Common use of Non-Covered Health Services with Care Coordination Clause in Contracts

Non-Covered Health Services with Care Coordination. Contractor must provide information in its Member Handbook about the availability of support from Contractor to access and coordinate care for Non-Covered Health Services with Care Coordination described in this Sec. 9 and how to request such support from Contractor. Additionally, Contractor is responsible for ensuring its Members have access to NEMT services for the services described in this Sec. 9. a. Except as provided in Sec. 10 below of this Ex. B, Part 2, Contractor shall coordinate services for each Member who requires health services not covered under this Contract. Such services not covered include, but are not limited to, the following: (1) Out-of-Hospital birth (OOHB), also known as Planned Community Birth (PCB), services including prenatal and postpartum care for individuals meeting criteria defined in OAR 000-000-0000. Specifically, OHA will be responsible for providing and paying for Care Coordination related to maternity care and primary OOHB services for those Members approved for OOHBs as well as for those Members in provisionally approved status. Further, OHA will be responsible for providing and paying for newborn initial assessment and newborn bloodspot screening test, including the screening kit obtained through Oregon State Public Health Laboratory. OHA will also be responsible for, with the assistance of Contractor, providing Care Coordination for the services ancillary to OOHBs including, but not limited to, pharmacy, ultrasounds, labs, prenatal vitamins, and all other Covered Services related to typical maternity care. However, Contractor shall be responsible for payment of the foregoing typical ancillary maternity care services in accordance with OAR 000-000-000000 and continue to be responsible for providing Care Coordination and payment of Covered Services other than those related to maternity care. 25 The CCO-specific telehealth rule at OAR 410-141-3566 will be repealed effective 1/1/2025. It will be replaced with the FFS telehealth rule at OAR 410-141-1990, which will be revised to incorporate CCO-specific requirements. OHA shall provide Contractor with a list of Members approved and not approved for OOHB services on a regular basis;

Non-Covered Health Services with Care Coordination. Contractor must provide information in its Member Handbook about the availability of support from Contractor to access and coordinate care for Non-Covered Health Services with Care Coordination described in this Sec. 9 and how to request such support from Contractor. Additionally, Contractor is responsible for ensuring its Members have access to NEMT services for the services described in this Sec. 9. a. Except as provided in Sec. 10 below of this Ex. B, Part 2, Contractor shall coordinate services for each Member who requires health services not covered under this Contract. Such services not covered include, but are not limited to, the following: (1) Out-of-Hospital birth (OOHB), also known as Planned Community Birth (PCB), services including prenatal and postpartum care for individuals meeting criteria defined in OAR 000-000-0000. Specifically, OHA will be responsible for providing and paying for Care Coordination related to maternity care and primary OOHB services for those Members approved for OOHBs as well as for those Members in provisionally approved status. Further, OHA will be responsible for providing and paying for newborn initial assessment and newborn bloodspot screening test, including the screening kit obtained through Oregon State Public Health Laboratory. OHA will also be responsible for, with the assistance of Contractor, providing Care Coordination for the services ancillary to OOHBs including, but not limited to, pharmacy, ultrasounds, labs, prenatal vitamins, and all other Covered Services related to typical maternity care. However, Contractor shall be responsible for payment of the foregoing typical ancillary maternity care services in accordance with OAR 000-000-000000 and continue to be responsible for providing Care Coordination and payment of Covered Services other than those related to maternity care. 25 The CCO-specific telehealth rule at OAR 410-141-3566 will be repealed effective 1/1/2025. It will be replaced with the FFS telehealth rule at OAR 410-141-1990, which will be revised to incorporate CCO-specific requirements. OHA shall provide Contractor with a list of Members approved and not approved for OOHB services on a regular basis; (2) [RESERVED] (3) Family Connects Oregon services, notwithstanding exclusion from Contractor reimbursement. b. Contractor shall assist its Members in gaining access to certain Behavioral Health services that are Carve-Out Services, including but not limited to the following: (1) Mental health drugs specified in OAR 000-000-00000 that include but are not limited to standard therapeutic class 7 & 11 Prescription Drugs, Depakote, Lamictal and their generic equivalents dispensed through a licensed pharmacy. These medications are paid through OHA’s Fee for Service system; (2) [RESERVED] (3) [RESERVED]; (4) Investigation of Members for Civil Commitment; (5) [RESERVED]; (6) [RESERVED]; (7) [RESERVED]; (8) [RESERVED]; (9) Residential mental health services for Members 18 years of age and older provided in licensed Community treatment programs; (10) Abuse investigations and protective services as described in OAR Chapter 943, Division 45 and ORS 430.735 through 430.765; (11) [RESERVED]; and (12) Enhanced Care Services and Enhanced Care Outreach Services as described in OAR 309- 019-0155.

