Existing Plans of Care. The contractor shall honor and pay for plans of care for new enrollees, including prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services initiated prior to enrollment with the contractor. Services shall be continued until the enrollee is evaluated by his/her primary care physician and a new plan of care is established with the contractor. The contractor shall use its best efforts to contact the new enrollee or, where applicable, authorized person and/or contractor care manager. However, if after documented, reasonable outreach (i.e., mailers, certified mail, use of MEDM system provided by the State, contact with the Medicaid District Office (MDO), DDD, or DYFS to confirm addresses and/or to request assistance in locating the enrollee) the enrollee fails to respond within 20 working days of certified mail, the contractor may cease paying for the pre-existing service until the enrollee or, where applicable, authorized person, contacts the contractor for re-evaluation.
Existing Plans of Care. The Contractor shall honor and pay for services in interim and established plans of care for new enrollees or when a new benefit is added as a covered service, including MLTSS services, prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services initiated prior to enrollment with the Contractor. Services shall be continued until the enrollee is evaluated by his/her primary care physician or for MLTSS Members, a face-to-face assessment is conducted by the Care Manager and an individualized plan of care is developed to meet the Member’s assessed needs. Contractor Exception: Atypical antipsychotic and anticonvulsant drugs ordered by a non- participating or participating HMO provider will always be covered by the HMO regardless of the treatment plan established by the HMO. The HMO’s formulary and prior authorization requirements will apply only when the initial medication treatment plan is changed.
Existing Plans of Care. The Contractor shall honor and pay for services in interim and established plans of care for new enrollees or when a new benefit is added as a covered service, including MLTSS services, prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services initiated prior to enrollment with the Contractor. Services shall be continued until the enrollee is evaluated by his/her primary care physician, his/her treatment plan changes, and/or a comprehensive needs assessment is completed and an updated plan of care is developed. If the member is receiving State Plan Services (i.e. PCA, PDN, MDC), authorization for services must remain in place until face-to-face re-assessments are completed. For MLTSS Members, services must remain in place until a face-to-face assessment is conducted by the Care Manager and an individualized plan of care is developed to meet the Member’s assessed needs. Contractor Exception: Atypical antipsychotic and anticonvulsant drugs ordered by a non-participating or participating HMO provider will always be covered by the HMO regardless of the treatment plan established by the HMO. The HMO’s formulary and prior authorization requirements will apply only when the initial medication treatment plan is changed.
Existing Plans of Care. The contractor shall honor and pay for plans of care for new enrollees, including prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services initiated prior to enrollment with the contractor. The contractor shall use its best efforts to contact the new enrollee or, where applicable, authorized person and/or contractor care manager. However, if after documented, appropriate, and reasonable outreach (i.e., at least three (3) attempts to reach the enrollees through mailers, certified mail, use of MEDM system provided by the State, contact with the Medical Assistance Customer Center (MACC), DDD, or DYFS/DCF to confirm addresses and/or to request assistance in locating the enrollee) the enrollee fails to respond within 20 working days of certified mail, the contractor may cease paying for the pre-existing service until the enrollee or, where applicable, authorized person, contacts the contractor for re-evaluation.
