Common use of Amount, Duration and Scope Clause in Contracts

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, 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'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 '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, 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- PH­ MCO must be on the same day as the Department’s, unless the PH- 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. CFR §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, 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. CFR §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. ‌ a. General - 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-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 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. . b. In Lieu Of Services - Pursuant to 42 C.F.R. §438.3(e)(2)(i) – (iii), the PH-MCO may cover services or settings for enrollees 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 cost- e ffe c ti v e substitute for the covered service or setting under the Medicaid State Plan. • The enrollee PH-MCO is not required to offer the In Lieu of Service to its members. • The Enrollee is not required by the PH-MCO to use the alternative service or setting. • The approved in lieu In Lieu of services Services are authorized and identified in the PH-MCO contractMCO’s Agreement. As of the date of this Agreement, there are no approved In Lieu of Services for PH-MCOs. • The approved in lieu In Lieu of services Services are offered to enrollees Enrollees at the option of the PH-MCO. • The In Lieu of Services do not violate any applicable federal requirements, including 42 CFR § 438.3(e)(2), general prohibitions on payment for room and board costs under Title XIX of the Social Security Act, the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, and the Emergency Medical Treatment and Labor Act. Refer to Exhibit I for additional information regarding In Lieu of Services.

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.