Common use of Covered Benefits Clause in Contracts

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid covered services as detailed in 405 IAC 5. Contract Exhibit 3 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 Care Connect 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:  Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor is prohibited from paying for items or services (other than an emergency item or service, not including items or services furnished in an emergency room or a hospital):  With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid 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 Care Connect 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:  • Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  • Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  • Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor Act and is prohibited from paying for items or services (other than an emergency Emergency item or service, not including items or services furnished in an emergency Emergency room or a hospital):  • With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  • With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  • With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.. EXHIBIT 1 SCOPE OF WORK

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid covered services as detailed in 405 IAC 5. Contract Exhibit 3 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 Care Connect 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:  • Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  • Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  • Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor is prohibited from paying for items or services (other than an emergency item or service, not including items or services furnished in an emergency room or a hospital):  • With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  • With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  • With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid 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 Care Connect 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:  • Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  • Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  • Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor Act and is prohibited from paying for items or services (other than an emergency Emergency item or service, not including items or services furnished in an emergency Emergency room or a hospital):  • With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  • With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  • With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.. EXHIBIT 1.A. SCOPE OF WORK

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid covered services as detailed in 405 IAC 5. Contract Exhibit 3 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 Care Connect 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:  • Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  • Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  • Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor is prohibited from paying for items or services (other than an emergency item or service, not including items or services furnished in an emergency room or a hospital):  • With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  • With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  • With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the EXHIBIT 1.M SCOPE OF WORK provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid covered services as detailed in 405 IAC 5. Contract Exhibit 3 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 Care Connect 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:  • Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  • Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  • Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor is prohibited from paying for items or services (other than an emergency item or service, not including items or services furnished in an emergency room or a hospital):  • With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  • With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  • With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.In

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid 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 Care Connect program in accordance with the terms of the Contract. A covered c overed service is medically necessary if, in a manner consistent with accepted standards of medical practice, it is reasonably expected to:  • Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  • Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  • Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor Act and is prohibited from paying for items or services (other than an emergency Emergency item or service, not including items or services furnished in an emergency Emergency room or a hospital):  • With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  • With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  • With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.. EXHIBIT 1.A. SCOPE OF WORK

Covered Benefits. The Hoosier Care Connect program includes all Indiana Medicaid 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 Care Connect 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:  Prevent or diagnose the onset of an illness, injury, condition, primary disability or secondary disability.  Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability.  Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. In accordance The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act, the Contractor Act and is prohibited from paying for items or services (other than an emergency Emergency item or service, not including items or services furnished in an emergency Emergency room or a hospital):  With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997.  With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan.  With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. In accordance with 42 CFR 438.210(a)(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. 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. In instances where the Contractor pays for a service provided to a Hoosier Care Connect member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Section 12 details which services require copayments and member copayment obligations. The Contractor may place appropriate limits on a service on the basis of 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 7.3.. EXHIBIT 1 SCOPE OF WORK