In Lieu of Services. The Contractor may offer cost effective alternative services/equipment to members, where the services/equipment are not identified as an in-plan benefit, when EOHHS has determined that the use of such alternative services/equipment are medically appropriate and cost effective. The Contractor may not require the member to accept an in lieu of service in the place of a covered service. The Contractor has flexibility and may provide all the in lieu of services identified in ATTACHMENT A. If the Contractor seeks to provide an in lieu of service that is not listed in ATTACHMENT A, the Contractor must receive prior authorization from EOHHS to deliver the proposed service as defined in EOHHS MCO Core Contract Requirements for Requesting In Lieu of Services. The Contractor must follow the procedures below for obtaining prior approval for in lieu of services not identified in ATTACHMENT A. • Requests for prior authorization must be submitted by the Contractor only; • Requests for prior authorization must be submitted through completion of the “Request for Cost-Effective Alternative (CEA)” form along with any accompanying documentation; • Submission must be sent by secure email to the designated EOHHS employee; and • To ensure EOHHS has the opportunity to adequately consider all requests for in lieu of services, the Contractor should submit the request at least 30 days prior to the desired date of service. In addition to the services identified in ATTACHMENT A as in lieu of services, another example of an approved in lieu of service is: • Psychiatric or substance use disorder treatment services provided in an Institution for Mental Disease (IMD) for members between the ages of 21-64, subject to the limitations described in 42 C.F.R. § 438.6(e).
In Lieu of Services. The Contractor may offer In-Lieu of Services (ILOS), as approved by EOHHS, in accordance with the policies and procedures defined in EOHHS MCO Core Contract Requirements for Requesting
a) EOHHS, in its sole discretion, determines the alternative service or setting is a medically appropriate substitute for the Covered Service or setting under the Rhode Island Medicaid State Plan.
b) EOHHS, in its sole discretion, determines the alternative service or setting is a cost- effective substitute for the Covered Service or setting under the State Plan.
c) The approved ILOS is listed in Attachment A, “In-Lieu of Services.” In its approval of the ILOS, EOHHS will designate a CPT code and fee schedule rate and other billing and coding guidelines, as appropriate. The Contractor must submit claims for ILOS using the designated code and rate. Further the Contractor must follow all EOHHS billing and coding guidelines applicable to that ILOS. The Contractor may not offer an ILOS until EOHHS has submitted a written notice of approval of the ILOS and its CPT code and rate and notified the Member as outlined in this Section. The Contractor may not require the Member to receive the ILOS in place of the Rhode Island Medicaid State Plan service. The Contractor must inform Members of any newly approved ILOS on its website and in an update to the Member Handbook. All updates must be posted no later than thirty (30) Days after EOHHS’ approval of the ILOS. If the Contractor seeks to provide an ILOS that is not listed in Attachment A, it must receive EOHHS’ prior approval to delivery of the ILOS.
In Lieu of Services. The Contractor may offer In-Lieu of Services (ILOS), as approved by EOHHS, in accordance with the policies and procedures defined in EOHHS MCO Core Contract Requirements for Requesting
In Lieu of Services. The projected benefit costs do not include costs for in lieu of services.
In Lieu of Services. The Contractor may offer In-Lieu of Services (ILOS), as approved by EOHHS, in accordance with the policies and procedures defined in EOHHS MCO Core Contract Requirements for Requesting In Lieu of Services. ILOS may be substituted for a Rhode Island Medicaid State Plan service when all of the following conditions are met:
In Lieu of Services. Services that are provided in lieu of a required covered benefit. These services are not part of the PASSE covered benefit, but because of special circumstances, it is deemed more cost effective to provide a non-covered service in lieu of more expensive institutional care which is covered under the PASSE program. For services provided in an Institution for Mental Diseases, the PASSE must ensure compliance with 42 CFR § 438.6(e).
In Lieu of Services. 5.9.1 The PASSE may provide in lieu of services to an enrolled member in an Institution for Mental Diseases for fifteen (15) days per month in accordance with 42 CFR § 438.6(e) when the PASSE determines that the in lieu of services will reduce cost and avoid institutional placement or enhance the enrolled member’s ability to move from an institutional or residential setting to a HCBS setting. DHS will periodically review any stays in an IMD.
5.9.2 The benefit to the PASSE is that the service will reduce expenditures for institutional care. For example, if providing a mobile phone or paying for a WIFI connection allows the PASSE to avoid residential or ICF placement by monitoring a member’s health and vitals remotely, the cost of the mobile phone service or WIFI service would be an in lieu of cost.
5.9.3 The PASSE may cover in lieu of services for members if the following conditions are met:
a. The member is not required by the PASSE to use the alternative service or setting; and
b. The approved in lieu of services are offered to members at the option of the PASSE, and only if the member agrees to the in lieu of service.
In Lieu of Services. In accordance with 42 CFR 438.3(e)(2), the MCOP may propose coverage for services that are in lieu of services under the Ohio Medicaid state plan (in lieu of services). In lieu of services must be prior approved by ODM in writing. The MCOP must not require a member to use an in lieu of service as an alternative to a service covered under the state plan.
a. The MCOP’s proposal must demonstrate that any in lieu of service is medically appropriate and cost-effective substitute for a service covered under the Ohio Medicaid state plan.
b. The MCOP proposal must include a cost-benefit analysis for any in lieu of service it proposes to provide, including how the proposed service would be a medically appropriate and cost- effective substitute for a service covered under the Ohio Medicaid state plan.
In Lieu of Services. 5.9.1 The PASSE may provide In Lieu of Services to an Enrolled Member in an Institution for Mental Diseases for fifteen (15) days per month in accordance with 42 CFR § 438.6(e) when the PASSE determines that the In Lieu of Services will reduce cost and avoid institutional placement or enhance the Enrolled Member’s ability to move from an institutional or residential setting to a HCBS setting. The PASSE will provide a monthly IMD report for DHS to review for any stays in an IMD greater than fifteen (15) days per month for Enrolled Members aged twenty- one (21) or older.
5.9.2 The benefit to the PASSE is that the service will reduce expenditures for institutional care. For example, if providing a mobile phone or paying for a WIFI connection allows the PASSE to avoid residential or ICF placement by monitoring a member’s health and vitals remotely, the cost of the mobile phone service or WIFI service would be an in lieu of cost.
5.9.3 The PASSE may cover In Lieu of Services for members if the following conditions are met:
a. The member is not required by the PASSE to use the alternative service or setting; and
b. The approved In Lieu of Services are offered to members at the option of the PASSE, and only if the member agrees to the In Lieu of Service.
In Lieu of Services. In general, these services are not covered by Medicaid and therefore are not a PASSE-covered benefit. However, the PASSE may determine it is more cost effective to provide a non-covered service in lieu of more expensive care which is covered under the PASSE program. The cost of the non-covered service may be reported in the numerator of the plan’s MLR and the capitation rate development will include the cost of the covered service that was replaced by the non- covered “in lieu of” service. See IMD.
