Common use of CONTRACTOR Physical Health Benefits Chart Clause in Contracts

CONTRACTOR Physical Health Benefits Chart. SERVICE BENEFIT LIMIT Inpatient Hospital Services Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Inpatient rehabilitation hospital facility services are not covered for adults unless determined by the CONTRACTOR to be a cost effective alternative (see Section A.2.6.5). Medicaid/Standard Eligible, Under age 21: As medically necessary, including rehabilitation hospital facility. Outpatient Hospital Services As medically necessary. Physician Inpatient Services As medically necessary. Physician Outpatient Services/Community Health Clinic Services/Other Clinic Services As medically necessary. TennCare Kids Services Medicaid/Standard Eligible, Age 21 and older: Not covered. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem. Screening, interperiodic screening, diagnostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. See Section A.2.7.6. Preventive Care Services As described in Section A.2.7.5. Lab and X-ray Services As medically necessary. Hospice Care As medically necessary. Shall be provided by a Medicare-certified hospice. SERVICE BENEFIT LIMIT Dental Services Dental Services shall be provided by the Dental Benefits Manager or in some cases, through an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation). However, the facility, medical and anesthesia services related to the dental service that are not provided by a dentist or in a dentist’s office shall be covered services provided by the CONTRACTOR when the dental service is covered by the DBM or though an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation). Vision Services Medicaid/Standard Eligible, Age 21 and older: Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), shall be covered as medically necessary. Routine periodic assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are not covered. One pair of cataract glasses or lenses is covered for adults following cataract surgery. Medicaid/Standard Eligible, Under age 21: Preventive, diagnostic, and treatments services (including eyeglasses) are covered as medically necessary in accordance with TennCare Kids requirements. Home Health Care Medicaid /Standard Eligible, Age 21 and older: Covered as medically necessary and in accordance with the definition of Home Health Care at Rule 1200-13-13- .01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Medicaid/Standard Eligible, Under age 21: Covered as medically necessary in accordance with the definition of Home Health Care at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard).

CONTRACTOR Physical Health Benefits Chart. SERVICE BENEFIT LIMIT Inpatient Hospital Services Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Inpatient rehabilitation hospital facility services are not covered for adults unless determined by the CONTRACTOR to be a cost effective alternative (see Section A.2.6.52.6.5). Medicaid/Standard Eligible, Under age 21: As medically necessary, including rehabilitation hospital facility. SERVICE BENEFIT LIMIT Outpatient Hospital Services As medically necessary. Physician Inpatient Services As medically necessary. Physician Outpatient Services/Community Health Clinic Services/Other Clinic Services As medically necessary. TennCare Kids TENNderCare Services Medicaid/Standard EligibleEligibles, Age 21 and older: Not covered. Medicaid/Standard EligibleEligibles, Under age 21: Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem. Screening, interperiodic screening, diagnostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. See Section A.2.7.62.7.5. Preventive Care Services As described in Section A.2.7.52.7.4. Lab and X-ray Services As medically necessary. Hospice Care As medically necessary. Shall be provided by a Medicare-certified hospice. SERVICE BENEFIT LIMIT Dental Services Dental Services shall be provided by the Dental Benefits Manager or in some cases, through an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)Manager. However, the facility, medical and anesthesia services related to the dental service that are not provided by a dentist or in a dentist’s office shall be covered services provided by the CONTRACTOR when the dental service is covered by the DBM or though an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)DBM. This requirement only applies to Medicaid/Standard Eligibles Under age 21. SERVICE BENEFIT LIMIT Vision Services Medicaid/Standard Eligible, Age 21 and older: Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), shall be covered as medically necessary. Routine periodic assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are not covered. One pair of cataract glasses or lenses is covered for adults following cataract surgery. Medicaid/Standard Eligible, Under age 21: Preventive, diagnostic, and treatments services (including eyeglasses) are covered as medically necessary in accordance with TennCare Kids TENNderCare requirements. Home Health Care Medicaid /Standard Eligible, Age 21 and older: Covered as medically necessary and in accordance with the definition of Home Health Care at Rule 1200-13-13- .01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Medicaid/Standard Eligible, Under age 21: Covered as As medically necessary in accordance with Xxxxxxxx. Pharmacy Services Pharmacy services shall be provided by the definition Pharmacy Benefits Manager (PBM), unless otherwise described below. The CONTRACTOR shall be responsible for reimbursement of Home Health Care at Rule 1200-13-13-.01 injectable drugs obtained in an office/clinic setting and to providers providing both home infusion services and the drugs and biologics. The CONTRACTOR shall require that all home infusion claims contain National Drug Code (NDC) coding and unit information to be paid. Services reimbursed by the CONTRACTOR shall not be included in any pharmacy benefit limits established by TENNCARE for TennCare Medicaid) and Rule 1200-13-14-.01 pharmacy services (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standardsee Section 2.6.2.2).

