Common use of Basic Standards Clause in Contracts

Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in Attachment C as promptly and continuously as is consistent with generally accepted standards of medical practice. (B) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished. (C) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the Enrollee. (D) The Contractor may place appropriate limits on a service on the basis of criteria applied under a State Plan such as Medical Necessity, or for the purpose of utilization control, provided: (1) the services furnished can reasonably be expected to achieve their purpose; and (2) the services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports; (3) family planning services are provided in a manner that protects and enables an Enrollee’s freedom to choose the method of family planning to be used.