Covered Benefits and Services Sample Clauses

Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A), Presumptive Eligibility (Package P) and CHIP (Package C) covered services. The Indiana Administrative Code at 407 IAC 3 sets forth the CHIP Package C covered services and the Indiana Administrative Code 405 IAC 5 details the Medicaid covered services. The Indiana Administrative Code at 405 IAC 2-3.2 sets forth the Package P covered services. Exhibit 3 of the Contract provides a general description of the Hoosier Healthwise benefit packages and the services and benefits that are available. During 2018 Package P members will be transitioned to HIP. Only existing Package P members on 2/1/18 will remain in HHW Package P until determined eligible for Medicaid or the member loses presumptive eligibility coverage.

Covered Benefits and Services. The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  On the basis of criteria applied under the State plan, such as medical necessity; or  For the purpose of utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network Providers in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, Part XVIII. PEDIATRIC DENTAL COVERAGE, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Providers within the Service Area, and AvMed will have no liability or obligation whatsoever on account of services or benefits sought or received by any Member from any Out-of-Network Provider or other person, institution or organization, unless prior arrangements have been made for the Member and confirmed by written referral or Prior Authorization from AvMed. b. Primary care services must be received from your designated PCP on record with AvMed. This means that if you receive services from a PCP other than the one we have on record for you, the services will not be covered by us, and you will be solely responsible for the cost of such services. c. You must have a referral from your PCP before visiting a Specialty Physician, in order for services to be covered. Except as provided for chiropractors, dermatologists, OB/GYNs and podiatrists, if you receive Specialty Physician services without the proper referral from your PCP the services will not be covered by us, and you will be solely responsible for the cost of such services. d. Members may access participating chiropractors, podiatrists, and OB/GYNs without the need for a referral or Prior Authorization. Coverage for such services is subject to Medical Necessity and utilization management guidelines, as well as any applicable benefit maximums described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES or Exclusions described in Part XI.

Covered Benefits and Services. HIP covered services include all services, including coverage criteria, limitations and procedures, identified in the HIP alternative benefit plans (ABP) approved by CMS and meeting the requirements as set forth in Section 1937 of the Social Security Act. In the event the requirements of any HIP alternative benefit plan as approved by CMS conflicts with any of the terms of this Contract, the requirements of the alternative benefit plan shall prevail. Exhibit 6 of the Contract provides a general summary description of the different HIP benefit packages and the services and benefits that are available under each. HIP covers the ten essential health benefits, as detailed by the alternative benefit plans: (i) ambulatory patient services; (ii) emergency services; (iii) hospitalization; (iv) maternity and newborn care; (v) mental health and substance use disorder services, including behavioral health treatment; (iv) prescription drugs; (vii) rehabilitative and habilitative services and devices; (viii) laboratory services; (ix) preventive and wellness services and chronic disease management; and (x) pediatric services. Except as otherwise stated in this Scope of Work, HIP covered services are subject to a $2,500 annual deductible, to be paid with POWER Account funds. In addition, HIP will cover additional pregnancy-only benefits which will only be available for pregnant HIP members enrolled in either the HIP Plus or HIP Basic plans. The additional pregnancy-only benefits are specified in the applicable ABP and include such services as non- emergency transportation, chiropractic manipulations, vision and dental. The Contractor shall reimburse both in- and out-of-network HIP providers for covered services at a rate not less than 1) Medicare reimbursement or 2) 130% of Medicaid rates if the service does not have a Medicare reimbursement rate. Pursuant to 405 IAC 10-8- 1(b), in instances where the Contractor pays for a service at the Medicare rate, any cost- sharing typically applicable in the Medicare program is not applicable and will be included in the rate paid by the Contractor. However, in instances where the Contractor pays for a service provided to a HIP Basic member, the Contractor shall exclude the amount of the required HIP Basic copayment from the rates paid to the provider.

Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A) and CHIP (Package C) covered services. The Indiana Administrative Code at 405 IAC 13-2-1 sets forth the CHIP Package C covered services and the Indiana Administrative Code 405 IAC 5 details the Medicaid covered services. In accordance with 42 CFR 438.210(a)(2)-(3), the Contractor must furnish covered services in an amount, duration or scope reasonably expected to achieve the purpose for which the services are furnished and is no less than the amount, duration and scope for the same services provided under Fee for Service Medicaid. The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary per 42 CFR 438.210(a)(3)(ii). In instances where the Contractor pays for a service provided to a Hoosier Healthwise member, the Contractor shall exclude the amount of the required copayment from the rates paid to the provider. Per 42 CFR 438.210(a)(4)(i) and CFR 438.210(a)(4)(ii)(A), the Contractor may place appropriate limits on a service on the basis of criteria applied under the State Plan and medical necessity criteria for the purpose of utilization control, provided the services can reasonably be expected to achieve their purpose. Further information on allowable and required utilization control measures is outlined in Section 6.3. The Hoosier Healthwise program includes all Indiana Health Coverage Programs covered services as detailed in 405 IAC 5. Contract Exhibit 3.A Program Description and Covered Benefits provides a general description of the covered benefits. The Contractor must cover, at minimum, all benefits and services deemed medically necessary and reasonable and covered under the Hoosier Healthwise program in accordance with the terms of the Contract. A covered service is medically necessary if, in a manner consistent with accepted standards of medical practice, it is reasonably expected to: 1. Not be more restrictive than the State Fee for Service Medicaid program, including Quantitative and Non-Quantitative Treatment Limits, as indicated in State statutes and regulations, the Contractor’s and other State policies and procedures per 42 CFR 438.210(a)(5)(i). 2. Address the prevention, diagnosis, and treatment of an enrollee’s disease, onset of an illness, injury, condition, primary disability or secondary disability, and/or disorder that results in health impairments and/o...

Covered Benefits and Services. The Contractor shall provide to its HIP members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered under the Contract with the State. Medically necessary means services or supplies that: are proper and needed for the diagnosis or treatment of the member’s medical condition, are provided for the diagnosis, direct care, and treatment of the member’s medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of the member or the member’s doctor (see also: 42 CFR § 438.210(a)(5)). Per 45 CFR § 156.115, habilitative services and devices include health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples may include therapy for a child who is not walking or talking at the expected age. These services may also include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Rehabilitative services and devices include health care services and devices to help a member recover from an illness or injury. These services may be given by nurses and physical, occupational, and speech therapists. Examples may include working with a physical therapist to help a member walk and with an occupational therapist to help a member get dressed. In accordance with 42 CFR 438.210(a)(2)-(3), the Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Per 42 CFR 438.210(a)(2), the Contractor must furnish covered services in an amount, duration and scope that is no less than the amount, duration and scope for the same services provided under Fee For Service (FFS) Medicaid. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage of services in amount, duration or scope may not be arbitrarily denied or reduced solely because of diagnosis, type of illness, or condition of the beneficiary per 42 CFR 438.210(a)(3)(ii). Coverage is subject to certain limitations in accordance with 42 CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services, regarding: ▪ Criteria applied under the State Plan and medical necessity determinations. ▪ Utilization control, provided the serv...

Covered Benefits and Services. The Contractor shall provide to its HIP members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered under the Contract with the State. A covered service is medically necessary if it meets the definition as set forth 405 IAC 10-2- 1(30). The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with 42 CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services, regarding:  Medical necessity determinations.  Utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

Covered Benefits and Services. HIP covered services include all services, including coverage criteria, limitations and procedures, identified in the HIP alternative benefit plans (ABP) approved by CMS and meeting the requirements as set forth in Section 1937 of the Social Security Act. In the event the requirements of any HIP alternative benefit plan as approved by CMS conflicts with any of the terms of this Contract, the requirements of the alternative benefit plan shall prevail. Exhibit 6 of the Contract provides a general summary description of the different HIP benefit packages and the services and benefits that are available under each. HIP covers the ten essential health benefits, as detailed by the alternative benefit plans: (i) ambulatory patient services; (ii) emergency services; (iii) hospitalization; (iv) maternity and newborn care; (v) mental health and substance use disorder services, including behavioral health treatment; (iv) prescription drugs; (vii) rehabilitative and habilitative services and devices; (viii) laboratory services; (ix) preventive and wellness services and chronic disease management; and

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, Part XVIII. PEDIATRIC DENTAL COVERAGE, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Plan creates three benefit payment levels: one for services provided by AvMed Participating In-Network Providers, a second for services provided by PHCS Network Providers, and a third for services provided by Out-of-Network Providers. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of the AvMed Choice Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.