Common use of Carved-out Services Clause in Contracts

Carved-out Services. The services described in this section are excluded from the Contractor’s capitation rate; these are referred to as “carved-out” services. The State’s fiscal agent pays claims for carved-out services on a fee-for-service basis for the Contractor’s members. While these services are not the financial responsibility of the Contractor, the Contractor shall ensure coordination of all Medicaid covered services and implement strategies to prevent duplication and fragmentation of care across the healthcare delivery system, including as may result from new initiatives. The Contractor shall maintain strategies to ensure coordination for carved-out services. 3.13.1 Medicaid Rehabilitation Option (MRO) Services MRO services are intensive community-based behavioral health services delivered exclusively by CMHCs. Medicaid members requiring MRO services are assigned a service package based on qualifying diagnosis and level of need, as determined by an individualized assessment conducted by CMHCs. The Contractor is not responsible for claims reimbursement for MRO services but is responsible for ensuring coordination of care for members receiving MRO services. The State shall provide data to the Contractor identifying members receiving MRO services. A complete listing of carved-out MRO services is provided in Contract Exhibit 3 Program Description and Covered Benefits. Further information on the behavioral health services which are the financial responsibility of the Contractor are described in Section 3.10. 3.13.2 1915(i) State Plan Home and Community-Based Services The State has three (3) 1915(i) State Plan Home and Community-Based services programs: Behavioral and Primary Healthcare Coordination (BPHC), Adult Mental Health Habilitation (AMHH) and Child Mental Health Wraparound (CMHW). These services are carved-out of the Contractor’s financial responsibility. The Contractor shall coordinate with 1915(i) service providers to prevent duplication and fragmentation of services. A listing of carved-out 1915(i) services is provided in Contract Exhibit 3 Program Description and Covered Benefits. 3.13.3 Individualized Family Services Plan (IFSP) IFSP services provided under the FSSA First Steps program are carved-out from the Contractor’s financial responsibility. 3.13.4 Individualized Education Plan (IEP) Services IEP services provided by a school are carved-out from the Contractor’s responsibility. The Contractor shall communicate and coordinate with the school to ensure continuity of care and avoid duplication of services. 3.13.5 Carved Out Drug Classes See Section 3.8.6.

Carved-out Services. The services described in this section are excluded from the Contractor’s capitation rate; these are referred to as “carved-out” services. Carved-out services, as defined by the State, include services that are carved out of managed care program coverage, meaning that they are the financial responsibility of the State to provide to managed care members via fee-for-service (FFS) Medicaid benefits. This definition also includes services that could potentially require a managed care member to be disenrolled from a managed care plan and instead be reenrolled into traditional Medicaid to obtain the FFS benefit. The State’s fiscal agent pays claims for carved-out services on a fee-for-service basis for the Contractor’s members. While these services are not the financial responsibility of the Contractor, the Contractor shall ensure coordination of all Medicaid covered services and implement strategies to prevent duplication and fragmentation of care across the healthcare delivery system, including as may result from new initiatives. The Contractor shall maintain strategies to ensure coordination for carved-out services.Contractor EXHIBIT 1. E SCOPE OF WORK 3.13.1 Medicaid Rehabilitation Option (MRO) Services MRO services are intensive community-based behavioral health services delivered exclusively by CMHCs. Medicaid members requiring MRO services are assigned a service package based on qualifying diagnosis and level of need, as determined by an individualized assessment conducted by CMHCs. The Contractor is not responsible for claims reimbursement for MRO services but is responsible for ensuring coordination of care for members receiving MRO services. The State shall provide data to the Contractor identifying members receiving MRO services. A complete listing of carved-out MRO services is provided in Contract Exhibit 3 3.B Program Description and Covered Benefits. Further information on the behavioral health services which are the financial responsibility of the Contractor are described in Section 3.10. 3.13.2 1915(i) State Plan Home and Community-Based Services The State has three (3) 1915(i) State Plan Home and Community-Based services programs: Behavioral and Primary Healthcare Coordination (BPHC), Adult Mental Health Habilitation (AMHH) and Child Mental Health Wraparound (CMHW). These services are carved-out of the Contractor’s financial responsibility. The Contractor shall coordinate with 1915(i) service providers to prevent duplication and fragmentation of services. A listing of carved-out 1915(i) services is provided in Contract Exhibit 3 3.B Program Description and Covered Benefits. 3.13.3 Individualized Family Services Plan (IFSP) IFSP services provided under the FSSA First Steps program are carved-out from the Contractor’s financial responsibility. 3.13.4 Individualized Education Plan (IEP) Services IEP services provided by a school are carved-out from the Contractor’s responsibility. The Contractor shall communicate and coordinate with the school to ensure continuity of care and avoid duplication of services. 3.13.5 Carved Out Drug Classes See Section 3.8.6.