Common use of Covered Benefits and Services Clause in Contracts

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 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. The Contractor shall provide to its HIP 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. 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 servic es 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 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 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: ▪ Criteria On the basis of criteria applied under the State Plan and plan, such as medical necessity determinations. necessity; or ▪ Utilization 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. Per 42 CFR § 400.203, State Plan refers to the comprehensive written commitment by a Medicaid agency, submitted under section 1902(a) of the Social Security Act, to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.

Covered Benefits and Services. The Contractor shall provide to its HIP 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. 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 loc al 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 physicalphys ical, 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 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 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: ▪ Criteria On the basis of criteria applied under the State Plan and plan, such as medical necessity determinations. necessity; or ▪ Utilization 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. Per 42 CFR § 400.203, State Plan refers to the comprehensive written commitment by a Medicaid agency, submitted under section 1902(a) of the Social Security Act, to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.

Covered Benefits and Services. The Contractor shall provide to its HIP 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. 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 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 servicesservices . 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 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: ▪ Criteria On the basis of criteria applied under the State Plan and plan, such as medical necessity determinations. necessity; or ▪ Utilization 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. Per 42 CFR § 400.203, State Plan refers to the comprehensive written commitment by a Medicaid agency, submitted under section 1902(a) of the Social Security Act, to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.

Covered Benefits and Services. The Contractor shall provide to its HIP 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. 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 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 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: ▪ Criteria On the basis of criteria applied under the State Plan and plan, such as medical necessity determinations. necessity; or ▪ Utilization 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. Per 42 CFR § 400.203, State Plan refers to the comprehensive written commitment by a Medicaid agency, submitted under section 1902(a) of the Social Security Act, to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.