Basic Benefit Package. After consideration of third party liability, including Medicare coverage pursuant to OAC rules 5160-58-01.1 and 5160-26-09.1, the MCOP shall ensure its members have timely access to all medically necessary medical, drug, emergency and post-stabilization, behavioral health, nursing facility, and home and community-based waiver services covered by Medicaid pursuant to OAC rules 5160-58-03, 5160-58-04, and 42 CFR 438.114 in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to members under FFS Medicaid in accordance with 42 CFR 438.210. This coverage shall be with limited exclusions, limitations, and clarifications (see OAC rule 5160-58-03 and specified in this appendix). The MCOP shall also ensure its members have access to any additional services specified in this Agreement. For information on Medicaid-covered services, the MCOP shall refer to the Ohio Department of Medicaid (ODM) website. Services covered by the MCOP benefit package include: a. Inpatient hospital services; b. Outpatient hospital services; c. Services provided by rural health clinics (RHCs) and federally qualified health centers (FQHCs); d. Physician services whether furnished in the physician’s office, the member’s home, a hospital, or elsewhere; e. Laboratory and x-ray services; f. Screening, diagnosis, and treatment services to children under the age of 21 under the Healthchek, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illness and conditions. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a), including services provided to members with a primary diagnosis of autism spectrum disorder, in excess of state Medicaid plan limits applicable to adults. An EPSDT screening is an examination and evaluation of the general physical and mental health, growth, development, and nutritional status of an individual under age 21. It includes the components set forth in 42 U.S.C. 1396d(r) and shall be provided by plans to children under the age of twenty-one; g. Family planning services and supplies; h. Home health and private duty nursing services in accordance with OAC Chapter 5160-12. State plan home health and private duty nursing services shall be accessed prior to using the same or similar waiver funded services For home health services, the MCP shall not apply a hard limit of 60 calendar days for the authorization period, but rather must prior authorize services in a manner that maximizes the effectiveness of the care provided in accordance with OAC 5160-26- 03.1. The MCOP must take into consideration the member’s specific health needs (e.g., whether the member is covered under Healthchek, and whether the health condition is stable, chronic, and/or debilitating) when determining the length of time for which to authorize services. Individual Care Plans must reflect needs and interventions, including services authorized and provided. i. Podiatry; j. Chiropractic services; k. Physical therapy, occupational therapy, developmental therapy, and speech therapy; l. Nurse-midwife, certified family nurse practitioner, and certified pediatric nurse practitioner services; m. Free-standing birth center services in free-standing birth centers as defined in OAC rule 5160-18- 01; n. Prescribed drugs and Pharmacist services; o. Ambulance and ambulette services; p. Dental services;
Appears in 2 contracts
Samples: Provider Agreement, Provider Agreement
Basic Benefit Package. After consideration of third party liability, including Medicare coverage pursuant to OAC rules 5160-58-01.1 and 5160-26-09.1, the MCOP shall ensure its members have timely access to all medically necessary medical, drug, emergency and post-stabilization, behavioral health, nursing facility, and home and community-based waiver services covered by Medicaid pursuant to OAC rules 5160-58-03, 5160-58-04, and 42 CFR 438.114 in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to members under FFS Medicaid in accordance with 42 CFR 438.210. This coverage shall be with limited exclusions, limitations, and clarifications (see OAC rule 5160-58-03 and specified in this appendix). The MCOP shall also ensure its members have access to any additional services specified in this Agreement. For information on Medicaid-covered services, the MCOP shall refer to the Ohio Department of Medicaid (ODM) website. Services covered by the MCOP benefit package include:
a. Inpatient hospital services;
b. Outpatient hospital services;
c. Services provided by rural health clinics (RHCs) and federally qualified health centers (FQHCs);
d. Physician services whether furnished in the physician’s office, the member’s home, a hospital, or elsewhere;
e. Laboratory and x-ray services;
f. Screening, diagnosis, and treatment services to children under the age of 21 under the Healthchek, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illness and conditions. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a), including services provided to members with a primary diagnosis of autism spectrum disorder, in excess of state Medicaid plan limits applicable to adults. An EPSDT screening is an examination and evaluation of the general physical and mental health, growth, development, and nutritional status of an individual under age 21. It includes the components set forth in 42 U.S.C. 1396d(r) and shall be provided by plans to children under the age of twenty-one;
g. Family planning services and supplies;
h. Home health and private duty nursing services in accordance with OAC Chapter 5160-12. State plan home health and private duty nursing services shall be accessed prior to using the same or similar waiver funded services For home health services, the MCP shall not apply a hard limit of 60 calendar days for the authorization period, but rather must prior authorize services in a manner that maximizes the effectiveness of the care provided in accordance with OAC 5160-26-
03.1. The MCOP MCP must take into consideration the member’s specific health needs (e.g., whether the member is covered under Healthchek, and whether the health condition is stable, chronic, and/or debilitating) when determining the length of time for which to authorize services. Individual Care Plans must reflect needs and interventions, including services authorized and provided.
