Common use of Covered Benefits and Services Clause in Contracts

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. 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- 8-1(b), in instances where the Contractor pays for a service at the Medicare rate, any cost- 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. HIP covered services include all services, including coverage criteria, limitations and procedures, identified in the HIP alternative benefit plans (ABP) and the Indiana State Plan (only applicable for HIP State Plan members) 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 3 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 the Medicaid rates if the service does not have a Medicare reimbursement ratefee schedule. 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.. The Contractor shall not pay for organ transplants unless the Contractor follows the written standards included in the State Plan that provide for similarly situated indi viduals to be treated alike and for any restriction on facilities or practitioners to be consistent with the accessibility of high-quality care to members. For additional information, please see the following: ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplem ents/Section_3/3.1e.pdf ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Section_3/3.1. f.g.h.pdf

Covered Benefits and Services. HIP covered services include all services, including coverage criteria, limitations and procedures, identified in the HIP alternative benefit plans (ABP) and the Indiana State Plan (only applicable for HIP State Plan members) 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 3 of the Contract provides a general summary description of the different HIP benefit packages and the services and benefits that are available under each. eac h. 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 the Medicaid rates if the service does not have a Medicare reimbursement ratefee schedule. Pursuant to 405 IAC 10-8- 1(b), in instances where the Contractor pays for a service at the Medicare rate, any cost- 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.. The Contractor shall not pay for organ transplants unless the Contractor follows the written standards included in the State Plan that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitioners to be consistent with the accessibility of high-quality care to members. For additional information, please see the following: ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplem ents/Section_3/3.1e.pdf ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Section_3/3.1. f.g.h.pdf