Common use of Amount, Duration and Scope Clause in Contracts

Amount, Duration and Scope. At a minimum, In-Plan Services must be provided in the amount, duration and scope set forth in the MA Fee-for-Service (FFS) Program and be based on the Recipient's benefit package, unless otherwise specified by the Department. The PH-MCO must ensure that the services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. If services or eligible consumers are added to the Pennsylvania MA Program or the HealthChoices Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the PH-MCO must be on the same day as the Department’s, unless the PH-MCO is notified by the Department of an alternative implementation date. If the scope of services or consumers that are the responsibility of the PH-MCO is changed,covered services or the definition of eligible consumers is expanded or reduced,, the Department will determine whether the change is sufficient that an actuarial analysis might conclude that a rate change is appropriate. If yes, the Department will arrange for the actuarial analysis, and the Department will determine whether a rate change is appropriate. The Department will take into account the actuarial analysis, and the Department will consider input from the PH-MCO, when making this determination. At a minimum, the Department will adjust the rates as necessary to maintain actuarial soundness of the rates. If the Department makes a change, the Department will provide the analysis used to determine the rate adjustment. If the scope of services or consumers that are the responsibility of the PH-MCO is changed, upon request by the PH- MCO, the Department will provide written information on whether the rates will be adjusted and how, along with an explanation for the Department’s decision. The Department has established benefit packages based on category of assistance, program status code, age, and, for some packages, the existence of Medicare coverage or a Deprivation Qualifying Code. In cases where the Member benefits are determined by the benefit package, the most comprehensive package remains in effect during the month the Consumer’s category of assistance changes. The PH-MCO may not arbitrarily deny or reduce the amount, duration or scope of a Medically Necessary service solely because of the Member’s diagnosis, type of illness or condition.

Amount, Duration and Scope. ‌ At a minimum, In-Plan Services must be provided in the amount, duration and scope set forth in the MA Fee-for-Service (FFS) Program and be based on the Recipient's benefit package, unless otherwise specified by the Department. The PH-MCO must ensure that the services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. If services or eligible consumers are added to the Pennsylvania MA Program or the HealthChoices Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the PH-MCO must be on the same day as the Department’s, unless the PH-MCO is notified by the Department of an alternative implementation date. If the scope of services or consumers that are the responsibility of the PH-MCO is changed,, covered services or the definition of eligible consumers is expanded or reduced,, ; the Department will determine whether the change is sufficient that an actuarial analysis might conclude that a rate change is appropriate. If yes, the Department will arrange for the actuarial analysis, and the Department will determine whether a rate change is appropriate. The Department will take into account the actuarial analysis, and the Department will consider input from the PH-MCO, when making this determination. At a minimum, the Department will adjust the rates as necessary to maintain actuarial soundness of the rates. If the Department makes a change, the Department will provide the analysis used to determine the rate adjustment. If the scope of services or consumers that are the responsibility of the PH-MCO is changed, upon request by the PH- MCO, the Department will provide written information on whether the rates will be adjusted and how, along with an explanation for the Department’s decision. The Department has established benefit packages based on category of assistance, program status code, age, and, for some packages, the existence of Medicare coverage or a Deprivation Qualifying Code. In cases where the Member benefits are determined by the benefit package, the most comprehensive package remains in effect during the month the Consumer’s category of assistance changes. The PH-MCO may not arbitrarily deny or reduce the amount, duration or scope of a Medically Necessary service solely because of the Member’s diagnosis, type of illness or condition.

Amount, Duration and Scope. At a minimum, In-Plan Services must be provided in the amount, duration and scope set forth in the MA Fee-for-Service (FFS) Program and be based on the Recipient's benefit package, unless otherwise specified by the Department. The PH-MCO must ensure that the services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. If services or eligible consumers are added to the Pennsylvania MA Program or the HealthChoices Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the PH-MCO must be on the same day as the Department’s, unless the PH-MCO is notified by the Department of an alternative implementation date. If the scope of services or consumers that are the responsibility of the PH-MCO is changed,, covered services or the definition of eligible consumers is expanded or reduced,, ; the Department will determine whether the change is sufficient that an actuarial analysis might conclude that a rate change is appropriate. If yes, the Department will arrange for the actuarial analysis, and the Department will determine whether a rate change is appropriate. The Department will take into account the actuarial analysis, and the Department will consider input from the PH-MCO, when making this determination. At a minimum, the Department will adjust the rates as necessary to maintain actuarial soundness of the rates. If the Department makes a change, the Department will provide the analysis used to determine the rate adjustment. If the scope of services or consumers that are the responsibility of the PH-MCO is changed, upon request by the PH- MCO, the Department will provide written information on whether the rates will be adjusted and how, along with an explanation for the Department’s decision. The Department has established benefit packages based on category of assistance, program status code, age, and, for some packages, the existence of Medicare coverage or a Deprivation Qualifying Code. In cases where the Member benefits are determined by the benefit package, the most comprehensive package remains in effect during the month the Consumer’s category of assistance changes. The PH-MCO may not arbitrarily deny or reduce the amount, duration or scope of a Medically Necessary service solely because of the Member’s diagnosis, type of illness or condition.