Common use of Pregnancy termination Clause in Contracts

Pregnancy termination. The CONTRACTOR shall pay Claims for State and federally approved pregnancy termination and pregnancy termination related services rendered to eligible Members. The CONTRACTOR shall be reimbursed by HCA for Medical Pregnancy Termination services as directed by HCA in the New Mexico Medicaid Billing Manual. The CONTRACTOR shall be reimbursed for paid Claims at either the established Medicaid fee schedule or the contracted rate in the provider agreement, whichever is greater, as of the date of service, plus GRT as applicable. HCA shall reimburse the CONTRACTOR with State funds for State-funded services and State funds and federal match for federally-funded services via invoicing methodology. Non-Contract Providers for Women in the Third Trimester of Pregnancy If a pregnant woman in the third trimester of pregnancy has an established relationship with an obstetrical provider and desires to continue that relationship, and the Provider is not a Contract Provider, the CONTRACTOR shall reimburse the Non-Contract Provider in accordance with the applicable Medicaid fee schedule appropriate to the provider type. Reimbursement for Members Who Disenroll or Whose Enrollment is Suspended While Hospitalized If a Member is hospitalized at the time of enrollment or disenrollment, the payor at the date of admission shall be responsible for payment of all covered inpatient facility and professional services provided within a licensed acute care facility, non-psychiatric specialty unit, or hospitals as designated by the DOH until the date of discharge. Upon discharge, the Member becomes the financial responsibility of HCA or the MCO receiving Capitation Payments during the month in which the Member is enrolled. Discharge, for the purposes of this Agreement, shall mean: (i) when a Member is moved from or to a PPS exempt unit (such as a rehabilitation or psychiatric unit) within an acute care hospital; (ii) when a Member is moved from or to a specialty hospital as designated by DOH or HCA; (iii) when a Member is moved from or to a PPS exempt hospital (such as a psychiatric or rehabilitation hospital); (iv) when a Member leaves the acute care hospital setting to a community setting; and (v) when a Member leaves the acute care hospital setting to an institutional setting. For (v), the “discharge” date is based upon approval of the abstract and/or approval by HCA. It is not a “discharge” when a Member is moved from one (1) acute care facility to another acute care facility, including out-of-State acute care facilities. If a Member is hospitalized and is disenrolled from a MCO due to a loss in Medicaid coverage, the MCO is only financially liable for the inpatient hospitalization and associated professional services until such time that the Member is determined to be ineligible for Medicaid. If a Member is in a NF at the time of disenrollment (not including loss of Medicaid eligibility) the CONTRACTOR shall be responsible for the payment of all Covered Services until the date of discharge or the date of disenrollment, whichever occurs first. State-Operated LTC Facilities The CONTRACTOR shall negotiate rate(s) and enter into agreements with DOH for State-operated LTC facilities. Compensation for UM Activities The CONTRACTOR shall ensure that, consistent with 42 C.F.R. § 438.3(i) and 422.208, compensation to individuals or entities that conduct UM activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue services to any Member. Pharmacy Services HCA maintains a Preferred Drug List (PDL) for covered outpatient prescription drugs in certain therapeutic classes. The CONTRACTOR shall adopt HCA’s PDL and prior authorization criteria for all drug classes listed on HCA’s PDL. Upon notice of any upcoming changes to HCA’s PDL prior authorization criteria, HCA will provide the CONTRACTOR at least sixty (60) Calendar Days advance notice to implement the updated PDL or prior authorization criteria on the effective date identified by HCA. HCA’s PDL shall be made available on the HCA website. The CONTRACTOR shall make its Formulary available to its Providers and Members through electronic prescribing tools and as a link on the CONTRACTOR’s website. HCA shall provide the CONTRACTOR with a list of drugs included on the HCA PDL by NDC number and drug name on a monthly basis. The CONTRACTOR shall not include any drugs on HCA’s PDL in any other rebate arrangements. Drugs included on HCA’s PDL may still be subject to edits, including but not limited to, prior authorization requirements for clinical appropriateness. However, the CONTRACTOR shall ensure that access to a drug on the HCA PDL is no more restrictive than HCA’s requirements applicable to that product. The CONTRACTOR shall ensure that drugs are dispensed in the preferred form as indicated by HCA (generic or brand name) or the prescriber has indicated in writing or indicated on e-scribing that the branded product is medically necessary. If a branded product is on HCA’s PDL, the CONTRACTOR shall consider the generic form non-preferred and shall not require the prescriber to indicate in writing that the branded product is medically necessary.

