General Core Benefits and Services Requirements. Core Benefits shall be available to each Medicaid Managed Care Member within the CONTRACTOR's Service Area. The CONTRACTOR shall provide Core Benefits and services to Medicaid Managed Care Members, pursuant to the provisions of this contract. The CONTRACTOR shall:
4.1.1. Implement Procedures to coordinate the delivery of physical health, Behavioral Health and long-term care services that it furnishes with services the member receives from any other entity.
4.1.2. Furnish Core Benefits and services in accordance with Medical Necessity and in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries and for beneficiaries under the age of 21 up to the limits as specified in the Medicaid FFS Program as defined in the State Plan, administrative rule and Department Policy, Procedure manuals and all applicable federal and state statues, rule, and regulations.
4.1.3. Follow any modified version of a Core Benefit and/or service under the Medicaid FFS Program—the amount, duration and/or scope of services—unless otherwise exempted by the Department.
4.1.4. Honor and pay for Core Benefits and services for new Medicaid Managed Care Members or when a new Benefit/service is added as a Core Benefit/service.
4.1.5. Ensure that services are covered in accordance with 42 CFR 438.210, as follows:
4.1.5.1. Shall ensure that services are sufficient in amount, duration, and scope to achieve the purpose for which the services are furnished.
4.1.5.2. May not arbitrarily deny or reduce the amount, duration, or scope of a required service because of diagnosis, type of illness, or condition of the Medicaid Managed Care Member.
4.1.5.3. The services supporting individuals with ongoing or chronic conditions or who require long-term services and supports are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports
4.1.5.4. Family Planning Services are provided in a manner that protects and enables the Enrollee’s freedom to choose the method of Family Planning to be used consistent with §441.20
4.1.5.5. May place appropriate limits on a service:
4.1.5.5.1. On the basis of certain criteria, such as Medical Necessity, Or,
4.1.5.5.2. For the purpose of utilization control, provided the services furnished can reasonably be expected to achieve their purpose.
4.1.6. Not condition the provision of services or otherwise discriminate against a Medicaid Managed Care Member based on whe...
General Core Benefits and Services Requirements. Core Benefits shall be available to each Medicaid Managed Care Member within the CONTRACTOR's Service Area. The CONTRACTOR shall provide Core Benefits and services to Medicaid Managed Care Members, pursuant to the provisions of this contract. The CONTRACTOR shall:
4.1.1. Implement Procedures to coordinate the delivery of physical health, Behavioral Health, and long-term care services that it furnishes with services the member receives from any other entity.
General Core Benefits and Services Requirements. Core Benefits shall be available to each Medicaid Managed Care Member within the CONTRACTOR's service area. The CONTRACTOR shall provide Core Benefits and Services to Medicaid Managed Care Members, pursuant to the provisions of this Contract. The CONTRACTOR shall:
4.1.1. Implement procedures to coordinate the delivery of physical health, behavioral health and long-term care services that it furnishes with services the member receives from any other entity.
4.1.2. Furnish Core Benefits and Services in accordance with medical necessity and in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries up to the limits as specified in the Medicaid FFS program as defined in the State Plan, administrative rule and Department policy, procedure manuals and all applicable federal and state statues, rule, and regulations.
4.1.3. Follow any modified version of a Core Benefit and/or Service under the Medicaid FFS Program—the amount, duration and/or scope of services—unless otherwise exempted by the Department.
4.1.4. Honor and pay for Core Benefits and Services for new Medicaid Managed Care Members or when a new Benefit/Service is added as a Core Benefit/Service.
4.1.5. Ensure that services are covered in accordance with 42 CFR 438.210(a)(3), as follows: Shall ensure that services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished. May not arbitrarily deny or reduce the amount, duration, or scope of a required service because of diagnosis, type of illness, or condition of the Medicaid Managed Care Member. May place appropriate limits on a service:
4.1.5.3.1. On the basis of certain criteria, such as medical necessity, Or,
4.1.5.3.2. For the purpose of utilization control, provided the services furnished can reasonably be expected to achieve their purpose.
4.1.6. Not condition the provision of services or otherwise discriminate against a Medicaid Managed Care Member based on whether or not the individual has executed an advance directive.
