Common use of Covered Benefits and Services Clause in Contracts

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

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

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

Covered Benefits and Services. The Contractor shall provide to its HIP members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered under the Contract with the State. A covered service is medically necessary if it meets the definition as set forth 405 IAC 10-2- 2-1(30). The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with 42 CFR 438.210(a)(4438.210(a)(3)(iii), which specifies when Contractors may place appropriate limits on services, regarding:   Medical necessity determinations.   Utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.