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 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:

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 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:

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. EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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 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:

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 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:

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 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: