Common use of Continuation of Services for Members Clause in Contracts

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware of a pregnant member’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware of a pregnant member’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure nono interruption to services; b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall allow a new member not identified in this Appendix who is transitioning from FFS to the MCP to receive services from network and out-of-network providers, as indicated, if any of the following applyapplies: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility (NF) on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility NF care at the same facility until a medical necessity review is has been completed and, and if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning, or receiving notification, of a pregnant memberwoman’s enrollmentenrollment with the MCP, the MCP shall identify the member’s maternal risk and shall facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The For all members, the MCP shall honor any current FFS prior authorizations approved prior and/or to allow its new members to continue to receive the member’s transition through the expiration of the authorizationfollowing services as provided by Medicaid FFS, regardless of whether the authorized or authorized/treating provider is in or out-of-network with the MCP.: 1. The MCP may conduct a medical necessity review member has been scheduled for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries surgery and has been prior-approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 2. The member is receiving ongoing chemotherapy or radiation treatment; 3. The member has been released from the hospital within 30 days prior to MCP enrollment and is following a treatment plan. 4. OrganAn organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 07.1 and 2.b.vii of Appendix G of this Agreement; ivG; 5. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care Dental services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membershipauthorized, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.have not yet been received;

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware of a pregnant member’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure nono interruption to services; b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education education, but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall must allow a new member not identified in section 33.b. of this Appendix who is transitioning from FFS to an MCP to receive services from network and out-of-network providers, as indicated, if any of the following applyapplies: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility (NF) on the effective date of enrollment with the MCP, the MCP shall must cover the nursing facility NF care at the same facility until a medical necessity review is has been completed and, and if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning, or receiving notification, of a pregnant memberwoman’s enrollmentenrollment with the MCP, the MCP shall must identify the member’s maternal risk and must facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall must allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The For all members, the MCP shall must honor any current FFS prior authorizations approved prior and /or to allow its new members to continue to receive the member’s transition through the expiration of the authorizationfollowing services as provided by Medicaid FFS, regardless of whether the authorized or authorized/treating provider is in or out-of-network with the MCP.: 1. The MCP may conduct a medical necessity review member has been scheduled for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries surgery and has been prior-approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 2. The member is receiving ongoing chemotherapy or radiation treatment; 3. The member has been released from the hospital within 30 days prior to MCP enrollment and is following a treatment plan. 4. OrganAn organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 07.1 and 2.b.vii of Appendix G of this Agreement; ivG; 5. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care Dental services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membershipauthorized, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.have not yet been received;

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning or receiving notification of a pregnant memberwoman’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 07.1 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education education, but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware of a pregnant member’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education education, but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, providers if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning or receiving notification of a pregnant memberwoman’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If service or if there are quality concerns identified with the previously authorized provider. 3iv. The MCP shall provide the following services to the member regardless of whether the authorized or treating provider is in or out-of-network with the MCP: 1. Scheduled inpatient or outpatient surgeries surgery that has been approved and/or pre-pre- certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 23. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 34. Private duty nursingOrgan, home care servicesbone marrow, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision or hematopoietic stem cell transplant pursuant to OAC rule 5160-262-03.1.07.1 and Appendix G of this Agreement; 45. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education education, but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall must allow a new member not identified in section 33.b. of this Appendix who is transitioning from FFS to an MCP to receive services from network and out-of-network providers, as indicated, if any of the following applyapplies: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility (NF) on the effective date of enrollment with the MCP, the MCP shall must cover the nursing facility NF care at the same facility until a medical necessity review is has been completed and, and if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning, or receiving notification, of a pregnant memberwoman’s enrollmentenrollment with the MCP, the MCP shall must identify the member’s maternal risk and must facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall must allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The For all members, the MCP shall must honor any current FFS prior authorizations approved prior and/or to allow its new members to continue to receive the member’s transition through the expiration of the authorizationfollowing services as provided by Medicaid FFS, regardless of whether the authorized or authorized/treating provider is in or out-of-network with the MCP.: 1. The MCP may conduct a medical necessity review member has been scheduled for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries surgery and has been prior-approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 2. The member is receiving ongoing chemotherapy or radiation treatment; 3. The member has been released from the hospital within 30 days prior to MCP enrollment and is following a treatment plan. 4. OrganAn organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 07.1 and 2.b.vii of Appendix G of this Agreement; ivG; 5. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care Dental services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membershipauthorized, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.have not yet been received;

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning or receiving notification of a pregnant memberwoman’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure nono interruption to services; b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 07.1 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education education, but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.

Continuation of Services for Members. The MCP shall allow a new member to receive services from network and out-of-network providers, as indicated, if any of the following apply: i. If the MCP confirms that the Adult Extension member is currently receiving care in a nursing facility on the effective date of enrollment with the MCP, the MCP shall cover the nursing facility care at the same facility until a medical necessity review is completed and, if applicable, a transition to an alternative location has been documented in the member’s care plan. ii. Upon becoming aware learning or receiving notification of a pregnant memberwoman’s enrollment, the MCP shall identify the member’s maternal risk and facilitate connection to services and supports in accordance with ODM’s Guidance for Managed Care Plans for the Provision of Enhanced Maternal Care Services. These services and supports include delivery at an appropriate facility and continuation of progesterone therapy covered by Medicaid FFS or another MCP for the duration of the pregnancy. In addition, the MCP shall allow the pregnant member to continue with an out-of-network provider if she is in her third trimester of pregnancy and/or has an established relationship with an obstetrician and/or delivery hospital. iii. The MCP shall honor any prior authorizations approved prior to the member’s transition through the expiration of the authorization, regardless of whether the authorized or treating provider is in or out-of-network with the MCP. 1. The MCP may conduct a medical necessity review for previously authorized services if the member’s needs change to warrant a change in service. The MCP must render an authorization decision pursuant to OAC rule 5160-26-03. 2. The MCP may assist the member to access services through a network provider when any of the following occur a. The member’s condition stabilizes and the MCP can ensure no b. The member chooses to change to a network provider; or c. If there are quality concerns identified with the previously authorized provider. 3. Scheduled inpatient or outpatient surgeries approved and/or pre-certified shall be covered pursuant to OAC rule 5160-2-40 (surgical procedures would also include follow-up care as appropriate); 4. Organ, bone marrow, or hematopoietic stem cell transplant shall be covered pursuant to OAC rule 5160-2-65 and Appendix G of this Agreement; iv. The MCP shall provide the following services to the member regardless of whether services were prior authorized/pre-certified or the treating provider is in or out-of- network with the MCP: 1. Ongoing chemotherapy or radiation treatment; 2. Hospital treatment plan (if member was released from hospital 30 days prior to enrollment); 3. Private duty nursing, home care services, and Durable Medical Equipment (DME) shall be covered at the same level with the same provider as previously covered until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. 4. Prescribed drugs shall be covered without prior authorization (PA) for at least the first 90 days of membership, or until a provider submits a prior authorization and the MCP completes a medical necessity review, whichever date is sooner. The MCP shall educate the member that further dispensation after the first 90 days will require the prescribing provider to request a PA. If applicable, the MCP shall offer the member the option of using an alternative medication that may be available without PA. Written member education notices shall use ODM-specified model language. Verbal member education may be substituted for written education education, but shall contain the same information as a written notice. Written notices or verbal member education shall be prior approved by ODM. 5. Upon notification from a member and/or provider of a need to continue services, the MCP shall allow a new member to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services.