOR
is not responsible for transporting an Enrollee from an acute care facility
to another acute care facility for a psychiatric admission..." Utah
Contract, Attachment C, pages 4-5.
"24. Services
for Children with Special Needs
1.
In General
In addition
to primary care, children with chronic illnesses and disabilities need
specialized care provided by trained experienced professionals. Since
early diagnosis and intervention will prevent costly complications later
on, the specialized care must be provided in a timely manner. The
specialized care must comprehensively address all areas of need to be most
effective and must be coordinated with primary care and other services
to be most efficient. The children's families must be involved in the planning
and delivery of the care for it to be acceptable and successful.
2.
Services Requiring Timely Access
All
children with special health care needs must have timely access to the
following services:
a.
Comprehensive evaluation for the condition
b.
Pediatric subspecialty consultation and care appropriate to the condition
c. Rehabilitative
services provided by professionals with pediatric training in areas such
as physical therapy, occupational therapy and speech therapy.
d.
Durable medical equipment appropriate for the condition.
e.
Care coordination for linkage to early intervention, special education
and family support services and for tracking progress..." Utah Contract,
Attachment C, pages 9-10.
"26. Diabetes
Education
The
CONTRACTOR shall provide diabetes self-management education from a Utah
certified or American Diabetes Association recognized program when an Enrollee:
1.
has recently been diagnosed with diabetes, or
2.
is determined by the health care professional to have experienced a significant
change in symptoms, progression of the disease or health condition that
warrants changes in the Enrollee's self-management plan, or
3.
is determined by the health care professional to require re-education or
refresher training." Utah Contract, Attachment C, page 12.
"ARTICLE I -
DEFINITIONS...
Enhanced Services
- Services offered by the Contractor to enrollees in addition to Medallion
II covered services. Enhanced services will not be paid for by the
Department." Virginia Contract, pages 7-8.
"2. Allowable
HMO Marketing Activities
The Contractor
may engage in the following marketing activities: ...
f. 'Wellness
vans' may be sponsored by the Contractor as part of approved health awareness
events, community events, or health fairs.
g. Health
screenings may be offered by the Contractor at community events, health
awareness events, and in wellness vans. The Contractor shall ensure
that every enrollee receiving a screening is instructed to contact his
or her PCP if medical follow-up is indicated and that the enrollee receives
a printed summary of the assessment information to take to his or her PCP…"
Virginia Contract, pages 19-20.
"8. Early
Intervention Services
The Contractor
shall cover all medically necessary Medicaid and CMSIP covered services
which are required to be provided by the Individuals with Disabilities
Education Act, and its implementing regulations. Any subcontract
shall identify all Medicaid and CMSIP covered services which the subcontractor
is required to provide under Federal law." Virginia Contract, page
44.
"18. Organ
Transplants
The Contractor
shall cover organ transplant services for kidneys and corneas for all eligible
individuals, regardless of age. The Contractor shall cover services
for bone marrow transplants and high-dose chemotherapy for adult (age twenty-one
(21) or over) enrollees diagnosed with breast cancer or lymphoma.
The Contractor shall cover services for medically necessary bone marrow
transplants for children. The Contractor shall cover liver, heart,
and any other medically necessary transplant procedures for enrollees up
to age twenty-one (21), as set forth in 12 VAC 30-50-540…
22. Physical
Therapy, Occupational Therapy and Speech-Language Pathology and Audiology
Services
The Contractor
shall cover all medically necessary physical therapy, occupational therapy
and speech-language pathology and audiology services as set forth in 12
VAC 30-50-160 and 12 VAC 30-50-220, regardless of where they are provided,
with two exceptions. The Contractor shall not be required to cover
those services rendered by a nursing facility or a school-based clinic.
The Contractor shall also cover all medically necessary intensive outpatient physical rehabilitation services in facilities which are certified as Comprehensive Outpatient Rehabilitation Facilities (CORFs), as set forth in 12 VAC 30-50-220...
24. Pediatric
Services
The Contractor
shall cover pediatric services which are defined as reasonable and necessary
diagnostic, medical, or surgical treatment of disease, injury, or defects
of the human foot...
26. Prostate
Specific Antigen (PSA)
The Contractor
shall cover Prostate Specific Antigen (PSA) testing and digital rectal
examinations for the purpose of screening for prostate cancer...
27. Prosthetic/Orthotic
Services
The Contractor
shall cover prosthetic services and devices (at minimum, artificial arms,
legs and their necessary supportive attachments) for all enrollees.
The Contractor shall cover medically necessary orthotics… for enrollees
under twenty-one (21) years of age. The Contractor shall over medically
necessary orthotics for enrollees when recommended as part of an approved
intensive rehabilitation program.
30. Transportation
The Contractor
shall cover emergency transportation as well as non-emergency transportation
to ensure that enrollees have necessary access to and from providers of
medical services for emergency or non-emergency services. Transportation
includes public transportation; taxicab, if one is necessary; ambulance,
a wheelchair van; or a Registered Driver...
31. Vision
Services
The Contractor
shall cover vision services which are defined as diagnostic examination
and optometry treatment procedures and services by ophthalmologists, optometrists,
and opticians. Routine refractions shall be allowed at least once
in twenty-four (24) months...
33. Medallion
II Carved-Out Services
(a) The
Contractor is not required to cover Medallion II carved-out services, which
are defined through Medicaid/CMSIP memos...
(b) The
following services are Medallion II carved-out services:
(1)
Community rehabilitation mental health services...
(2)
School-based services, mandated special education services...
(3)
Targeted case management services provided to the elderly...
(4)
Regular assisted living services provided to residents of adult care residents
of adult care residencies...
(5)
Investigations by local health departments to determine the source of lead
contamination in the home as part of the management and treatment of Medicaid
and CMSIP eligible children who have been diagnosed with elevated blood
levels...
C. However,
in no event is the Contractor responsible for provision of the following
services which will be reimbursed by the Department...
(3)
Hospice services...
(4)
Skilled nursing facility care...
(5)
Private duty nursing services… when provided through HCBS waivers.
(6)
Personal care services in a recipients home, when provided through HCBS
waivers...
35. Medicaid
Non-Covered Services...
Some, but not
all, Medicaid non-covered services are listed below:
a. Services
rendered by chiropractors...
b. Private
duty nursing services...
c. Services
of Christian Science nurses and care...
d. Personal
care services in a recipient's home…
e. Any
procedure that is experimental or investigational, as defined by the Department…"
Virginia Contract, pages 48-58.
"COVERED SERVICES…
Provider Services:
The Contractor shall cover services provided in an inpatient or outpatient
(e.g. office, clinic, emergency room, or home) setting by licensed professionals
including, but not limited to… podiatrists, private duty nurses, audiologists,
registered nurses, and certified dieticians...
Tissue and
Organ Transplants: The Contractor shall cover the following types
of transplants: Heart, kidney, liver, bone marrow, lung, heart-lung,
pancreas, kidney-pancreas, cornea, and peripheral blood stem cell...
Vision Care: The Contractor shall cover eye examinations for visual acuity and refraction once every twenty-four (24) months for adults and once every twelve (12) months for children under age twenty-one (21)...
Occupational Therapy, Speech Therapy, and Physical Therapy: The Contractor shall cover therapy services for the restoration or maintenance of a function affected by a member's illness, disability, condition or injury, or for the amelioration of the effects of a developmental disability...
Oxygen and Respiratory Services: Oxygen; and respiratory therapy equipment and supplies.
Hospice Services: When the member elects hospice care and the PCP and Contractor's Medical Director determine that it is appropriate for the member's medical care needs, the Contractor shall cover hospice services.
Blood, Blood
Components and Human Blood Products: ...
Hemodialysis:
...
Ambulance and Medical Transportation: ...
Chiropractic Services: The Contractor shall cover chiropractic services for children when they are referred during an EPSDT visit.
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 COVERED
BY OTHER DIVISIONS/ADMINISTRATIONS IN THE DEPARTMENT: …
- Nursing facility
and community-based services (e.g. COPES and Personal Care Services) covered
through the Aging and Adult Services Administration...
- Health care
services covered through the Division of Developmental Disabilities for
institutionalized clients.
- Infant formula
for oral feeding provided by the Women, Infants, and Children (WIC) program
in the Department of Health. Other medically necessary nutritional
supplements for infants are covered under the pharmacy benefit.
SERVICES COVERED
BY MAA FEE-FOR-SERVICE OR THROUGH SELECTIVE CONTRACTS:
- School Medical
Services for Special Students as described in the MAA billing instructions
for School Medical Services
- Eyeglass
Frames, Lenses, and Fabrication Services covered under MAA's selective
contract for these services, and associated fitting and dispensing services
- Voluntary
Termination of Pregnancy, including complications
- Transportation
Services Other Than Ambulance: Taxi, ambulance, voluntary transportation,
public transportation...
- Hearing Aid
Devices, including fitting, follow-up care, and repair...
