Family Planning The MCO must ensure that its network includes sufficient family planning providers to ensure timely access to covered family planning services for enrollees. Although family planning services are included within the MCO’s list of covered benefits, Medicaid enrollees are entitled to obtain all Medicaid covered family planning services without prior authorization through any Medicaid provider, who will bill the MCO and be paid on a FFS basis.4 The MCO must give each enrollee, including adolescents, the opportunity to use his/her own primary care provider or go to any family planning center for family planning services without requiring a referral. The MCO must make a reasonable effort to Subcontract with all local family planning clinics and providers, including those funded by Title X of the Public Health Services Act, and must reimburse providers for all family planning services regardless of whether they are rendered by a participating or non-participating provider. Unless otherwise negotiated, the MCO must reimburse providers of family planning services at the Medicaid rate. The MCO may, however, at its discretion, impose a withhold on a contracted primary care provider for such family planning services. The MCO may require family planning providers to submit claims or reports in specified formats before reimbursing services. MCOs must provide their Medicaid enrollees with sufficient information to allow them to make an informed choice including: the types of family planning services available, their right to access these services in a timely and confidential manner, and their freedom to choose a qualified family planning provider both within and outside the MCO’s network of providers. In addition, MCOs must ensure that network procedures for accessing family planning services are convenient and easily comprehensible to enrollees. MCOs must also educate enrollees regarding the positive impact of coordinated care on their health outcomes, so enrollees will prefer to access in-network services or, if they should decide to see out-of-network providers, they will agree to the exchange of medical information between providers for better coordination of care. In addition, MCOs are required to provide timely reimbursement for out-of-network family planning and related STD services consistent with services covered in their contracts. The reimbursement must be provided at least at the applicable West Virginia Medicaid FFS rate 4 Access to family planning services without prior notification is a federal law. Under OBRA 1987 Section 4113(c)(1)(B), “enrollment of an individual eligible for medical assistance in a primary case management system, a health maintenance organization or a similar entity must not restrict the choice of the qualified person, from whom the individual may receive services under Section 1905(a)(4)(c).” Therefore, Medicaid enrollees must be allowed freedom of choice of family planning providers and may receive such services from any family planning provider, including those outside the MCO’s provider network, without prior authorization. appropriate to the provider type (current family planning services fee schedule available from BMS). The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must keep family planning information and records confidential in favor of the individual patient, even if the patient is a minor. The MCO, its staff, contracted providers and its contractors that are providing cost, quality, or medical appropriateness reviews, or coordination of benefits or subrogation must also keep family planning information and records received from non-participating providers confidential in favor of the individual patient even if the patient is a minor. Maternity services, hysterectomies, and pregnancy terminations are not considered family planning services.
Early Intervention Services (EIS) In accordance with Rhode Island General Law §27-20-50, this agreement provides coverage for Early Intervention Service. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The children must have been certified by the Rhode Island Department of Human Services to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. We cover Early Intervention Services as defined by the Rhode Island Department of Human Services including, but not limited to, the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices. See the Summary of Medical Benefits for the maximum benefit limit and the amount that you pay.
Tobacco Use Counseling and Intervention This plan covers smoking cessation programs when prescribed by a physician in accordance with R.I. General Law §27-20-53 and ACA guidelines. Smoking cessation programs include, but are not limited to, the following: • Smoking cessation counseling must be provided by a physician or upon his or her referral to a qualified licensed practitioner. • Over-the-counter and FDA approved nicotine replacement therapy and/or smoking cessation prescription drugs, prescribed by a physician, and purchased at a pharmacy. See the Summary of Pharmacy Benefits for details on coverage. Vaccinations/Immunizations This plan covers adult and pediatric preventive vaccinations and immunizations in accordance with current guidelines. Our allowance includes the administration and the vaccine. If a covered immunization is provided as part of an office visit, the office visit copayment and deductible (if any) will apply. Travel immunizations are covered to the extent that such immunizations are recommended for adults and children by the Centers for Disease Control and Prevention (CDC). The recommendations are subject to change by the CDC. Preventive Screening/Early Detection Services This plan covers preventive screenings based on the ACA guidelines noted above. Preventive screenings include but are not limited to: • mammograms; • pap smears; • prostate-specific antigen (PSA) tests; • flexible sigmoidoscopy; • double contrast barium enema; • fecal occult blood tests, screening for gestational diabetes, and human papillomavirus; and • genetic counseling for breast cancer susceptibility gene (BRCA). This plan covers colonoscopies in accordance with R.I. General Laws § 27-18-58. Covered healthcare services include an initial colonoscopy or other medical tests or procedures for colorectal cancer screening and a follow-up colonoscopy if the results of the initial test are abnormal. Contraceptive Methods and Sterilization Procedures for Women This plan covers the following contraceptive services: • FDA approved contraceptive drugs and devices requiring a prescription; • barrier method (cervical cap, diaphragm, or implantable) fitted and supplied during an office visit; and • surgical and sterilization services for women with reproductive capacity, including but not limited to tubal ligation. Breastfeeding Counseling and Equipment This plan covers lactation (breastfeeding) support and counseling during the pregnancy or postpartum period when provided by a licensed lactation counselor. This plan covers manual, electric, or battery operated breast pumps for a female member in conjunction with each birth event.
Multi-Year Planning The CAPS will be in a form acceptable to the LHIN and may be required to incorporate (1) prudent multi-year financial forecasts; (2) plans for the achievement of performance targets; and (3) realistic risk management strategies. It will be aligned with the LHIN’s then current Integrated Health Service Plan and will reflect local LHIN priorities and initiatives. If the LHIN has provided multi-year planning targets for the HSP, the CAPS will reflect the planning targets.
Discharge Planning If further care at home or in another facility is appropriate following discharge from the Hospital, Blue Shield will work with the Member, the attending Physician and the Hospital discharge planners to determine the most appropriate and cost effective way to provide this care.
Exit Planning 6. The Grant Recipient will, in conjunction with the Authority, maintain, and as necessary update, the Exit Plan throughout the Funding Period so that it can be implemented immediately, if required. From time-to-time either the Authority or the Grant Recipient may instigate a review of the Exit Plan.
Procurement Planning Prior to the issuance of any invitations to bid for contracts, the proposed procurement plan for the Project shall be furnished to the Association for its review and approval, in accordance with the provisions of paragraph 1 of Appendix 1 to the Guidelines. Procurement of all goods and works shall be undertaken in accordance with such procurement plan as shall have been approved by the Association, and with the provisions of said paragraph 1.
Vacation Planning The following general rules shall be observed in implementing the vacation planning program:
Selection Planning Prior to the issuance to consultants of any requests for proposals, the proposed plan for the selection of consultants under the Project shall be furnished to the Association for its review and approval, in accordance with the provisions of paragraph 1 of Appendix 1 to the Consultant Guidelines. Selection of all consultants’ services shall be undertaken in accordance with such selection plan as shall have been approved by the Association, and with the provisions of said paragraph 1.
Protection Planning Annually, sub-geographic area Unit Administrators will determine efficiencies to be gained from reciprocal assistance and acquisition of protection services. Operating plans will document decisions. Plans should be reviewed, and agreement reached concerning such items as placement of crews, engines, air tankers, helicopters, fixed and aerial detection, regulated use, closures and other joint fire suppression efforts.
