Common use of Covered Benefits and Services Clause in Contracts

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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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

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)(ii438. 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 3 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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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 high-quality care to members. For additional information, please see the following: • xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplem ents▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplemen ts/Section_3/3.1e.pdf • ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Section_3/3.1. f.g.h.pdf

Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A) and CHIP (Package C) covered services. The Indiana Administrative Code at 405 407 IAC 13-2-1 3 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 servic e 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 3 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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 43 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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.

Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A) and CHIP (Package C) covered services. The Indiana Administrative Code at 405 407 IAC 13-2-1 3 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 3 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-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/or disability per 42 CFR 438.210(a)(5)(ii)(A438.210(a)(5)(ii) (A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 43 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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

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 3 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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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 high-quality care to members. For additional information, please see the following: • xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplem ents▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplemen ts/Section_3/3.1e.pdf • ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Section_3/3.1. f.g.h.pdf

Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A) and CHIP (Package C) covered services. The Indiana Administrative Code at 405 407 IAC 13-2-1 3 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 3 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-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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects effec ts of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 43 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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.

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 3 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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section secti on 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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 high-quality care to members. For additional information, please see the following: • xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplem ents▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Attachments_and_Supplemen ts/Section_3/3.1e.pdf • ▪ xxxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/ihcp/StatePlan/Section_3/3.1. f.g.h.pdf

Covered Benefits and Services. Hoosier Healthwise covered services include Medicaid (Package A) and CHIP (Package C) covered services. The Indiana Administrative Code at 405 407 IAC 13-2-1 3 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 3 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-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/or disability per 42 CFR 438.210(a)(5)(ii)(A). 3. Cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability. 4. Reduce or ameliorate the pain or suffering caused by an illness, injury, condition or disability. 5. Cover services related to the ability for an enrollee to achieve age-appropriate growth and development per 42 CFR 438.210(a)(5)(ii)(B). 6. Cover services related to the ability for an enrollee to attain, maintain, or regain functional capacity per 42 43 CFR 438.210(a)(5)(ii)(C). The Contractor shall comply with sections 1903(i)(16), 1903(i)(17), and 1903(i)(18) of the Social Security Act and is prohibited from paying for items or services (other than an Emergency item or service, not including items or services furnished in an Emergency room or a hospital): 1. With respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. 2. With respect to any amount expended for roads, bridges, stadiums, or any other item or service not covered under the Medicaid State plan. 3. With respect to any amount expended for home health care services provided by an agency or organization unless the agency or organization provides the State on a continuing basis a surety bond as specified under paragraph (7) of section 1861(o) of the Social Security Act. The Contractor may cover services necessary for compliance with requirements for parity in mental health and substance use disorder benefits in 42 CFR Part 438, subpart K, identified with the analysis of parity compliance conducted by the state or the Contractor per 42 CFR 438.3(e)(1)(ii). 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.