Covered Benefits and Services. The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services: On the basis of criteria applied under the State plan, such as medical necessity; or For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A), Presumptive Eligibility (Package P) and CHIP (Package C) covered services. The Indiana Administrative Code at 407 IAC 3 sets forth the CHIP Package C covered services and the Indiana Administrative Code 405 IAC 5 details the Medicaid covered services. The Indiana Administrative Code at 405 IAC 2-3.2 sets forth the Package P covered services. Exhibit 3 of the Contract provides a general description of the Hoosier Healthwise benefit packages and the services and benefits that are available. During 2018 Package P members will be transitioned to HIP. Only existing Package P members on 2/1/18 will remain in HHW Package P until determined eligible for Medicaid or the member loses presumptive eligibility coverage.
Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, Part XVIII. PEDIATRIC DENTAL COVERAGE, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein.
Covered Benefits and Services. The Contractor shall provide to its HIP members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered under the Contract with the State. A covered service is medically necessary if it meets the definition as set forth 405 IAC 10-2- 1(30). The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with 42 CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services, regarding: Medical necessity determinations. Utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, Part XVIII. PEDIATRIC DENTAL COVERAGE, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein.
Covered Benefits and Services. HIP covered services include all services, including coverage criteria, limitations and procedures, identified in the HIP alternative benefit plans (ABP) approved by CMS and meeting the requirements as set forth in Section 1937 of the Social Security Act. In the event the requirements of any HIP alternative benefit plan as approved by CMS conflicts with any of the terms of this Contract, the requirements of the alternative benefit plan shall prevail. Exhibit 6 of the Contract provides a general summary description of the different HIP benefit packages and the services and benefits that are available under each. HIP covers the ten essential health benefits, as detailed by the alternative benefit plans: (i) ambulatory patient services; (ii) emergency services; (iii) hospitalization; (iv) maternity and newborn care; (v) mental health and substance use disorder services, including behavioral health treatment; (iv) prescription drugs; (vii) rehabilitative and habilitative services and devices; (viii) laboratory services; (ix) preventive and wellness services and chronic disease management; and
Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein.
Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A) and CHIP (Package C) covered services. The Indiana Administrative Code at 405 IAC 13-2-1 sets forth the CHIP Package C covered services and the Indiana Administrative Code 405 IAC 5 details the Medicaid covered services. In accordance with 42 CFR 438.210(a)(2)-(3), the Contractor must furnish covered services in an amount, duration or scope reasonably expected to achieve the purpose for which the services are furnished and is no less than the amount, duration and scope for the same services provided under Fee for Service Medicaid. 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 beneficiary per 42 CFR 438.210(a)(3)(ii). In instances where the Contractor pays for a service provided to a Hoosier Healthwise member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Per 42 CFR 438.210(a)(4)(i) and CFR 438.210(a)(4)(ii)(A), the Contractor may place appropriate limits on a service on the basis of criteria applied under the State Plan and medical necessity criteria for the purpose of utilization control, provided the services can reasonably be expected to achieve their purpose. Further information on allowable and required utilization control measures is outlined in Section 6.3. The Hoosier Healthwise program includes all Indiana Health Coverage Programs covered services as detailed in 405 IAC 5. Contract Exhibit 3 Program Description and Covered Benefits provides a general description of the covered benefits. The Contractor must cover, at minimum, all benefits and services deemed medically necessary and reasonable and covered under the Hoosier Healthwise program in accordance with the terms of the Contract. A covered service is medically necessary if, in a manner consistent with accepted standards of medical practice, it is reasonably expected to:
Covered Benefits and Services. HIP covered services include all services, including coverage criteria, limitations and procedures, identified in the HIP alternative benefit plans (ABP) approved by CMS and meeting the requirements as set forth in Section 1937 of the Social Security Act. In the event the requirements of any HIP alternative benefit plan as approved by CMS conflicts with any of the terms of this Contract, the requirements of the alternative benefit plan shall prevail. Exhibit 6 of the Contract provides a general summary description of the different HIP benefit packages and the services and benefits that are available under EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK each. HIP covers the ten essential health benefits, as detailed by the alternative benefit plans:
Covered Benefits and Services. The Contractor shall provide to its HIP members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered under the Contract with the State. Medically necessary means services or supplies that: are proper and needed for the diagnosis or treatment of the member’s medical condition, are provided for the diagnosis, direct care, and treatment of the member’s medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of the member or the member’s doctor (see also: 42 CFR § 438.210(a)(5)). Per 45 CFR § 156.115, habilitative services and devices include health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples may include therapy for a child who is not walking or talking at the expected age. These services may also include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Rehabilitative services and devices include health care services and devices to help a member recover from an illness or injury. These services may be given by nurses and physical, occupational, and speech therapists. Examples may include working with a physical therapist to help a member walk and with an occupational therapist to help a member get dressed. In accordance with 42 CFR 438.210(a)(2)-(3), the Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Per 42 CFR 438.210(a)(2), the Contractor must furnish covered services in an amount, duration and scope that is no less than the amount, duration and scope for the same services provided under Fee For Service (FFS) Medicaid. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage of services in amount, duration or scope may not be arbitrarily denied or reduced solely because of diagnosis, type of illness, or condition of the beneficiary per 42 CFR 438.210(a)(3)(ii). Coverage is subject to certain limitations in accordance with 42 CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services, regarding: ▪ Criteria applied under the State Plan and medical necessity determinations. ▪ Utilization control, provided the serv...
