Common use of Current Medicaid Programs’ Services and Extent of Coverage Clause in Contracts

Current Medicaid Programs’ Services and Extent of Coverage. The Contractor shall cover all services for its Members at the appropriate level, in the appropriate setting and as necessary to meet Members’ needs to the extent services are currently covered. The Contractor may expand coverage to include other services not routinely covered by Kentucky Medicaid, if the expansion is approved by the Department, if the services are deemed cost effective and Medically Necessary, and as long as the costs of the additional services do not affect the Capitation Rate. The Contractor shall provide covered services as required by statutes or administrative regulations. The current location of Covered Services can be found in the following regulations:  Alternative Birthing Center Services (907 KAR 1:180)  Ambulatory Surgical Center (907 KAR 1:008)  Behavioral Health Service Organization Services (907 KAR 15:020)  Behavioral Health Services Provided by Independent Providers (907 KAR 15:010)  Chemical Dependency Treatment Center Services (907 KAR 15:080)  Chiropractic Services (907 KAR 3:125)  Commission for Children with Special Health Care Needs (911 KAR Chapter 1) Coverage includes physician, EPSDT, dental, occupational therapy, physical therapy, speech therapy, durable medical equipment, genetic screening and counseling, audiological, vision, case management, laboratory and x-ray, psychological and hemophilia treatment and related services.  Community Mental Health Center Primary Care Services (907 KAR 1:046)  Community Mental Health Center Behavioral Health Services (907 KAR 1:044)  Dental Health Services (907 KAR 1:026)  Dialysis Center Services (907 KAR 1:400)  Durable Medical Equipment, Medical Supplies, Orthotic and Prosthetic Devices (907 KAR 1:479)  Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (907 KAR 11:034)  Family Planning Clinic Services (907 KAR 1:048 & 1:434)  Federally Qualified Health Clinics, Primary Care Clinics and Rural Health Center Services (907 KAR 1:054, 1:082, )  Hearing Program Services (907 KAR 1:038)  Home Health Services (907 KAR 1:030)  Hospice Services – non-institutional (907 KAR 1:330 & 1: 436)  Hospital Inpatient Services (907 KAR 10:012)  Hospital Outpatient Services (907 KAR 10:014)  Independent Occupational Therapy Services (907 KAR 8:005 and 907 KAR 8:101)  Independent Physical Therapy Services (907 KAR 8:005 and 907 KAR 8:020)  Independent Speech Language Pathology Services (907 KAR 8:005 and 907 KAR 8:030)  Inpatient Psychiatric Hospital Services (907 KAR 10:016)  Laboratory Services (907 KAR 1:028)  Medical Necessity and Clinical Appropriate Determination Basis (907 KAR 3:130)  Medicare Non-Covered Services (907 KAR 1:006)  Mental Health Inpatient Services (907 KAR 10:012 & 10:016)  Mental Health Outpatient Services (see physician, community mental health center, FQHC and RHC, 907 KAR Chapter 15)  Psychiatric Hospital Inpatient Services (907 KAR 10:016)  Psychiatric Hospital Outpatient Services ( 907 KAR 10:020)  Nursing Facility Services (907 KAR 1:022 & 1:037)  Organ Transplants (907 KAR 1:350)  Other Laboratory and X-ray Provider Services (907 KAR 1:028)  Outpatient Pharmacy Prescriptions and Over-the-Counter Drugs including Behavioral Health Drugs (907 KAR 1:019, KRS 205.5631, 205,5632, 205.560)  Outpatient Psychiatric Hospital Behavioral Health Services (907 KAR 10:020)  Physicians and Nurses in Advanced Practice Medical Services (907 KAR 3:005 and 907 KAR 1:102)  Podiatry Services (907 KAR 1:270)  Preventive and Remedial Public Health Services (907 KAR 1:360)  Private Duty Nursing (907 KAR Chapter13)  Psychiatric Residential Treatment Facility Services – (907 KAR 9:005)  Residential Crisis Stabilization Unit Services (907 KAR 15:075)  Specialized Children’s Services Clinics (907 KAR 3:160)

