SC O PE O F SER Sample Clauses

SC O PE O F SER. V I C ES The Contractor is responsible for managing, covering, and providing all medically necessary physical health services and behavioral health services, as well as the following LTSS: Nursing Facility, Emergency Alert System Services and Habilitative Physical Therapy for members twenty-one (21) years of age and older. All other LTSS and Support Coordination are managed, covered and provided by the Division. The Contractor shall assure and demonstrate that it has the capacity to serve the expected enrollment in accordance with the Division’s standards for access and timeliness of care [42 CFR 457.1230(b), 42 CFR 438.207(a), 42 CFR 438.68, 42 CFR 438.206(c)(1)]. The Contractor is responsible for providing all services as required under this Contract. Medicaid covered services shall be provided in accordance with all applicable Federal and State laws, regulations and policies. The Contractor shall ensure that the services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished [42 CFR 434.6(a)(4)]. The Contractor shall not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of diagnosis, type of illness or condition of the member [42 CFR 457.1230(d), 42 CFR 438.210(a)(3)(ii)]. The Contractor may place appropriate limits on a service based on criteria such as evidence-based practice or medical necessity; or for utilization control, provided the services furnished can be reasonably expected to achieve their purpose [42 CFR 457.1230(d), 42 CFR 438.210(a)(3)(i); 42 CFR 438.210(a)(4)]. The Contractor is prohibited from avoiding costs for services covered in its Contract by referring members to publicly supported health care resources [42 CFR 457.1201(p)]. The Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) with respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997 (1903(i) final sentence and 1903(i)(16) of the Social Security Act). The Contractor shall assure and demonstrate that it has the capacity to serve the expected enrollment in its service area in accordance with the Division’s standards for access and timeliness of care [42 CFR 457.1230(b), 42 CFR 438.207(a), 42 CFR 438.68, 42 CFR 438.206(c)(1)]. The Contractor shall obtain consent and auth...