Common use of Self-Referral Services Clause in Contracts

Self-Referral Services. In accordance with state and federal requirements, the PathWays program includes some benefits and services that are available to members on a self-referral basis. These self- referral services shall not require a referral from the member’s PMP or authorization from the Contractor. The Contractor shall include self-referral providers in its contracted network. Note that network is defined as a list of the doctors, other health care providers, and hospitals that the Contractor contracts with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that isn’t contracted with the Contractor is called an “out-of-network provider.” The Contractor and its PMPs may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. The Contractor cannot require that the members receive such services from network providers, unless otherwise noted. PathWays members may self-refer to any IHCP provider qualified to provide the service(s). When PathWays members choose to receive self-referral services from IHCP-enrolled self- referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at an amount not less than 100% of Indiana Medicaid FFS rates, except for situations described under Section 2.8 of this contract. Members may not self-refer to a provider who is not enrolled in IHCP. The following services are considered self-referral services and 405 IAC 5 provides further detail regarding these benefits. ▪ Chiropractic services may be provided by a licensed chiropractor, enrolled as an Indiana Medicaid provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-2-1 who has entered into a provider agreement under IC 12-15-11. ▪ Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (Doctor of Medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11. ▪ Routine Dental services may be provided by any in-network licensed dental provider who has entered into a provider agreement under IC 12-15-11. ▪ Podiatric services may be provided by any provider licensed under IC 25-22.5 (Doctor of Medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11. EXHIBIT 1

Self-Referral Services. In accordance with state and federal requirements, the PathWays Hoosier Healthwise program includes some benefits and services that are available to members on a self-referral basis. These self- referral services shall not require a referral from the member’s PMP or authorization from the Contractor. The Contractor shall include self-referral providers in its contracted network. Note that network is defined as a list of the doctors, other health care providers, and hospitals that the Contractor contracts with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that isn’t contracted with the Contractor is called an “out-of-network provider.” The Contractor and its PMPs may direct members to seek the services of the self-referral providers contracted in the Contractor’s network. The Contractor cannot require that the members receive such services from network providers, unless otherwise noted. PathWays Hoosier Healthwise members may self-refer to any IHCP provider qualified to provide the service(s). When PathWays Hoosier Healthwise members choose to receive self-referral services from IHCP-enrolled self- self-referral providers who do not have contractual relationships with the Contractor, the Contractor is responsible for payment to these providers up to the applicable benefit limits and at an amount not less than 10098% of Indiana Medicaid FFS rates, except for situations described under Section 2.8 of this contract. Members may not self-refer to a provider who is not enrolled in IHCP. The following services are considered self-referral services and services. The Indiana Administrative Code 405 IAC 5 (Hoosier Healthwise) and provides further detail regarding these benefits. ▪  Chiropractic services may be provided by a licensed chiropractor, enrolled as an Indiana Medicaid provider, when rendered within the scope of the practice of chiropractic as defined in IC 25-10-1-1 and 846 IAC 1-2-1 who has entered into a provider agreement under IC 12-15-111. ▪  Eye care services, except surgical services may be provided by any provider licensed under IC 25-22.5 (Doctor doctor of Medicine medicine or doctor of osteopathy) or IC 25-24 (optometrist) who has entered into a provider agreement under IC 12-15-11. ▪  Routine Dental services may be provided by any in-network licensed dental provider who has entered into a provider agreement under IC 12-15-11. ▪  Podiatric services may be provided by any provider licensed under IC 25-22.5 (Doctor doctor of Medicine medicine or doctor of osteopathy) or IC 25-29 (doctor of podiatric medicine) who has entered into a provider agreement under IC 12-15-11. EXHIBIT  Psychiatric services may be provided by any provider licensed under IC 25-22.5 (doctor of medicine or doctor of osteopathy) who has entered into a provider agreement under IC 12-15-11.  Family planning services under federal regulation 42 CFR 431.51(b)(2) require a freedom of choice of providers and access to family planning services and supplies. Family planning services are those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. Family planning services also include sexually transmitted disease testing. Abortions and abortifacients are not covered family planning services, except as allowable under the federal Hyde Amendment. Members may self-refer to any IHCP provider qualified to provide the family planning service(s), including providers that are not in the Contractor’s network. Members may not be restricted in choice of a family planning service provider, so long as the provider is an IHCP provider. The IHCP Provider Manual provides a complete and current list of family planning services. Under the Contractor’s Hoosier Healthwise line of business, the Contractor shall provide all covered family services and supplies, with the exception of the following items:  Diaphragms  Spermicides  Condoms  Cervical caps  Emergency services are covered without the need for prior authorization or the existence of a Contractor contract with the emergency care provider. Emergency services shall be available twenty four (24)-hours-a-day, seven (7)-days-a-week subject to the “prudent layperson” standard of an emergency medical condition, as defined in 42 CFR 438.114, which relates to emergency and post-stabilization services, and IC 12- 15-12. See Section 3.6 for more information.  Urgent care services are covered for members on a self-referral basis. See Section 5.2.13 for specific urgent care network requirements.  Immunizations are self-referral to any IHCP-enrolled provider. Immunizations are covered regardless of where they are received.  Diabetes self-management services are self-referral if rendered by a self-referral provider. See Section 3.10 for more.  Behavioral health services are self-referral if rendered by an in-network provider. Members may self-refer, within the Contractor’s network, for behavioral health services not provided by a psychiatrist, including mental health, substance abuse and chemical dependency services rendered by mental health specialty providers. The mental health providers to which the member may self-refer within network are:  Outpatient mental health clinics;  Community mental health centers;  Psychologists;  Certified psychologists;  Health services providers in psychology (HSPPs);  Certified social workers;  Certified clinical social workers;  Psychiatric nurses;  Independent practice school psychologists;  Advanced practice nurses under IC 25-23-1-1(b)(3), credentialed in psychiatric or mental health nursing by the American Nurses Credentialing Center; and  Persons holding a master’s degree in social work, marital and family therapy or mental health counseling (under the Clinic Option).