i. Podiatry;
j. Chiropractic services;
k. Physical therapy, occupational therapy, developmental therapy, and speech therapy;
l. Nurse-midwife, certified family nurse practitioner, and certified pediatric nurse practitioner services;
m. Free-standing birth center services in free-standing birth centers as defined in OAC rule 5160-18- 01;
n. Prescribed drugs and Pharmacist services;
o. Ambulance and ambulette services; ;
p. Dental services;
q. Durable medical equipment and medical supplies, including expedited wheelchair fitting, purchase, maintenance and repair, professional evaluation, home assessment, the services of skilled wheelchair technicians, pick-up and delivery, timely repairs, training, demonstration, and loaner chairs;
r. Vision care services, including eyeglasses;
s. Nursing facility services; t. Hospice care;
Appears in 2 contracts
Samples: Provider Agreement, Provider Agreement
Basic Benefit Package. After consideration of third party liability, including Medicare coverage pursuant to OAC rules 5160-58-01.1 and 5160-26-09.1, the MCOP shall ensure its members have timely access to all medically necessary medical, drug, emergency and post-stabilization, behavioral health, nursing facility, and home and community-based waiver services covered by Medicaid pursuant to OAC rules 5160-58-03, 5160-58-04, and 42 CFR 438.114 in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to members under FFS Medicaid in accordance with 42 CFR 438.210. This coverage shall be with limited exclusions, limitations, and clarifications (see OAC rule 5160-58-03 and specified in this appendix). The MCOP shall also ensure its members have access to any additional services specified in this Agreement. For information on Medicaid-covered services, the MCOP shall refer to the Ohio Department of Medicaid (ODM) website. Services covered by the MCOP benefit package include:.
a. Inpatient hospital services;
b. Outpatient hospital services;
c. Services provided by rural health clinics (RHCs) and federally qualified health centers (FQHCs);
d. Physician services whether furnished in the physician’s office, the member’s home, a hospital, or elsewhere;
e. Laboratory and x-ray services;
f. Screening, diagnosis, and treatment services to children under the age of 21 under the Healthchek, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illness and conditions. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a), including services provided to members with a primary diagnosis of autism spectrum disorder, in excess of state Medicaid plan limits applicable to adults. An EPSDT screening is an examination and evaluation of the general physical and mental health, growth, development, and nutritional status of an individual under age 21. It includes the components set forth in 42 U.S.C. 1396d(r) and shall be provided by plans to children under the age of twenty-one;
g. Family planning services and supplies;
h. Home health and private duty nursing services in accordance with OAC Chapter 5160-12. State plan home health and private duty nursing services shall be accessed prior to using the same or similar waiver funded services For home health servicesservices and private duty nursing, the MCP MCOP shall not apply a hard limit of 60 calendar days for the authorization period, but rather must prior authorize services in a manner that maximizes the effectiveness of the care provided in accordance with OAC 5160-26-in
03.11. The MCOP must take into consideration the member’s specific health needs (e.g., whether the member is covered under Healthchek, and whether the health condition is stable, chronic, and/or debilitating) when determining the length of time for which to authorize services. Individual Care Plans must reflect needs and interventions, including services authorized and provided.
i. Podiatry;
j. Chiropractic services;
k. Physical therapy, occupational therapy, developmental therapy, and speech therapy;
l. Nurse-midwife, certified family nurse practitioner, and certified pediatric nurse practitioner services;
m. Free-standing birth center services in free-standing birth centers as defined in OAC rule 5160-18- 01;
n. Prescribed drugs and Pharmacist services;
o. Ambulance and ambulette services; ;
p. Dental services;
q. Durable medical equipment and medical supplies, including expedited wheelchair fitting, purchase, maintenance and repair, professional evaluation, home assessment, the services of skilled wheelchair technicians, pick-up and delivery, timely repairs, training, demonstration, and loaner chairs;
r. Vision care services, including eyeglasses;
s. Nursing facility services;
t. Hospice care;
u. Behavioral health services including those provided by Ohio Department of Mental Health and Addiction Services (OhioMHAS)-certified providers, as described in OAC Chapter 5160-27. For members under the age of 21, MCOP covered behavioral health services include Child and Adolescent Needs and Strengths (CANS) assessments as described in OAC rule 5160-27-02 and Mobile Response and Stabilization Services (MRSS) as described in OAC rule 5160-27-13.
