COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Extended Health Care Plan (a) The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable Extended Health Care Plan.
EDUCATION PROGRAM Measure 1a Is the school implementing the material elements of its Educational Program as defined in the charter contract? Meets Standard: The school implemented the material elements of its Educational Program in all material respects, and, in operation, the education program reflects the essential terms as defined in the charter contract, or the school has obtained approval for a modification to the essential terms. Measure 1b Is the school complying with applicable education requirements? Meets Standard: The school materially complies with applicable laws, rules, regulations and provisions of the charter contract relating to education requirements, including but not limited to: • Academic standards, including Common Core • Graduation requirements • State assessment and student testing • Implementation of mandated programming as a result of state or federal funding, including Title I and Title II funding Measure 1c Is the school protecting the rights of students with disabilities? Meets Standard: Consistent with the school’s status and responsibilities as a school within a single LEA under the State Department of Education, the school materially complies with applicable laws, rules, regulations and provisions of the charter contract (including the Individuals with Disabilities Education Act, Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act Amendment Act) relating to the treatment of students with identified disabilities and those suspected of having a disability, including but not limited to: • Equitable access and opportunity to enroll • Identification and referral • Appropriate development and implementation of Individualized Education Plans (IEPs) and Section 504 plans • Operational compliance including the academic program, assessments and all other aspects of the school’s program and responsibilities • Discipline, including due process protections, manifestation determinations and behavioral intervention plans • Access to the school’s facility and program to students in a lawful manner and consistent with students’ IEPs or Section 504 plans • Appropriate use of all available, applicable funding Measure 1d Is the school protecting the rights of English Language Learner (ELL) students? Meets Standard: The school materially complies with applicable laws, rules, regulations and provisions of the charter contract relating to ELL requirements (including Title III of the Elementary and Secondary Education Act [ESEA] and U.S. Department of Education authorities), including but not limited to: • Equitable access and opportunity to enroll • Required policies related to the service of ELL students • Proper steps for identification of students in need of ELL services • Appropriate and equitable delivery of services to identified students • Appropriate accommodations on assessments • Exiting of students from ELL services • Ongoing monitoring of exited students
Clinical Management for Behavioral Health Services (CMBHS) System The CMBHS is the official record of documentation by System Agency. Grantee shall:
Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.
Health Promotion and Health Education Both parties to this Agreement recognize the value and importance of health promotion and health education programs. Such programs can assist employees and their dependents to maintain and enhance their health, and to make appropriate use of the health care system. To work toward these goals:
Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. Inpatient This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. Residential Treatment Facility This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. Intermediate Care Services This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.
Extended Health Care The Hospital shall contribute on behalf of each eligible employee seventy-five percent (75%) of the billed premium under the Extended Health Care Plan (Liberty Health $15-25 deductible plan including hearing aids with a maximum of $300.00 per person and vision care with a maximum of $150.00 every 24 months per person, or its equivalent) provided the balance of the monthly premium is paid by employees through payroll deduction. Any Hospital currently paying more than 75% of the premium shall continue to do so. The drug formulary shall be as defined by Liberty Health Formulary Three.
Educational Program a. The educational program of the School (Section 4, Subsection 6 from the original contract and unchanged here) is as follows:
Federally Qualified Health Centers (A) The Contractor shall not restrict an Enrollee’s right to obtain FQHC services outside the PMHP through the Fee For Service Medicaid program.
