Common use of Self-Referral Services Clause in Contracts

Self-Referral Services. In accordance with state and federal requirements, some covered benefits are available to members on a self-referral basis. These services shall not require a physician’s referral or other authorization from the Contractor. The Contractor must include self-referral providers in its contracted network. Note that network is defined as a list of the doctors, other health care providers, and hospitals that the Contractor contracts with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that isn’t contracted with the Contractor is called an “out-of-network provider.” The Contractor may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. However, with the exception of behavioral health and routine dental services, the Contractor cannot require that the members receive such services from network providers. Members may self-refer to any IHCP provider qualified to provide the service(s). When members choose to receive self-referral services from IHCP- enrolled self-referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at a rate not less than 100% of Indiana Medicaid fee-for- service (FFS) rates. ▪ Chiropractic services may be provided by a licensed chiropractor, enrolled as an IHCP provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1. ▪ Eye care services, except surgical services may be provided by any IHCP provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11. ▪ Podiatric services may be provided by any IHCP provider licensed under IC 25-

Self-Referral Services. In accordance with state and federal requirements, the Hoosier Healthwise program includes some covered benefits and services that are available to members on a self-referral basis. These self- referral services shall not require a physicianreferral from the member’s referral PMP or other authorization from the Contractor. The Contractor must shall include self-referral providers in its contracted network. Note that network is defined as a list of the doctors, other health care providers, and hospitals that the Contractor contracts with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that isn’t contracted with the Contractor is called an “out-of-network provider.” The Contractor and its PMPs may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. However, with the exception of behavioral health and routine dental services, the The Contractor cannot require that the members receive such services from network providers. Members Hoosier Healthwise members may self-refer to any IHCP provider qualified to provide the service(s). When Hoosier Healthwise members choose to receive self-referral services from IHCP- IHCP-enrolled self-referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at a rate not less than 10098% of Indiana Medicaid fee-for- service (FFS) FFS rates. ▪ Members may not self-refer to a provider who is not enrolled in IHCP. The following services are considered self-referral services. The Indiana Administrative Code 405 IAC 5 (Hoosier Healthwise) and provides further detail regarding these benefits.  Chiropractic services may be provided by a licensed chiropractor, enrolled as an IHCP Indiana Medicaid provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-1. ▪  Eye care services, except surgical services may be provided by any IHCP provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11. ▪  Routine Dental services may be provided by any in-network licensed dental provider who has entered into a provider agreement under IC 12-15-11.  Podiatric services may be provided by any IHCP provider licensed under IC 25-25-22.5 (doctor of medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11.  Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11.  Family planning services under federal regulation 42 CFR 431.51(b)(2) require a freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Family planning services also include sexually transmitted disease testing. Abortions and abortifacients are not covered family planning services, except as allowable under the federal Hyde Amendment. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services. Under the Contractor’s Hoosier Healthwise line of business, the Contractor shall provide all covered family services and supplies, with the exception of the following items:  Diaphragms  Spermicides  Condoms  Cervical caps  Emergency services are covered without the need for prior authorization or the existence of a Contractor contract with the emergency care provider. Emergency services shall be available twenty four (24)-hours-a-day, seven (7)-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12- 15-12. See Section 3.6 for more information.  Urgent care services are covered for members on a self-referral basis. See Section 5.2.13 for specific urgent care network requirements.  Immunizations are self-referral to any IHCP-enrolled provider. Immunizations are covered regardless of where they are received.  Diabetes self-management services are self-referral if rendered by a self-referral provider. See Section 3.10 for more.  Behavioral health services are self-referral if rendered by an in-network provider. Members may self-refer, within the Contractor’s network, for behavioral health services not provided by a psychiatrist, including mental health, substance abuse and chemical dependency services rendered by mental health specialty providers. The mental health providers to which the member may self-refer within network are:  Outpatient mental health clinics;  Community mental health centers;  Psychologists;  Certified psychologists;  Health services providers in psychology (HSPPs);  Certified social workers;  Certified clinical social workers;  Psychiatric nurses;  Independent practice school psychologists;  Advanced practice nurses under IC 25-23-1-1(b)(3), credentialed in psychiatric or mental health nursing by the American Nurses Credentialing Center; and  Persons holding a master’s degree in social work, marital and family therapy or mental health counseling (under the Clinic Option).