v. Immunizations, following the coverage requirements provided by ODM for any newly approved vaccine under the Vaccines for Children (VFC) program. The MCOP may, at their discretion, elect to pay non-VFC providers for both the toxoid and the administration of vaccines outside of the VFC program;
w. Preventive services covered by Ohio Medicaid in accordance with Section 4106 of the Affordable Care Act and 42 CFR 440.130(c);
x. All U.S. Preventive Services Task Force (USPSTF) grade A and grade B preventive services and approved vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration, without cost-sharing, as provided in Section 4106 of the Affordable Care Act. Additionally, the MCOP shall cover, without cost-sharing, services specified under Public Health Service Act Section 2713, in alignment with the Alternative Benefit Plan;
y. Screening and counseling for obesity provided during an evaluation and management or preventive medicine visit, as described in OAC rule 5160-1-16.;
z. Telemedicine;
aa. Services for members with a primary diagnosis of Autism Spectrum Disorder (ASD) including coverage mandated by ORC section 1751.84; bb. Home and community-based waiver services as listed in OAC rule 5160-58-04; and cc. Acupuncture services covered by Ohio Medicaid as described in OAC rule 5160-8-51.
Appears in 1 contract
Samples: Provider Agreement
Basic Benefit Package. After consideration of third party liability, including Medicare coverage pursuant to OAC rules 5160-58-01.1 and 5160-26-09.1, the MCOP shall ensure its members have timely access to all medically medically-necessary medical, drug, emergency and post-stabilization, behavioral health, nursing facility, and home and community-based waiver services covered by Medicaid pursuant to OAC rules 5160-58-03, 5160-58-04, and 42 CFR 438.114 in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to members under FFS Medicaid in accordance with 42 CFR 438.210. This coverage shall be with limited exclusions, limitations, and clarifications (see OAC rule 5160-58-03 and specified in this appendix). The MCOP shall also ensure its members have access to any additional services specified in this Agreement. For information on Medicaid-covered services, the MCOP shall refer to the Ohio Department of Medicaid (ODM) website. Services covered by the MCOP benefit package include:
a. Inpatient hospital services;
b. Outpatient hospital services;
c. Services provided by rural health clinics (RHCs) and federally qualified health centers (FQHCs);
d. Physician services whether furnished in the physician’s office, the member’s home, a hospital, or elsewhere;
e. Laboratory and x-ray services;
f. Screening, diagnosis, and treatment services to children under the age of 21 under the Healthchek, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illness and conditions. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a), including services provided to members with a primary diagnosis of autism spectrum disorder, in excess of state Medicaid plan limits applicable to adults. An EPSDT screening is an examination and evaluation of the general physical and mental health, growth, development, and nutritional status of an individual under age 21. It includes the components set forth in 42 U.S.C. 1396d(r) and shall be provided by plans to children under the age of twenty-one;
g. Family planning services and supplies;
h. Home health and private duty nursing services in accordance with OAC Chapter 5160-12. State plan home health and private duty nursing services shall be accessed prior to using the same or similar waiver funded services For home health services, the MCP shall not apply a hard limit of 60 calendar days for the authorization period, but rather must prior authorize services in a manner that maximizes the effectiveness of the care provided in accordance with OAC 5160-26-
03.1. The MCOP must take into consideration the member’s specific health needs (e.g., whether the member is covered under Healthchek, and whether the health condition is stable, chronic, and/or debilitating) when determining the length of time for which to authorize services. Individual Care Plans must reflect needs and interventions, including services authorized and provided.;
i. Podiatry;
j. Chiropractic services;
k. Physical therapy, occupational therapy, developmental therapy, and speech therapy;
l. Nurse-midwife, certified family nurse practitioner, and certified pediatric nurse practitioner services;
m. Free-standing birth center services in free-standing birth centers as defined in OAC rule 5160-18- 01;
n. Prescribed drugs and Pharmacist services;
o. Ambulance and ambulette services; ;
p. Dental services;
q. Durable medical equipment and medical supplies, including expedited wheelchair fitting, purchase, maintenance and repair, professional evaluation, home assessment, the services of skilled wheelchair technicians, pick-up and delivery, timely repairs, training, demonstration, and loaner chairs;
r. Vision care services, including eyeglasses;
s. Nursing facility services; t. Hospice care;
Appears in 1 contract
Samples: Provider Agreement