Current Medicaid Programs’ Services and Extent of Coverage. The Contractor shall cover all services for its Members at the appropriate level, in the appropriate setting and as necessary to meet Members’ needs to the extent services are currently covered. The Contractor may expand coverage to include other services not routinely covered by Kentucky Medicaid, if the expansion is approved by the Department, if the services are deemed cost effective and Medically Necessary, and as long as the costs of the additional services do not affect the Capitation Rate. The Contractor shall provide covered services as required by the following statutes or administrative regulations. The current location of Covered Services can be found in the following regulations:  • Medical Necessity and Clinical Appropriate Determination Basis (907 KAR 3:130) • Alternative Birthing Center Services (907 KAR 1:180)  • Ambulatory Surgical Center and Anesthesia Services (907 KAR 1:008)  Behavioral Health Service Organization Services (907 KAR 15:020)  Behavioral Health Services Provided by Independent Providers (907 KAR 15:010)  Chemical Dependency Treatment Center Services (907 KAR 15:080)  • Chiropractic Services (907 KAR 3:125)  • Commission for Children with Special Health Care Needs (911 907 KAR Chapter 11:440) Certain Medically Necessary services provided by the Commission for Children with Special Health Care Needs for Members identified with special needs. Coverage includes physician, EPSDT, dental, occupational therapy, physical therapy, speech therapy, durable medical equipment, genetic screening and counseling, audiological, vision, case management, laboratory and x-ray, psychological and hemophilia treatment and related services.  • Community Mental Health Center Primary Care Services (907 KAR 1:046)  Community Mental Health Center Behavioral Health Services (1:044 and 907 KAR 1:0443:110)  • Dental Health Services (907 KAR 1:026)  • Dialysis Center Services (907 KAR 1:400)  • Durable Medical Equipment, Medical Supplies, Orthotic and Prosthetic Devices (907 KAR 1:479)  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (907 KAR 11:034)  • Family Planning Clinic Services (907 KAR 1:048 & 1:434)  Federally Qualified Health Clinics, Primary Care Clinics and Rural Health Center Services (907 KAR 1:054, 1:082, )  • Hearing Program Services (907 KAR 1:038)  • Home Health Services (907 KAR 1:030)  • Hospice Services – non-institutional (907 KAR 1:330 & 1: 436)  • Hospital Inpatient Services (907 KAR 10:01210:012 & 10:376)  • Hospital Outpatient Services (907 KAR 10:01410:014 & 10:376)  Independent Occupational Therapy Services (907 KAR 8:005 and 907 KAR 8:101)  Independent Physical Therapy Services (907 KAR 8:005 and 907 KAR 8:020)  Independent Speech Language Pathology Services (907 KAR 8:005 and 907 KAR 8:030)  Inpatient Psychiatric Hospital Services (907 KAR 10:016)  • Laboratory Services (907 KAR 1:028)  Medical Necessity and Clinical Appropriate Determination Basis (907 KAR 3:130)  • Medicare Non-Covered Services (907 KAR 1:006)  • Mental Health Inpatient Services (907 KAR 10:012 & 10:016)  • Mental Health Outpatient Services (see physician, community mental health center, FQHC and RHC, 907 KAR Chapter 15)  Psychiatric Hospital Inpatient Services (907 KAR 10:016)  Psychiatric Hospital Outpatient Services ( 907 KAR 10:020)  • Nursing Facility Services (907 KAR 1:022 & 1:0371:374)  Organ Transplants (907 KAR 1:350)  • Other Laboratory and X-ray Provider Services (907 KAR 1:028)  • Outpatient Pharmacy Prescriptions and Over-the-Counter Drugs including • Mental/Behavioral Health Drugs (907 KAR 1:019, KRS 205.5631, 205,5632, • KS 205.560)  Outpatient Psychiatric Hospital Behavioral Health Residential Treatment Facility Services – (907 KAR 10:0201:505)  • Physicians and Nurses in Advanced Practice Medical Services (907 KAR 3:005 and 907 KAR 1:102)  • Podiatry Services (907 KAR 1:270)  • Preventive and Remedial Public Health Services (907 KAR 1:360)  Private Duty Nursing (907 KAR Chapter13)  Psychiatric Residential Treatment Facility Services – (907 KAR 9:005)  Residential Crisis Stabilization Unit • Primary Care and