CONTRACTOR Physical Health Benefits Chart. SERVICE BENEFIT LIMIT Inpatient Hospital Services Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Inpatient rehabilitation hospital facility services are not covered for adults unless determined by the CONTRACTOR to be a cost effective alternative (see Section A.2.6.5). Medicaid/Standard Eligible, Under age 21: As medically necessary, including rehabilitation hospital facility. Outpatient Hospital Services As medically necessary. Physician Inpatient Services As medically necessary. Physician Outpatient Services/Community Health Clinic Services/Other Clinic Services As medically necessary. SERVICE BENEFIT LIMIT TennCare Kids Services Medicaid/Standard Eligible, Age 21 and older: Not covered. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem. Screening, interperiodic screening, diagnostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. See Section A.2.7.6. Preventive Care Services As described in Section A.2.7.5. Lab and X-ray Services As medically necessary. Hospice Care As medically necessary. Shall be provided by a Medicare-certified hospice. SERVICE BENEFIT LIMIT Dental Services Dental Services shall be provided by the Dental Benefits Manager or in some cases, through an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)disabilities. However, the facility, medical and anesthesia services related to the dental service that are not provided by a dentist or in a dentist’s office shall be covered services provided by the CONTRACTOR when the dental service is covered by the DBM or though an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)disabilities. Vision Services Medicaid/Standard Eligible, Age 21 and older: Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), shall be covered as medically necessary. Routine periodic assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are not covered. One pair of cataract glasses or lenses is covered for adults following cataract surgery. Medicaid/Standard Eligible, Under age 21: Preventive, diagnostic, and treatments services (including eyeglasses) are covered as medically necessary in accordance with TennCare Kids requirements. SERVICE BENEFIT LIMIT Home Health Care Medicaid /Standard Eligible, Age 21 and older: Covered as medically necessary and in accordance with the definition of Home Health Care at Rule 1200-13-13- .01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Medicaid/Standard Eligible, Under age 21: Covered as medically necessary in accordance with the definition of Home Health Care at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Pharmacy Services Pharmacy services shall be provided by the Pharmacy Benefits Manager (PBM), unless otherwise described below. The CONTRACTOR shall be responsible for reimbursement of injectable drugs obtained in an office/clinic setting and to providers providing both home infusion services and the drugs and biologics. The CONTRACTOR shall require that all home infusion claims contain National Drug Code (NDC) coding and unit information to be paid. Services reimbursed by the CONTRACTOR shall not be included in any pharmacy benefit limits established by TENNCARE for pharmacy services (see Section A.2.6.2.2).

CONTRACTOR Physical Health Benefits Chart. SERVICE BENEFIT LIMIT Inpatient Hospital Services Medicaid/Standard Eligible, Age 21 and older: As medically necessary. Inpatient rehabilitation hospital facility services are not covered for adults unless determined by the CONTRACTOR to be a cost effective alternative (see Section A.2.6.52.6.5). Medicaid/Standard Eligible, Under age 21: As medically necessary, including rehabilitation hospital facility. Outpatient Hospital Services As medically necessary. Physician Inpatient Services As medically necessary. Physician Outpatient Services/Community Health Clinic Services/Other Clinic Services As medically necessary. TennCare Kids SERVICE BENEFIT LIMIT TENNderCare Services Medicaid/Standard Eligible, Age 21 and older: Not covered. Medicaid/Standard Eligible, Under age 21: Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem. Screening, interperiodic screening, diagnostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. See Section A.2.7.62.7.6. Preventive Care Services As described in Section A.2.7.52.7.5. Lab and X-ray Services As medically necessary. Hospice Care As medically necessary. Shall be provided by a Medicare-certified hospice. SERVICE BENEFIT LIMIT Dental Services Dental Services shall be provided by the Dental Benefits Manager or in some cases, through an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)Manager. However, the facility, medical and anesthesia services related to the dental service that are not provided by a dentist or in a dentist’s office shall be covered services provided by the CONTRACTOR when the dental service is covered by the DBM or though an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)DBM. This requirement only applies to Medicaid/Standard Eligibles Under age 21. Vision Services Medicaid/Standard Eligible, Age 21 and older: Services Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), shall be covered as medically necessary. Routine periodic assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are not covered. One pair of cataract glasses or lenses is covered for adults following cataract surgery. Medicaid/Standard Eligible, Under age 2121 : Preventive, diagnostic, and treatments services (including eyeglasses) are covered as medically necessary in accordance with TennCare Kids TENNderCare requirements. SERVICE BENEFIT LIMIT Home Health Care Medicaid /Standard Eligible, Age 21 and older: Care Covered as medically necessary and in accordance with the definition of Home Health Care at Rule 1200-13-13- .01 13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Medicaid/Standard Eligible, Under age 21: Covered as medically necessary in accordance with the definition of Home Health Care at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Pharmacy Services Pharmacy services shall be provided by the Pharmacy Benefits Manager (PBM), unless otherwise described below. The CONTRACTOR shall be responsible for reimbursement of injectable drugs obtained in an office/clinic setting and to providers providing both home infusion services and the drugs and biologics. The CONTRACTOR shall require that all home infusion claims contain National Drug Code (NDC) coding and unit information to be paid. Services reimbursed by the CONTRACTOR shall not be included in any pharmacy benefit limits established by TENNCARE for pharmacy services (see Section 2.6.2.2).