- Health care
services provided by a neurodevelopmental center
- Certain services
provided by a health department or family planning clinic when a client
self-refers for care...
SERVICES NOT
COVERED BY EITHER MAA OR THE CONTRACTOR:
- Products,
Services and Supplies Related to Sex Transformations
- Medical examinations
for Social Security Disability
- Cosmetic
Services: Services for which plastic surgery or other services are
indicated primarily for cosmetic reasons.
- Physical
examinations required for obtaining or continuing employment, insurance
or governmental licensing.
- Experimental
and Investigation Services, and any services associated with services that
are experimental or investigational.
- Reversal
of Voluntary, Surgically-Induced Sterilization
- Personal
Comfort Items, including but not limited to guest trays, television, and
telephone charges.
- Biofeedback
Therapy
- Diagnosis
and Treatment of Infertility, Impotence, and Sexual Dysfunction
- Orthoptic
(Eye Training) Care for Eye Conditions
- Tissue or
organ transplants other than those specifically listed as covered.
- Immunizations
required for international travel purposes only
- Court-ordered
services
- Any service
provided to an incarcerated enrollee, beginning when the enrollee has been
taken into legal custody by a law enforcement officer…" Washington
Contract, Exhibit 6, Attachment 1, pages 1, 2-8.
"2.3 Covered
Services
2.31
CHIP clients are eligible for the same scope of care as Healthy Options
enrollees. There are no exclusions based on pre-existing conditions in
CHIP. Bidders will be at risk for the same services under CHIP as they
are under Healthy Options, with the same exclusions. Clients will be able
to self-refer for the same services under CHIP as they can under Healthy
Options.
2.32 The Department of Health will provide vaccines for CHIP children at no cost to providers or plans." Washington CHIP RFQQ, page 8.
"Exhibit A...
HMO Covered
Services...
The HMO must
promptly provide or arrange to make available for enrollees all medically
necessary services listed below and assume financial responsibility for
the provision of these services...
MEDICAL SERVICE
Abortion...
Children with
Special Health Care Needs Services...
Chiropractor
Services...
Clinic Services...
Hospice...
Other Services
Speech
Therapy
Physical
Therapy
Occupational
Therapy...
Podiatry Services...
Private Duty
Nursing...
Right from
the Start Services...
Transportation,
Emergency (Note: Non-emergency transportation is covered under Fee-For-Services
Medicaid. See description of service below.)...
Vision Services
MEDICAID BENEFITS
COVERED UNDER FEE-FOR-SERVICE MEDICAID
The following
services are excluded from HMOs' capitation rates, but will remain covered
Medicaid services for persons who are enrolled in HMOs...
MEDICAL SERVICE
Behavioral
Health Services for Children Under Three...
Nursing Facility
Services...
Personal Care...
Transportation,
Non-Emergency…" West Virginia Contract, Exhibit A, pages 1-7.
"2.1.4.1 Excluded
Services
MCPs are not
permitted to provide excluded services which include, but are not limited
to, the following: ...
c) Except
in an emergency, inpatient hospital tests that are not ordered by the attending
physician or other licensed practitioner, acting within the scope of practices,
who is responsible for the diagnosis or treatment of a particular patient's
condition.
d) All
organ transplants, except for heart, kidney, liver, bone marrow and cornea
transplants, cannot be provided.
e) Treatments
for infertility and for the reversal of sterilization.
f) Sex
transformation procedures and hormone therapy associated with sex transformation
procedures.
g) All
cosmetic services, except for those provided as a result of accidents or
birth defects, cannot be provided.
h) Christian
Science nurses and sanitariums.
2.1.4.2 Provision
of Additional Services
MCPs cannot
enhance the benefits provided to Medicaid enrollees, with the exception
of clinical preventive services as described in Section 3.4.2, without
the prior approval of DHHR." West Virginia RFA, pages 12-13.
"MR/DD and Aged/Disabled
Waivers
The following
services are excluded from the MCP's capitation rates and will be provided
under separate waivers:
MEDICAL SERVICE/
DEFINITION/ SCOPE OF BENEFITS/ LIMITATION ON SERVICES
Aged/Disabled
Waiver/ Community based services for aged/disabled as an alternative to
nursing facility care./ Nursing care, home health chore service, case management,
and any service comparable to that received in a nursing facility./ May
not be provided in a hospital, nursing facility, on ICR/MR. Cost
of service must be less than nursing facility care.