Rural Health Center Services (907 KAR 15:0751:054, 1:082, 1:418 and 1:427)  • Sterilization, Hysterectomy and Induced Termination of Pregnancy Procedures (Sterilizations of both male and female Members are covered only when performed in compliance with federal regulations 42 CFR 441.250.) These services are covered in accordance with Kentucky Law (KRS 205.560) and a United States District Court judge ruling in the case of Xxxxxx Hope, et al. x. Xxxxxx Childers, et al. • Targeted Case Management Services (907 KAR 1:515, 907 KAR 1:525, 907 KAR 1:550 and 907 KAR 1:555) • Transportation, including Emergency and Non-emergency Ambulance (907 KAR 1:060) • Vaccines for Children (VFC) Program (907 KAR 1:680) Vision Services (907 KAR 1:038) • Specialized Children’s Services Clinics (907 KAR 3:160)) Affordable Care Act Additional Services • Substance Use Disorder Services • Private Duty Nursing • Essential Services (TBD) Appendix J Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) Periodicity Schedule Infancy -- < 1 month -- 2 months -- 4 months -- 6 months -- 9 months -- 12 months Early Childhood -- 15 months -- 18 months -- 24 months -- 3 years -- 4 years Middle Childhood -- 5 years -- 6 years -- 8 years -- 10 years Adolescence -- 11 years -- 12 years -- 13 years -- 14 years -- 15 years -- 16 years -- 17 years -- 18 years -- 19 years -- 20 years August 28, 2013 MCO Reports Description Page | 71 Early and Periodic Screening, Diagnosis and Treatment Program Required Components - Initial and Periodic Health Assessments Health History: Complete History Initial Visit Interval History Each Visit By History /Physical Exam: Developmental Assessment Each Visit (Age appropriate physical and mental health milestones) Nutritional Assessment Each Visit Lead Exposure Assessment 6 mo. through 6 yr. age visits Physical Exam: Complete/ Unclothed Each Visit Growth Chart Each Visit Vision Screen Assessed each visit *According to recommended medical standards (AAP1) Hearing Screen Assessed Each Visit *According to recommended medical standards (AAP1) Laboratory: Hemoglobin/ Hematocrit *According to recommended medical standards (AAP1) Urinalysis *According to recommended medical standards (AAP1) Lead Blood Level (Low Risk History) 12 mo. and 2 year age visit Lead Blood Level (High Risk History) Immediately Cholesterol Screening *According to recommended medical standards (AAP1) Sickle Cell Screening Documentation X 1 Hereditary/ Metabolic Screening *According to Kentucky statute (Newborn Screening) Sexually Transmitted Disease Screening *According to recommended medical standards (AAP1) Pelvic Exam (pap smear *According to recommended medical standards (AAP1) Immunizations: DPT Assessed Each Visit DTaP *According to recommended OPV medical standards (AAP1, ACIP2, Hepatitis BAAFP3) August 28, 2013 MCO Reports Description Page | 72 Immunizations: Cont. HiB MMR Varicella Td PPD Health Education/ Anticipatory Guidance (Age Appropriate) Each Visit Dental Referral Age 1

Current Medicaid Programs’ Services and Extent of Coverage. The Contractor shall cover all services for its Members at the appropriate level, in the appropriate setting and as necessary to meet Members’ needs to the extent services are currently coveredincluded in Covered Services. The Contractor may expand coverage to include other services not routinely covered by Kentucky Medicaid, if the expansion is approved by the Department, if the services are deemed cost effective and Medically Necessary, and as long as the costs of the additional services do not affect the Capitation Rate. The Contractor shall provide covered services as required by the following statutes or administrative regulations. The current location of Covered Services can be found in the following regulations:  Alternative Birthing • Medical Necessity and Clinical Appropriate Determination Basis (907 KAR 3:130) • Freestanding Birth Center Services (907 KAR 1:180)  • Allergy Testing and Treatment for Adults (907 KAR 3:005) 68 • Ambulatory Surgical Center