CONTRACTOR Physical Health Benefits Chart. SERVICE BENEFIT LIMIT Inpatient Hospital Services Medicaid/Standard Medicaid Eligible, Age 21 and older: As medically necessary. Inpatient rehabilitation hospital facility services are not covered for adults unless determined by the CONTRACTOR to be a cost effective alternative (see Section A.2.6.52.6.5). Medicaid/Standard Eligible, Under age 21: As medically necessary, including rehabilitation hospital facility. Outpatient Hospital Services As medically necessary. Physician Inpatient Services As medically necessary. Physician Outpatient Services/Community Health Clinic Services/Other Clinic Services As medically necessary. TennCare Kids TENNderCare Services Medicaid/Standard EligibleMedicaid Eligibles, Age 21 and older: Not covered. Medicaid/Standard EligibleEligibles, Under age 21: Covered as medically necessary, except that the screenings do not have to be medically necessary. Children may also receive screenings in-between regular checkups if a parent or caregiver believes there is a problem. Screening, interperiodic screening, diagnostic and follow-up treatment services as medically necessary in accordance with federal and state requirements. See Section A.2.7.62.7.5. Preventive Care Services As described in Section A.2.7.52.7.4. Lab and X-ray Services As medically necessary. Hospice Care As medically necessary. Shall Must be provided by a Medicare-certified hospice. SERVICE BENEFIT LIMIT Dental Services Dental Services shall be provided by the Dental Benefits Manager or in some cases, through an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)Manager. However, the provision of transportation to and from said services as well as the facility, medical and anesthesia services related to the dental service that are not provided by a dentist or in a dentist’s office shall be covered services provided by the CONTRACTOR when the dental service is covered by the DBM or though an HCBS waiver program for persons with intellectual disabilities (i.e., mental retardation)DBM. This requirement only applies to Medicaid/Standard Eligibles Under age 21. Vision Services Medicaid/Standard Medicaid Eligible, Age 21 and older: Medical eye care, meaning evaluation and management of abnormal conditions, diseases, and disorders of the eye (not including evaluation and treatment of refractive state), shall will be covered as medically necessary. Routine periodic assessment, evaluation, or screening of normal eyes and examinations for the purpose of prescribing fitting or changing eyeglass and/or contact lenses are not covered. One pair of cataract glasses or lenses is covered for adults following cataract surgery. Medicaid/Standard Eligible, Under age 21: Preventive, diagnostic, and treatments services (including eyeglasses) are covered as medically necessary in accordance with TennCare Kids TENNderCare requirements. Home Health Care Medicaid /Standard Eligible, Age 21 and older: Covered as medically necessary and in accordance with the definition of Home Health Care at Rule 1200-13-13- .01 (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standard). Prior authorization required for home health nurse and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard). Medicaid/Standard Eligible, Under age 21: Covered as As medically necessary in accordance with Nxxxxxxx. Pharmacy Services Pharmacy services shall be provided by the definition Pharmacy Benefits Manager (PBM), unless otherwise described below. The CONTRACTOR shall be responsible for reimbursement of Home Health Care at Rule 1200-13-13-.01 injectable drugs obtained in an office/clinic setting and to providers providing both home infusion services and the drugs and biologics. The CONTRACTOR shall require that all home infusion claims contain NDC coding and unit information to be paid. Services reimbursed by the CONTRACTOR shall not be included in any pharmacy benefit limits established by TENNCARE for pharmacy services (for TennCare Medicaid) and Rule 1200-13-14-.01 (for TennCare Standardsee Section 2.6.2.2). Prior authorization required for home health nurse Durable Medical Equipment As medically necessary. Specified DME services shall be covered/non-covered in accordance with TennCare rules and home health aide services, as described in Rule 1200-13-13-.04 (for TennCare Medicaid) and 1200-13-14-.04 (for TennCare Standard)regulations.