MR/DD Waiver/ Community based services for mentally retarded/developmentally disabled individuals as an alternative to ICR/MR level of care./ Day and residential habitation (aggressive active treatment), respite, transportation, and case management./ May not be provided in a hospital, nursing facility, or ICF/MR. Cost of service must be less than nursing facility care." West Virginia RFA, Appendix A, page A8.
"MCP Covered
Services
The following
charts present as explanation of the medical services which the MCP is
required to provide...The MCP must promptly provide or arrange to make
available for enrollees all medically necessary services listed below and
assume financial responsibility for the provision of these services...
MEDICAL SERVICES/
SCOPE OF BENEFITS/ LIMITATION ON SERVICES
Chiropractor
Services/ Manipulation to correct sublimation. Radiological examinations
related to the service/ Services may mot exceed 40 visits per beneficiary
per year.
Clinic Services/ general clinics, birthing centers and health department clinics, including vaccinations for children...
Handicapped Children's services/ Specialty medical care, diagnosis and treatment./ Services are provider to children under 21with the following diagnoses: cystic fibrosis; myelocystomeningocete/myelodysplasia; congenital birth defects; crainofacial deformities; seizure disorder; and metabolic disorders...
Hospice/ Nursing care, physical services, medical social services, short-term inpatient care, durable medical equipment, drugs, biologicals, home health aide, and homemaker./ Must have physician certification that recipient has a life expectancy of 6 month less. Recipient waives right to other Medicaid services related to the terminal illness...
Nursing Facility Services/ Full range of nursing, social services and therapies./ Pre-Admission screening and annual resident review. Limited to the first 30 consecutive days.
Other Services Speech Therapy Physical therapy Occupational Therapy/ Treatment of other measures provided by speech, physical or occupational therapists to correct or ameliorate and condition within the scope of their practice./ Hearing aid evaluation, hearing aids, hearing aid supplies, batteries and repairs are limited to recipients under age 21. Prior approval required after 10 sessions of occupational therapy and physical therapy. Applied speech therapy requires prior approval...
Podiatry Services/ Treatment for acute conditions, i.e. infections, inflammations, ulcers, bursitis, etc. Surgeries for bunions, ingrown tow nails…/ Treatment of children limited to acute conditions. Routine foot care treatment for flat foot, and sublocations of the foot are not covered.
Private Duty Nursing/ Twenty-four hour nursing care in medically necessary./ Prior required. Limited to children...
Right from the Start Services./ Care coordination and enhanced prenatal care services./ Pregnant women (including adolescent females) to 60 days postpartum and infants less than one year of age...
Vision Services/ Children-exam, lenses, frames, and needed repairs./ Adults limited to medical treatment only. Prescription sunglasses and designer frames are excluded. First pair of eyeglasses after cataract surgery. Contact lenses for adults and children covered for certain diagnosis.
Transportation Emergency/ Emergency: Ambulance and air ambulance/ Emergency: Transportation provided to the nearest resource. By most economical means determined by patient needs. Out-of-state prior authorization." West Virginia RFA, appendix A, pages A1-A5.
"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 -
1. Promptly
provide or arrange for the provision of all services required under s.
49.46(2), Wis. Stats., and HFS 107 Wis. Adm. Code; as further clarified
in all Wisconsin Medical Assistance Program Provider Handbooks and Bulletins,
and HMO Contract Interpretation Bulletins (CIBs) and as otherwise specified
in this Contract except:
a. County
Transportation by common carrier or private motor vehicle… HMOs are required
to arrange for transportation for HealthCheck visits...
b. Milwaukee
County HMOs will provide common carrier transportation to Medicaid enrollees.
Transportation services will be limited to:
• Transporting
Medicaid/HMO members only.
• Transportation
of Medicaid/HMO members to and from Medicaid covered services...
d. Prenatal
Care Coordination.
2. Cover chiropractic services. State law mandates coverage...
7. Be responsible for experimental surgery and procedures as follows: (1) As a general principle, Wisconsin Medicaid does not pay for items that it determines to be experimental in nature. Certain procedures that are covered by Medicaid that are no longer considered experimental are cornea transplants and kidney transplants. HMOs shall cover those services. (2) There are other procedures that are approved only at particular institutions, including bone marrow transplants, liver, heart, heart-lung, lung, and pancreas transplants. HMOs need not cover those services…" Wisconsin Contract, pages 5-7.
"Y. QUALITY
IMPROVEMENT (QI)...
b. The HMO
must have written protocols to ensure that enrolled recipients have access
to screening, diagnosis and referral, and appropriate treatment for those
conditions and services covered under the Wisconsin Medicaid Program…"
Wisconsin Contract, pages 21, 25.