Pregnancy termination. The CONTRACTOR shall pay Claims for State and federally approved pregnancy termination and pregnancy termination related services rendered to eligible Members. The CONTRACTOR shall be reimbursed by HCA HSD for Medical Pregnancy Termination services as directed by HCA HSD in the New Mexico Medicaid Billing Manual. The CONTRACTOR shall be reimbursed for paid Claims at either the established Medicaid fee schedule or the contracted rate in the provider agreement, whichever is greater, as of the date of service, plus GRT as applicable. HCA HSD shall reimburse the CONTRACTOR with State funds for State-funded services and State funds and federal match for federally-funded services via invoicing methodology. Non-Contract Providers for Women in the Third Trimester of Pregnancy If a pregnant woman in the third trimester of pregnancy has an established relationship with an obstetrical provider and desires to continue that relationship, and the Provider is not a Contract Provider, the CONTRACTOR shall reimburse the Non-Contract Provider in accordance with the applicable Medicaid fee schedule appropriate to the provider type. Reimbursement for Members Who Disenroll or Whose Enrollment is Suspended While Hospitalized If a Member is hospitalized at the time of enrollment or disenrollment, the payor at the date of admission shall be responsible for payment of all covered inpatient facility and professional services provided within a licensed acute care facility, non-psychiatric specialty unit, or hospitals as designated by the DOH until the date of discharge. Upon discharge, the Member becomes the financial responsibility of HCA HSD or the MCO receiving Capitation Payments during the month in which the Member member is enrolled. Discharge, for the purposes of this Agreement, shall mean: (i) when a Member is moved from or to a PPS exempt unit (such as a rehabilitation or psychiatric unit) within an acute care hospital; (ii) when a Member is moved from or to a specialty hospital as designated by DOH or HCAHSD; (iii) when a Member is moved from or to a PPS exempt hospital (such as a psychiatric or rehabilitation hospital); (iv) when a Member leaves the acute care hospital setting to a community setting; and (v) when a Member leaves the acute care hospital setting to an institutional setting. For (v), the “discharge” date is based upon approval of the abstract and/or approval by HCAHSD. It is not a “discharge” when a Member is moved from one (1) acute care facility to another acute care facility, including out-of-State acute care facilities. If a Member is hospitalized and is disenrolled from a MCO due to a loss in Medicaid coverage, the MCO is only financially liable for the inpatient hospitalization and associated professional services until such time that the Member is determined to be ineligible for Medicaid. If a Member is in a NF at the time of disenrollment (not including loss of Medicaid eligibility) the CONTRACTOR shall be responsible for the payment of all Covered Services until the date of discharge or the date of disenrollment, whichever occurs first. State-Operated LTC Facilities The CONTRACTOR shall negotiate rate(s) and enter into agreements with DOH for State-operated LTC facilities. Compensation for UM Activities The CONTRACTOR shall ensure that, consistent with 42 C.F.R. § 438.3(i) and 422.208, compensation to individuals or entities that conduct UM activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue services to any Member. Pharmacy Services HCA HSD maintains a Preferred Drug List (PDL) for covered outpatient prescription drugs in certain therapeutic classes. The CONTRACTOR shall adopt HCAHSD’s PDL and prior authorization criteria for all drug classes listed on HCAHSD’s PDL. Upon notice of any upcoming changes to HCAHSD’s PDL or prior authorization criteria, HCA HSD will provide the CONTRACTOR at least sixty thirty (6030) Calendar Days advance notice to implement the updated PDL or prior authorization criteria on the effective date identified by HCAHSD. HCAHSD’s PDL shall be made available on the HCA HSD website. The CONTRACTOR shall make its Formulary available to its Providers and Members through electronic prescribing tools and as a link on the CONTRACTOR’s website. HCA HSD shall provide the CONTRACTOR with a list of drugs included on the HCA HSD’s PDL by NDC number and drug name on a monthly quarterly basis. The CONTRACTOR shall not include any drugs on HCAHSD’s PDL in any other rebate arrangements. Drugs included on HCAHSD’s PDL may still be subject to edits, including but not limited to, prior authorization requirements for clinical appropriateness. However, the CONTRACTOR shall ensure that access to a drug on the HCA HSD’s PDL is no more restrictive than HCAHSD’s PDL requirements applicable to that product. The CONTRACTOR shall ensure that drugs are dispensed in the preferred generic form unless otherwise required as indicated by HCA (generic or brand name) on HSD’s PDL or the prescriber has indicated in writing or indicated on e-scribing that the branded product is medically necessary. If a branded product is on HCAHSD’s PDL, the CONTRACTOR shall consider the generic form non-preferred and shall not require the prescriber to indicate in writing that the branded product is medically necessary.