Common use of Out-of-Network Services Clause in Contracts

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- network provider reimbursement.

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.23.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester as described in Section 3.4, and members with presumptive eligibility seeking initial care3.13, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 85. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles 60) miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-out of network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-of- network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate rate, or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s absence of a negotiated rate, an amount equal to ninety-eight percent (98%) of the Medicaid fee-for-service area within the Contractor’s networkrate. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- network provider reimbursement.EXHIBIT 1.E

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-non- emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-of- network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- assigned provider number for reimbursement. An NPI number shall be sufficient for outout- of-of- network provider reimbursement.

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-15- 44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- Contractor-assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- of-network provider reimbursement.. EXHIBIT 2.I SCOPE OF WORK – HEALTHY INDIANA PLAN

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate rate, or according in the absence of a negotiated rate, an amount equal to administrative code 405 IAC 10ninety-9eight percent (98%) of the Medicaid fee-4 (b) and State statute IC 12for-15-44.5-5service rate. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- Contractor-assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- of-network provider reimbursement.

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-out- of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-of- network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate rate, or according in the absence of a negotiated rate, an amount equal to administrative code 405 IAC 10ninety-9eight percent (98%) of the Medicaid fee-4 (b) and State statute IC 12for-15-44.5-5service rate. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. In HIP, Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- Contractor-assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- of-network provider reimbursement.

Out-of-Network Services. With the exception of certain the self-referral services described in Section 6.23.1, and the requirements requirement to allow continuity of care for pregnant women transferring to with an out-of-network provider during the Contractor in their third trimester first ninety (90) days of the Contract as described in Section 3.43.15, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access adequacy standards set forth described in Section 86.0, the Contractor may require members to seek covered services from in-network providers. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- network care if the Contractor is unable to provide the necessary covered medical services in- network to a member within sixty (60)-miles 60) miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance noticeresidence, the State may also require the Contractor to begin providing shall provide such services out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services network, for as long as the Contractor is unable to provide the covered services them in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the a member for out-of-network services shall must be no greater than it would be if the services were furnished received in-network. The Contractor must cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. However, the Contractor may require non-contracted providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate rate, or according in the absence of a negotiated rate, an amount equal to administrative code 405 IAC 10ninety-9eight percent (98%) of the Medicaid fee-4 (b) and State statute IC 12for-15-44.5-5service rate. Contractors shall The Contractor must make nurse practitioner services available to members. Members shall must be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area areas within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall must inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- Contractor assigned provider number for reimbursement. An NPI A National Provider Identifier (NPI) number shall be sufficient for out-of- of-network provider reimbursement.

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.23.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester as described in Section 3.4, and members with presumptive eligibility seeking initial care3.13, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 85. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles 60) miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-out of network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-out -of- network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate rate, or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s absence of a negotiated rate, an amount equal to ninety -eight percent (98%) of the Medicaid fee-for-service area within the Contractor’s networkrate. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- network provider reimbursement.EXHIBIT 1.E

Out-of-Network Services. With the exception of certain self-referral services described in Section 6.2, and the requirements to allow continuity of care for pregnant women transferring to the Contractor in their third trimester described in Section 3.4, and members with presumptive eligibility seeking initial care, the Contractor may limit its coverage to services EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK provided by in-network providers once the Contractor has met the network access standards set forth in Section 8. However, in accordance with 42 CFR 438.206(b)(4), which relates to coverage of out-of-network services, the Contractor shall authorize and pay for out-of- of-network care if the Contractor is unable to provide necessary covered medical services within sixty (60)-miles of the member’s residence by the Contractor’s provider network. In addition, upon at least thirty (30) calendar days’ advance notice, the State may also require the Contractor to begin providing out-of-network care in the event the Contractor is unable to provide necessary covered medical services within the Contractor’s provider network within specified timeliness standards defined by the State. The Contractor shall authorize these out-of-network services in the timeframes established in Section 9.3.2 and shall adequately cover the services for as long as the Contractor is unable to provide the covered services in-network. The Contractor shall require out-of-network providers to coordinate with the Contractor with respect to payment. Per 42 CFR 438.206(b)(5), the cost to the member for out-of-network services shall be no greater than it would be if the services were furnished in-network. The Contractor may require providers not contracted in the Contractor’s network to obtain prior authorization from the Contractor to render any non-self-referral or non-emergent services to Contractor members. If the out-of-network provider has not obtained such prior authorization, the Contractor may deny payment to that out-of-network provider. The Contractor shall cover and reimburse for all authorized, routine care provided to its members by out-of-network providers. The Contractor shall reimburse any out-of-network provider’s claim for authorized services at a negotiated rate or according to administrative code 405 IAC 10-9-4 (b) and State statute IC 12-15-15- 44.5-5. Contractors shall make nurse practitioner services available to members. Members shall be allowed to use the services of nurse practitioners out-of-network if no nurse practitioner is available in the member’s service area within the Contractor’s network. If nurse practitioner services are available through the Contractor, the Contractor shall inform the member that nurse practitioner services are available. Contractors shall make covered services provided by FQHCs and RHCs available to HIP members out-of-network if an FQHC or RHC is not available in the member’s service area within the Contractor’s network. The Contractor may not require an out-of-network provider to acquire a Contractor- Contractor-assigned provider number for reimbursement. An NPI number shall be sufficient for out-of- of-network provider reimbursement.. EXHIBIT 2.I SCOPE OF WORK – HEALHTY INDIANA PLAN