Common use of Covered Benefits and Services Clause in Contracts

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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Entrust Plan, 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 Under this Entrust Plan, 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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by InParticipating Physicians and Providers or Non-Network Providers 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. Except 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 Emergency Medical Services reimbursing AvMed for the services and Care as supplies received. b. The AvMed Empower Plan creates three benefit payment levels: one for services provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from by In-Network Providers within the Service AreaTier A Providers, a second for services provided by In-Network Tier B Providers, and AvMed will have no liability or obligation whatsoever on account of a third for services or benefits sought or received provided by any Member from any Out-of-Network Provider Providers. Your choice of Health Professional or other personfacility, institution or organizationand wise use of these benefits, unless prior arrangements have been made for can save you money. The Benefit Level this Plan will pay depends on the Member and confirmed by written referral or Prior Authorization from AvMedHealth Professional and/or facility you select to provide covered Health Care Services. b. Primary care services must be received from i. If the Health Professional or facility used is part of the Tier A Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in 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 Schedule of such servicesBenefits. c. You must have a referral from ii. If the Health Professional or facility used is part of the Tier B Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in 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 Schedule of such servicesBenefits. d. Members may access participating chiropractorsiii. If the Health Professional or facility used is an Out-of-Network Provider, podiatrists, and OB/GYNs without benefits for Covered Services are payable at 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 Non-Participating low Benefit Level shown in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES or Exclusions described in Part XIyour Schedule of Benefits.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Elect Plan, 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 If a referral from your PCP before visiting a Specialty PhysicianMember does not follow the access rules described herein, 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 he risks having the services will and supplies received not be covered by us, and you will be solely responsible for the cost of such servicesunder this Contract. 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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Entrust Plan, 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 Under this Entrust Plan, 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. Members are entitled to receive Covered Benefits and Services only as specified hereindescribed in this Contract, 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 hereinmade a part of this Contract. 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 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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network Providers or Out-of-Nework 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 hereinmade a part of this Contract. a. Except 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 Emergency Medical Services reimbursing AvMed for the services and Care as supplies received. b. The AvMed Choice Plan creates two benefit payment levels: one for services provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from by AvMed In-Network Providers providers within the Service Area, or provided by PHCS providers located outside the Service Area; and AvMed will have no liability or obligation whatsoever on account of a second for services or benefits sought or received provided by any Member from any Out-of-Network Provider Providers. Your choice of Health Professional or other personfacility, institution or organizationand wise use of these benefits, unless prior arrangements have been made for the Member and confirmed by written referral or Prior Authorization from AvMedcan save you money. b. Primary care services must be received i. If the Health Professional or facility is an In-Network Provider inside the Service Area, or the Health Professional or facility is a PHCS provider and is outside the Service Area, benefits for Covered Services are payable at the high Benefit Level shown in your Schedule of Benefits. NOTE: Covered Services from PHCS providers are only payable at the high Benefit Level when the PHCS provider is located outside the Service Area. ii. If the Health Professional or facility is an Out-of-Network Provider, or is a PHCS provider located inside the Service Area, benefits for Covered Services are payable at the low Benefit Level shown in 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 Schedule of such servicesBenefits. c. You must Members choosing In-Network Providers while inside the Service Area, or PHCS providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers, or PHCS providers while inside the Service Area, will 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 pay higher Deductibles and podiatrists, if you receive Specialty Physician services without the proper referral from your PCP the services will not be covered by usCoinsurance, and you will also be solely responsible at risk for the cost provider fees that are in excess of such servicesallowable charges. 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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Focus Plan, 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 Under this Focus Plan, 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. Members are entitled The MCO must provide to receive Covered Benefits its Hoosier Healthwise members, at a minimum, all benefits and Services only services deemed “medically reasonable and necessary” (as specified herein, appropriately prescribed or directed by Indefined in 405 IAC 5-Network Providers 2-17) and covered under the MCO contract with OMPP. The MCO must provide free oral interpretation services to its members seeking healthcare-related services in conformity a provider’s service location in accordance with Part II42 CFR 438.10 (c)(4). DEFINITIONS, Part IXHoosier Healthwise covered services include all Medicaid (Packages A and B) and CHIP (Package C) covered services. 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, The Indiana Administrative Code at 407 IAC 3 sets forth the CHIP Package C covered services and the Schedule Indiana Administrative Code 405 IAC 5 details the Medicaid covered services. Attachment E of Benefitsthis RFP provides a general description of the Hoosier Healthwise benefit packages and the benefits that are available. The covered services for Hoosier Healthwise risk-based managed care are similar to the Hoosier Healthwise benefits and services. The MCO must 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 MCO’s capitation rate and are, therefore, the responsibility of the MCO. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with 42 CFR 438.210(a)(3)(iii) 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 by reference is incorporated herein. a. Except for Emergency Medical Services the services are furnished The MCO must develop procedures to monitor and Care assess its effectiveness in delivering quality health care to its Hoosier Healthwise members. The MCO must submit performance data related to its medical necessity determinations and utilization management as provided described in Part IXthe MCO Reporting Manual. COVERED MEDICAL SERVICESThe State reserves the right to audit the MCO’s utilization management and medical necessity determination process at anytime. The MCO must have policies and procedures that integrate all health care delivery service activities (including but not limited to: self-referral, all services must be received from Inself-Network Providers within the Service Areamanagement, disease management, pharmacy, transportation, continuity of care, case management, emergency room and AvMed will have no liability or obligation whatsoever on account of services or benefits sought or received by any Member from any Outout-of-Network Provider or other personnetwork services) with the MCO’s quality management and improvement plan described in Section 5.0. Although the covered services for Hoosier Healthwise MCO members’ care are similar to the Hoosier Healthwise benefits and services in PrimeStep, institution or organization, unless prior arrangements have been made for Federal and State regulations may impact the Member MCO’s service administration and confirmed by written referral or Prior Authorization from AvMedbenefit management. Descriptions of these services and benefits are below. b. Primary care services must be received from your designated PCP on record 2.1 Self-referral Services In accordance with AvMed. This means that if you receive services from a PCP other than the one we have on record for youState and Federal requirements, the Hoosier Healthwise program includes some benefits and services will that are available to all Hoosier Healthwise members (i.e., PCCM and RBMC members) on a self-referral basis. These self-referral services do not be covered by us, and you will be solely responsible for the cost of such services. c. You must have require a referral from your PCP before visiting a Specialty Physicianthe member’s PMP. The MCO must include self-referral providers in its contracted network. The MCO and its PMPs may direct members to seek the services of the self-referral providers contracted in the MCO’s network, in order but the MCO cannot require that the members receive such services from network providers. When members choose to receive self-referred services from IHCP-enrolled self-referral providers who do not have contractual relationships with the MCO, the MCO is responsible for payment to these providers (as out-of-plan providers). The following services are considered self-referral services: • Chiropractic, eye care services and podiatric services are self-referral services under state law. The Indiana Administrative Code 405 IAC 5 provides further detail regarding these benefits. Hoosier Healthwise members may self-refer these services to any IHCP provider qualified to provide the service. • Family planning services under Federal regulation 42 CFR 431.51(b)(2) require a freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy including, but not limited to, birth control pills. Hoosier Healthwise members may not be coveredrestricted in choice of a family planning service provider. Except as provided The IHCP Provider Manual provides a complete and current list of family planning services. The MCO participating in Hoosier Healthwise must allow its members to obtain birth control pills on a self-referral basis. OMPP recognizes the need for chiropractorsappropriate management of prescription medication in the interest of the member’s health; however, dermatologistsOMPP also recognizes the importance of removing barriers to family planning services. To reduce potential barriers to obtaining birth control pills, OB/GYNs and podiatristswhich may include, but may not be limited to, transportation to pharmacies for periodic refills, the MCO must, at a minimum, reimburse for the dispensation of up to a 90 calendar day supply of birth control pills at one time per member, if you receive Specialty Physician prescribed. • HIV/AIDS targeted case management services without are limited to no more than 60 hours per quarter and are available to Package A and Package B members (as the proper case management services relate to the pregnancy). For more detailed information concerning member’s self-referral from your PCP for HIV/AIDS case management services, see the IHCP Provider Manual. • Emergency services will not be are 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 prior authorization or the existence of an MCO contract with the emergency care provider. Emergency services must be available 24-hours-a-day, seven-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in 42 CFR 438.114 and IC 12-15-12. See Section 2.3 of this