Non-Covered Health Services with Care Coordination. Contractor must provide information in its Member Handbook about the availability of support from Contractor to access and coordinate care for Non-Covered Health Services with Care Coordination described in this Sec. 9 and how to request such support from Contractor. Additionally, Contractor is responsible for ensuring its Members have access to NEMT services for the services described in this Sec. 9. a. Except as provided in Sec. 10 below of this Ex. B, Part 2, Contractor shall coordinate services for each Member who requires health services not covered under this Contract. Such services not covered include, but are not limited to, the following: (1) Out-of-Hospital birth (OOHB), also known as Planned Community Birth (PCB), services including prenatal and postpartum care for individuals meeting criteria defined in OAR 000-000-0000. Specifically, OHA will be responsible for providing and paying for Care Coordination related to maternity care and primary OOHB services for those Members approved for OOHBs as well as for those Members in provisionally approved status. Further, OHA will be responsible for providing and paying for newborn initial assessment and newborn bloodspot screening test, including the screening kit obtained through Oregon State Public Health Laboratory. OHA will also be responsible for, with the assistance of Contractor, providing Care Coordination for the services ancillary to OOHBs including, but not limited to, pharmacy, ultrasounds, labs, prenatal vitamins, and all other Covered Services related to typical maternity care. However, Contractor shall be responsible for payment of the foregoing typical ancillary maternity care services in accordance with OAR 000410-000141-000000 3826 and continue to be responsible for providing Care Coordination and payment of Covered Services other than those related to maternity care. 25 The CCO-specific telehealth rule at OAR 410-141-3566 will be repealed effective 1/1/2025. It will be replaced with the FFS telehealth rule at OAR 410-141-1990, which will be revised to incorporate CCO-specific requirements. OHA shall provide Contractor with a list of Members approved and not approved for OOHB services on a regular basis; (2) Long Term Services and Supports excluded from Contractor reimbursement pursuant to ORS 414.631; (3) Family Connects Oregon services; (4) 7KH SRUWLRQ RI WKH +23 EHQHILW SDFNDJH Medicaid Contract, which is paid with Emergency Health Benefit Funding (“EHB”); (5) 3UHVFULSWLRQ GUXJV IRU &RQWUDFWRU¶V &2) an Oral Health Provider for treatment of an Oral Health condition covered by the

Non-Covered Health Services with Care Coordination. Contractor must provide information in its Member Handbook about the availability of support from Contractor to access and coordinate care for Non-Covered Health Services with Care Coordination described in this Sec. 9 and how to request such support from Contractor. Additionally, Contractor is responsible for ensuring its Members have access to NEMT services for the services described in this Sec. 9. a. Except as provided in Sec. 10 below of this Ex. B, Part 2, Contractor shall coordinate services for each Member who requires health services not covered under this Contract. Such services not covered include, but are not limited to, the following: (1) Out-of-Hospital birth (OOHB), also known as Planned Community Birth (PCB), services including prenatal and postpartum care for individuals meeting criteria defined in OAR 000-000-0000. Specifically, OHA will be responsible for providing and paying for Care Coordination related to maternity care and primary OOHB services for those Members approved for OOHBs as well as for those Members in provisionally approved status. Further, OHA will be responsible for providing and paying for newborn initial assessment and newborn bloodspot screening test, including the screening kit obtained through Oregon State Public Health Laboratory. OHA will also be responsible for, with the assistance of Contractor, providing Care Coordination for the services ancillary to OOHBs including, but not limited to, pharmacy, ultrasounds, labs, prenatal vitamins, and all other Covered Services related to typical maternity care. However, Contractor shall be responsible for payment of the foregoing typical ancillary maternity care services in accordance with OAR 000410-000141-000000 3826 9 and continue to be responsible for providing Care Coordination and payment of Covered Services other than those related to maternity care. 25 The CCO-specific telehealth rule at OAR 410-141-3566 will be repealed effective 1/1/2025. It will be replaced with the FFS telehealth rule at OAR 410-141-1990, which will be revised to incorporate CCO-specific requirements. OHA shall provide Contractor with a list of Members approved and not approved for OOHB services on a regular basis;