Common use of Coverage and Authorization of Services (42 CFR §438 Clause in Contracts

Coverage and Authorization of Services (42 CFR §438. 210). i. The Contractor shall furnish medically necessary services covered by this Agreement in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid, as set forth in 42 CFR §440.230, and for beneficiaries under the age of 21, as set forth in 42 CFR Section 440, subpart B. ii. The Contractor: a. Shall ensure that the medically necessary services provided are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; and b. Shall not arbitrarily deny or reduce the amount, duration, or scope of a medically necessary service solely because of diagnosis, type of illness, or condition of the beneficiary. iii. The Contractor may place appropriate limits on a service based on criteria applied under the State Plan, such as medical necessity. iv. The Contractor may place appropriate limits on a service for the purpose of utilization control, provided that: a. The services furnished can reasonably achieve their purpose; and b. The services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the enrollee’s ongoing need for such services and supports.

Coverage and Authorization of Services (42 CFR §438. 210). i. The Contractor shall furnish medically necessary services covered by this Agreement in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid, as set forth in 42 CFR §440.230, and for beneficiaries under the age of 21, as set forth in 42 CFR Section 440, subpart B.CFR ii. The Contractor: a. Shall ensure that the medically necessary services provided are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished; and. b. Shall not arbitrarily deny or reduce the amount, duration, or scope of a medically necessary service solely because of diagnosis, type of illness, or condition of the beneficiary. iii. The Contractor may place appropriate limits on a service based on criteria applied under the State Plan, such as medical necessity. iv. The Contractor may place appropriate limits on a service for the purpose of utilization control, provided that: a. The services furnished can reasonably achieve their purpose; and. b. The services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the enrollee’s ongoing need for such services and supports.