Common use of In Lieu of Services or Settings Clause in Contracts

In Lieu of Services or Settings. In Lieu of Services or Settings are alternative services or services in settings that are not Medicaid covered benefits, as set forth in Attachment 1: Turquoise Care Covered Services or Attachment 4: Alternative Benefit Plan Covered Services, but are medically appropriate and cost-effective substitutes. The CONTRACTOR may not require a Member to use in Lieu of Services or Settings as a substitute for Covered Services, but may offer and cover such services or settings, if approved by HCA, as a means of ensuring that appropriate care is provided in a cost-effective manner. The CONTRACTOR must obtain approval in writing from HCA prior to offering or paying Claims for In Lieu of Services or Settings services. The CONTRACTOR shall ensure that the In Lieu of Services or Settings service is a cost-effective substitute for the Covered Service and shall provide support of the services cost effectiveness to HCA. HCA may not consider the costs of the in Lieu of Services and Settings service in the CONTRACTOR’s Capitation Rate if the In Lieu of Services and Settings service is not approved by HCA, not cost effective, or the CONTRACTOR fails to provide supporting documentation to HCA.

In Lieu of Services or Settings. In Lieu of Services or Settings are alternative services or services in settings that are not Medicaid covered benefits, as set forth in Attachment 1: Turquoise Care Covered Services or Attachment 4: Alternative Benefit Plan Covered Services, but are medically appropriate and cost-effective substitutes. The CONTRACTOR may not require a Member to use in Lieu of Services or Settings as a substitute for Covered Services, but may offer and cover such services or settings, if approved by HCAHSD, as a means of ensuring that appropriate care is provided in a cost-effective manner. The CONTRACTOR must obtain approval in writing from HCA HSD prior to offering or paying Claims for In Lieu of Services or Settings services. The CONTRACTOR shall ensure that the In Lieu of Services or Settings service is a cost-effective substitute for the Covered Service and shall provide support of the services cost effectiveness to HCAHSD. HCA HSD may not consider the costs of the in Lieu of Services and Settings service in the CONTRACTOR’s Capitation Rate if the In Lieu of Services and Settings service is not approved by HCAHSD, is not cost effective, or the CONTRACTOR fails to provide supporting documentation to HCAHSD.