and Anesthesia Services (907 KAR 1:008)  Behavioral Health Service Organization Services (907 KAR 15:020)  Behavioral Health Services Provided by Independent Providers (907 KAR 15:010)  Chemical Dependency Treatment Center Services (907 KAR 15:080)  • Chiropractic Services (907 KAR 3:125)  • Commission for Children with Special Health Care Needs (911 907 KAR Chapter 11:440) Coverage includes physician, EPSDT, dental, occupational therapy, physical therapy, speech therapy, durable medical equipment, genetic screening and counseling, audiological, vision, case management, laboratory and x-ray, psychological and hemophilia treatment and related services.  • Community Mental Health Center Primary Care Services (907 KAR 1:046)  Community Mental Health Center Behavioral Health Services (1:044 and 907 KAR 1:0443:110)  • Dental Health Services (907 KAR 1:026)  • Dialysis Center Services (907 KAR 1:400)  • Durable Medical Equipment, Medical Supplies, Orthotic and Prosthetic Devices (907 KAR 1:479)  • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services (907 KAR 11:034)  • Family Planning Clinic Services (907 KAR 1:048 & 1:434)  Federally Qualified Health Clinics, Primary Care Clinics and Rural Health Center Services (907 KAR 1:054, 1:082, )  • Hearing Program Services (907 KAR 1:038)  • Home Health Services (907 KAR 1:030)  • Hospice Services – non-institutional (907 KAR 1:330 & 1: 436)  • Hospital Inpatient Services (907 KAR 10:012)  • Hospital Outpatient Services (907 KAR 10:014)  Independent Occupational Therapy Services (907 KAR 8:005 and 907 KAR 8:101)  Independent Physical Therapy Services (907 KAR 8:005 and 907 KAR 8:020)  Independent Speech Language Pathology Services (907 KAR 8:005 and 907 KAR 8:030)  Inpatient Psychiatric Hospital Services (907 KAR 10:016)  • Laboratory Services (907 KAR 1:028)  Medical Necessity and Clinical Appropriate Determination Basis (907 KAR 3:130)  • Medicare Non-Covered Services (907 KAR 1:006)  Mental • Behavioral Health Inpatient Services (907 KAR 10:012 & 10:016)  Mental Health Outpatient Services (see physician, community mental health center, FQHC and RHC, 907 KAR Chapter 15)  Psychiatric Hospital Inpatient Services (907 KAR 10:016)  Psychiatric Hospital • Behavioral Health Outpatient Services ( 907 KAR 10:02015:010)  Nursing Facility Services (907 KAR 1:022 & 1:037)  Organ Transplants (907 KAR 1:350)  Other 1:022)Other Laboratory and X-ray Provider Services (907 KAR 1:028)  • Outpatient Pharmacy Prescriptions and Over-the-Counter Drugs including • Mental/Behavioral Health Drugs (907 KAR 1:019, KRS 205.5631, 205,5632, 205.5632,KRS 205.560)  Outpatient Psychiatric Hospital Behavioral Health Services • Out-Patient Physical Therapy, Speech Therapy, Occupational Therapy, (907 KAR 10:0208:010, Occupational therapy services, 907 KAR 8:020, Physical therapy services, 907 KAR 8:030, Speech therapy services)  • Psychiatric Residential Treatment Facility Services – (907 KAR 9:005) • Physicians and Nurses in Advanced Practice Medical Services (907 KAR 3:005 and 907 KAR 1:102)  • Podiatry Services (907 KAR 1:270)  • Preventive and Remedial Public Health Services (907 KAR 1:360)  • Primary Care and Rural Health Center Services (907 KAR 1:054, 1:082, 1:418 and 1:427) • Private Duty Nursing (907 KAR Chapter1313:010)  Psychiatric Residential Treatment Facility Services – • Sterilization, Hysterectomy and Induced Termination of Pregnancy Procedures (907 KAR 9:005Sterilizations of both male and female Members are covered only when performed in compliance with federal regulations 42 CFR 441.250.)  Residential Crisis Stabilization Unit • Substance Use Disorder Services (907 KAR 15:07515:020)  • Targeted Case Management Services (907 KAR 1:515, 907 KAR 1:525, 907 KAR 1:550 and 907 KAR 1:555) • Transportation, including Emergency and Non-emergency Ambulance (907 KAR 1:060) • Vaccines for Children (VFC) Program (907 KAR 1:680) • Vision Services (907 KAR 1:038) • Specialized Children’s Services Clinics (907 KAR 3:160) XXXXXXXX X. (Revised)