Amount, Duration and Scope. At a minimum, the PH-MCO must provide In-Plan Services in the amount, duration and scope set forth in the MA FFS Program and be based on the Recipient's benefit package, unless otherwise specified by the Department. This includes quantitative and non-quantitative treatment limits (QTL) (NQTL) as indicated in state statutes and regulations, the Medicaid state plan and other state policies and procedures. The PH-MCO must provide services that are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. If services or eligible consumers are added to the Pennsylvania MA Program or the HealthChoices Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the PH- MCO must be on the same day as the Department’s, unless the PH- MCO is notified by the Department of an alternative implementation date. The PH-MCO may not arbitrarily deny or reduce the amount, duration or scope of a Medically Necessary service solely because of the Member’s diagnosis, type of illness or condition. Pursuant to 42 C.F.R. §438.3(e)(2)(i) – (iii), the PH-MCO may cover services or settings for enrollees that are in lieu of those covered under the Medicaid State Plan if: • The State determines that the alternative service or setting is a medically appropriate substitute for the covered service or setting under the Medicaid State Plan. • The State determines that the alternative service or setting is a cost effective substitute for the covered service or setting under the Medicaid State Plan. • The enrollee is not required by the PH-MCO to use the alternative service or setting. • The approved in lieu of services are authorized and identified in the PH-MCO contract. • The approved in lieu of services are offered to enrollees at the option of the PH-MCO.
Amount, Duration and Scope. At a minimum, In-Plan Services must be provided in the amount, duration and scope set forth in the MA Fee-for-Service (FFS) Program and be based on the Recipient's benefit package, unless otherwise specified by the Department. The PH-MCO must ensure that the services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. If services or eligible consumers are added to the Pennsylvania MA Program or the HealthChoices Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the PH-MCO must be on the same day as the Department’s, unless the PH-MCO is notified by the Department of an alternative implementation date. If the scope of services or consumers that are the responsibility of the PH-MCO is changed,covered services or the definition of eligible consumers is expanded or reduced,, the Department will determine whether the change is sufficient that an actuarial analysis might conclude that a rate change is appropriate. If yes, the Department will arrange for the actuarial analysis, and the Department will determine whether a rate change is appropriate. The Department will take into account the actuarial analysis, and the Department will consider input from the PH-MCO, when making this determination. At a minimum, the Department will adjust the rates as necessary to maintain actuarial soundness of the rates. If the Department makes a change, the Department will provide the analysis used to determine the rate adjustment. If the scope of services or consumers that are the responsibility of the PH-MCO is changed, upon request by the PH- MCO, the Department will provide written information on whether the rates will be adjusted and how, along with an explanation for the Department’s decision. The Department has established benefit packages based on category of assistance, program status code, age, and, for some packages, the existence of Medicare coverage or a Deprivation Qualifying Code. In cases where the Member benefits are determined by the benefit package, the most comprehensive package remains in effect during the month the Consumer’s category of assistance changes. The PH-MCO may not arbitrarily deny or reduce the amount, duration or scope of a Medically Necessary service solely because of the Member’s diagnosis, type of illness or condition.
Amount, Duration and Scope. At a minimum, the CHC-MCO must provide the Covered Services in Exhibit A, Covered Services List, in the amount, duration, and scope available in the MA FFS Program and in the approved 1915(c) waiver for CHC. The CHC- MCO must provide services that are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished. If services are added to the MA Program or the CHC Program, or if Covered Services are expanded or eliminated, the CHC-MCO must implement such changes on the same day as the Department, unless the CHC-MCO is notified by the Department of an alternative implementation date. The CHC-MCO shall not arbitrarily deny or reduce the amount, duration, or scope of a Covered Service based on a Participant’s diagnosis, disability, or type of illness/condition.
Amount, Duration and Scope. Provider shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition of the member in accordance with 42 CFR 438.210(a)(3)(ii).
