Necessity or Appropriateness of Services a. Use of Approved Service Authorization Policies The IDT shall use the MCO’s Department-approved service authorization policies and procedures to authorize services. The IDT shall not deny services that are necessary to reasonably and effectively support the member’s long term care outcomes identified in the comprehensive assessment as well as those necessary to assist the member to be as self- reliant and autonomous as possible.
Necessity or Appropriateness of Services a. Use of Approved Service Authorization Policies The IDT shall use the MCO’s Department-approved service authorization policies and procedures to authorize services. The IDT shall not deny services that are reasonable and necessary to cost-effectively support the member’s long term care outcomes identified in the comprehensive assessment as well as those necessary to assist the member to be as self- reliant and autonomous as possible. Long-term care outcomes for which services are authorized may relate to:
i. The prevention, diagnosis, and treatment of a disease, condition, and/or disorder that results in health impairments and/or disability;
ii. The ability to achieve age-appropriate growth and development;
iii. The ability to attain, maintain, or regain functional capacity; and
iv. The opportunity to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice.
Necessity or Appropriateness of Services a. Use of Approved Service Authorization Policies The IDT shall use the MCO’s Department-approved service authorization policies and procedures to authorize services. The IDT shall not deny services that are reasonable and necessary to cost-effectively support the member’s long term care outcomes identified in the comprehensive assessment as well as those necessary to assist the member to be as self- reliant and autonomous as possible. Long-term care outcomes for which services are authorized may relate to:
i. The prevention, diagnosis, and treatment of a disease, condition, and/or disorder that results in health impairments and/or disability;
ii. The ability to achieve age-appropriate growth and development;
iii. The ability to attain, maintain, or regain functional capacity; and
iv. The opportunity to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice.
b. Amount, Duration and Scope of Medicaid Services Members shall have access to services in the benefit package that are identified as necessary to support the long term care outcomes in an amount, duration and scope that will support member outcomes and are no less effective than would be achieved through the amount, duration and scope of services that would otherwise be furnished to fee-for-service Medicaid recipients, as set forth in 42 CFR § 440.230 and, for members under the age of 21, as additionally set forth in 42 CFR §§ 441.50 – 441.62 (EPSDT).
