Common use of Existing Plans of Care Clause in Contracts

Existing Plans of Care. The Contractor shall honor and pay for services in interim and established plans of care for new enrollees or when a new benefit is added as a covered service, including MLTSS services, prescriptions, durable medical equipment, medical supplies, prosthetic and orthotic appliances, and any other on-going services initiated prior to enrollment with the Contractor. Services shall be continued until the enrollee is evaluated by his/her primary care physician or for MLTSS Members, a face-to-face assessment is conducted by the Care Manager and an individualized plan of care is developed to meet the Member’s assessed needs. Contractor Exception: Atypical antipsychotic and anticonvulsant drugs ordered by a non- participating or participating HMO provider will always be covered by the HMO regardless of the treatment plan established by the HMO. The HMO’s formulary and prior authorization requirements will apply only when the initial medication treatment plan is changed.