Attachment for more information. • Behavioral health services, including mental health, substance abuse and chemical dependency services, rendered by mental health specialty providers enrolled in IHCP are by State law self-referral services. Behavioral health services rendered by mental health providers are also carved out of the MCO responsibility. The State’s fiscal agent, on a fee-for-service basis, will reimburse the mental health specialty providers for behavioral health services. Hoosier Healthwise members receiving behavioral health services from providers other than mental health specialists must receive a referral from their PMP or Prior Authorizationauthorization from an MCO. Coverage The Hoosier Healthwise program requires that the member’s MCO reimburse providers for such behavioral health services when providers other than mental health specialists (e.g., physicians and acute care hospitals) render behavioral health services. The mental health provider specialties are: • Psychiatric hospitals • Outpatient mental health clinics • Community mental health clinics • Psychiatrists • Psychologists • Certified psychologists • Health services providers in psychology • Certified social workers • Certified clinical social workers • Psychiatric nurses • Independent practice school psychologists • Advanced practice nurses under IC 25-23-1-1(b)(3), credentialed in psychiatric or mental health nursing by the American Nurses Credentialing Center 2.2 Carved-out Services Hoosier Healthwise provides some services that are not included in the MCO capitation and, therefore, not the responsibility of the MCO. These services are referred to as “carved-out” services. The State’s fiscal agent, on a FFS basis, pays for carved-out services rendered to MCO members. However, under some circumstances, services related to the carved-out services are the responsibility of the MCO for reimbursement. Listed below are the carved-out services and the conditions under which related services are the MCO’s responsibility. The MCO Policy and Procedure Manual describes these carved-out services in greater detail: • Behavioral health services, as described above are self-referral services that are carved out from the MCO’s responsibilities when rendered by mental health specialty providers enrolled in the IHCP. However, the MCO is responsible for associated services related to behavioral health services including but not limited to transportation and pharmacy services. • Dental services rendered by providers enrolled in the IHCP as providers in a dental specialty are not the MCO’s responsibility; however, some associated services related to dental surgery (e.g., anesthesia, post-operative services, pharmaceuticals, transportation) may be the MCO’s responsibility. The dental specialties are: • Endodontists • General dentistry practitioners • Oral surgeons • Orthodontists • Pediatric dentists • Periodontists • Pedodontists • Prosthodontists • Individualized Education Plan (IEP) services provided by a school are carved-out from the MCO’s responsibility. The MCO should communicate and coordinate with the school to ensure continuity of care and avoid duplication of services. 2.3 Diabetes Self-management Service The MCO must cover self-management services for diabetes for its member when the member obtains the services from IHCP self-referral providers. However, IC 27-8-14.5-6 also provides that coverage for diabetes self-management is subject to Medical Necessity the requirements of the insurance plan (i.e., MCO) when member seeks diabetes self-management services from providers other than providers designated as IHCP self-referral providers. The statue also recognizes that eye care and utilization podiatry, which may include diabetes self-management guidelinesservices, as well as any applicable benefit maximums described are self-referral services. The MCO may direct its members to providers in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES or Exclusions described in Part XIthe MCO’s network for diabetes self-management services. However, the MCO must cover diabetes self-management services if the member chooses an IHCP self-referral provider outside the MCO’s network.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Engage Plan, 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 Under this Engage Plan, 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 and any applicable benefit maximums described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES or Exclusions described in Part XI.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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 hereinmade a part of this Contract. a. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Participating 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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network Participating Physicians and Providers in conformity with Part P art II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED C OVERED MEDICAL SERVICES, Part P art XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION P RESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, Part XVIII. PEDIATRIC DENTAL COVERAGEC OVERAGE, 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 Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Engage Plan, 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 Under this Engage Plan, 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 P art X. LIMITATIONS OF COVERED MEDICAL SERVICES or Exclusions described in Part XI.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 With the Engage Plan, 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 Under this Engage Plan, 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. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by In-Network 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.DENTAL a. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL SERVICES, all services must be received from In-Network Participating Physicians and 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 OutNon-of-Network Provider Participating Physician, 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 Under this Engage Plan, 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. c. 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.