Amount, Duration and Scope. At a minimum, In-Plan Services shall be provided in the amount, duration and scope set forth in the MA FFS Program and be based on the MA Consumer's benefit package, unless otherwise specified by the Department. If new services or eligible consumers are added to the Pennsylvania MA Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the Contractor shall be on the same day as the Department's, unless the Contractor is notified by the Department of an alternative implementation date. When new services are added, the Department shall conduct an actuarial analysis including appropriate input by the Contractor, to determine if there is a need for a rate change and if necessary, adjust the rates to appropriately reflect the addition of the new services. The Department has established benefit packages based on category of assistance, program status code, age, and, for some packages, the existence of Medicare coverage or a deprivation qualifying code. In cases where the Member benefits are determined by the benefit package, the most comprehensive package is to be honored.
Amount, Duration and Scope. At a minimum, the CHC-MCO must provide Covered Services in Exhibit EE Covered Services in the amount, duration and scope available in the MA FFS Program and CHC 1915(c)
Amount, Duration and Scope. The Subcontractor shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition of the member [42 CFR 438.210(a)(3)(ii)].
Amount, Duration and Scope. At a minimum, the PH-MCO must provide In-Plan Services in the amount, duration and scope set forth in the MA FFS Program and be based on the Recipient's benefit package, unless otherwise specified by the Department. The PH-MCO must provide services that are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. If services or eligible consumers are added to the Pennsylvania MA Program or the HealthChoices Program, or if covered services or eligible consumers are expanded or eliminated, implementation by the PH-MCO must be on the same day as the Department’s, unless the PH-MCO is notified by the Department of an alternative implementation date. The PH-MCO may not arbitrarily deny or reduce the amount, duration or scope of a Medically Necessary service solely because of the Member’s diagnosis, type of illness or condition.
Amount, Duration and Scope. The PCO must provide Physical and Behavioral Health Services which are, at a minimum, included in the Healthy Pennsylvania Program essential health benefits package designated in Exhibit B of this Agreement. If services or Beneficiaries are added to the Healthy Pennsylvania Program, or if covered services or Beneficiaries are expanded or eliminated, the PCO will implement on the date the PCO is notified by the Department to commence or discontinue services. If the scope of services or Members that are the responsibility of the PCO is changed, covered services or the definition of Beneficiaries is expanded or reduced, or other significant change in the Healthy Pennsylvania Program (as a result of legislative, regulatory or policy changes); the Department will determine whether the change is sufficient that an actuarial analysis might conclude that a rate change is appropriate. The Department then may arrange for the actuarial analysis, and the Department will determine whether a rate change is appropriate. The Department will take into account the actuarial analysis, and will consider input from the PCO, when making this determination. At a minimum, the Department will adjust the rates as necessary to maintain actuarial soundness of the rates. If the Department makes a change, the Department will provide the analysis used to determine the rate adjustment. If the scope of services or Members that are the responsibility of the PCO is changed, upon request by the PCO, the Department will provide written information on whether the rates will be adjusted and how, along with an explanation for the Department’s decision. The PCO, its subcontractors and Network Providers must adopt a definition of “medically necessary services” in accordance with 42 C.F.R. §438.210(a)(4). The PCO may not arbitrarily deny or reduce the amount, duration or scope of a service solely because of a Member’s diagnosis, type of illness or condition. The PCO must pay Medicare deductibles and coinsurance amounts relating to any Medicare-covered service for qualified Medicare beneficiaries. If no contracted PCO rate exists or if the Provider of the service is an Out-of-Network Provider, the PCO must pay deductibles and coinsurance up to the applicable PCO fee schedule for the service. The PCO, its subcontractors and Providers are prohibited from balance billing Members for Medicare deductibles or coinsurance. The PCO must ensure that a Member who is eligible for both the Healthy Pennsylvania ...
Amount, Duration and Scope. Section 1902(a)(10)(B)
