Common use of STATE PLAN SERVICES Clause in Contracts

STATE PLAN SERVICES. 5.4.1 The PASSE is required to ensure that all enrolled members have access to all mandatory and optional Medicaid State Plan Services including services available through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program for children that are medically necessary and HCBS described in Exhibit V, and LTSS in Section 5.7. 5.4.2 The PASSE must comply with Sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and Federal regulations at 42 C.F.R. Part 441 Subpart B that require EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services. 5.4.3 The PASSE must cover and pay for emergency services and post-stabilization services provided to an enrolled member regardless of whether the provider that furnishes the services is a participating provider. In accordance with Section 1932(b)(2)(D) of the Act and State Medicaid Director Letter (SMDL) 06-010, the PASSE may not pay a non-contracted provider for emergency services more than the amount that would have been paid if the service had been provided under the Arkansas Medicaid Fee for Service program. a. The PASSE is responsible for coverage and payment of services until the attending emergency physician, or the provider actually treating the member, determines that the member is sufficiently stabilized for transfer or discharge. b. The determination of the attending emergency physician, or the provider actually treating the member, of when the member is sufficiently stabilized for transfer or discharge is binding on the PASSE. 5.4.4 When processing claims, the PASSE shall not: a. Deny payment for treatment obtained when an enrolled member had an emergency medical condition, including cases in which the absence of immediate medical attention would not result in placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; b. Deny payment for treatment obtained when the a PASSE representative instructs the member to seek emergency services; c. Limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms; d. Refuse to cover emergency services based on the emergency services provider not notifying the member’s PCP or care coordinator of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services; or e. Hold a member liable for payment of subsequent screening or treatment needed to diagnosis or stabilize the specific emergency medical condition. 5.4.5 The PASSE must cover post-stabilization care services, regardless of whether they are obtained from participating providers, if: a. They are pre-approved by the PASSE; b. They are not pre-approved under sub-section 5.

STATE PLAN SERVICES. 5.4.1 The PASSE is required to ensure that all enrolled members Enrolled Members have access to all mandatory and optional Medicaid State Plan Services including services available through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program for children that are medically necessary and necessary, HCBS described in Exhibit VII, and LTSS in Section 5.7. 5.4.2 The PASSE must comply with Sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and Federal regulations at 42 C.F.R. Part 441 Subpart B that require requires EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services. 5.4.3 The PASSE must cover and pay for emergency services and post-stabilization services provided to an enrolled member Enrolled Member regardless of whether the provider that furnishes the services is a participating provider. In accordance with Section 1932(b)(2)(D) of the Act and State Medicaid Director Letter (SMDL) 06-010, the PASSE may not pay a non-contracted provider for emergency services more than the amount that would have been paid if the service had been provided under the Arkansas Medicaid Fee for Fee-for-Service program. a. The PASSE is responsible for coverage and payment of services until the attending emergency physician, or the provider actually treating the member, determines that the member is sufficiently stabilized for transfer or discharge. b. The determination of the attending emergency physician, or the provider actually treating the member, of when the member is sufficiently stabilized for transfer or discharge is binding on the PASSE. 5.4.4 When processing claimsClean Claims, the PASSE shall not: a. Deny payment for treatment obtained when an enrolled member Enrolled Member had an emergency medical condition, including cases in which the absence of immediate medical attention would not result in placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; b. Deny payment for treatment obtained when the a PASSE representative instructs the member to seek emergency services; c. Limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms; d. Refuse to cover emergency services based on the emergency services provider not notifying the member’s PCP or care coordinator of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services; or e. Hold a member liable for payment of subsequent screening or treatment needed to diagnosis or stabilize the specific emergency medical condition. 5.4.5 The PASSE must cover post-stabilization care services, regardless of whether they are obtained from participating providers, if: a. They are pre-approved by the PASSE; b. They are not pre-approved under sub-section 55.4.5.a, but are administered to maintain the Enrolled Member’s stabilized condition within one (1) hour of a request to the PASSE for pre-approval; c. Are administered to maintain, improve, or resolve the member’s stabilized condition without pre-approval, when the PASSE did not respond to the request for pre-approval within one (1) hour of the request or the PASSE could not be contacted; or d. The PASSE and the treating physician could not reach an agreement concerning the member’s care and a PASSE physician was not available for consultation. 5.4.6 The PASSE is financially obligated to cover post-stabilization services when: a. They are pre-approved by the PASSE; b. Until one of the following occurs: i. A PASSE physician with privileges at the treating hospital assumes responsibility for the Enrolled Member’s care; ii. A PASSE physician assumes responsibility for the member’s care through transfer; iii. A PASSE representative and the treating physician reach an agreement concerning the member’s care; or iv. The member is discharged.

STATE PLAN SERVICES. 5.4.1 The PASSE is required to ensure that all enrolled members Members have access to all mandatory and optional Medicaid State Plan Services including services available through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program for children that are medically necessary and necessary, HCBS described in Exhibit VII, and LTSS in Section 5.7. 5.4.2 The PASSE must comply with Sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and Federal federal regulations at 42 C.F.R. CFR Part 441 Subpart B that require requires EPSDT services to include outreach and informing, screening, tracking, and, and diagnostic and treatment services. 5.4.3 The PASSE must cover and pay for emergency services and post-stabilization services provided to an enrolled member regardless of whether the provider that furnishes the services is a participating provider. In in accordance with Section 1932(b)(2)(D) of the Act and State Medicaid Director Letter (SMDL) 06-010, the PASSE may not pay a non-contracted provider for emergency services more than the amount that would have been paid if the service had been provided under the Arkansas Medicaid Fee for Fee-for-Service program. a. The PASSE is responsible for coverage and payment of services until the attending emergency physician, or the provider actually treating the member, determines that the member is sufficiently stabilized for transfer or discharge. b. The determination of the attending emergency physician, or the provider actually treating the member, of when the member is sufficiently stabilized for transfer or discharge is binding on the PASSE. 5.4.4 When processing claimsClean Claims, the PASSE shall not: a. Deny payment for treatment obtained when an enrolled member a Member had an emergency medical condition, including cases in which the absence of immediate medical attention would not result in placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; b. Deny payment for treatment obtained when the a PASSE representative instructs the member to seek emergency services; c. Limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms; d. Refuse to cover emergency services based on the emergency services provider not notifying the member’s PCP or care coordinator of the member’s screening and treatment within ten (10) calendar days of presentation for emergency services; or e. Hold a member liable for payment of subsequent screening or treatment needed to diagnosis or stabilize the specific emergency medical condition. 5.4.5 The PASSE must cover post-stabilization care services, regardless of whether they are obtained from participating providers, if: a. They are pre-approved by the PASSE; b. They are not pre-approved under sub-section 55.4.5.a, but are administered to maintain the Member’s stabilized condition within one (1) hour of a request to the PASSE for pre-approval; c. Are administered to maintain, improve, or resolve the member’s stabilized condition without pre-approval, when the PASSE did not respond to the request for pre-approval within one (1) hour of the request or the PASSE could not be contacted; or d. The PASSE and the treating physician could not reach an agreement concerning the member’s care and a PASSE physician was not available for consultation. 5.4.6 The PASSE is financially obligated to cover post-stabilization services when: a. They are pre-approved by the PASSE; b. Until one of the following occurs: i. A PASSE physician with privileges at the treating hospital assumes responsibility for the Member’s care; ii. A PASSE physician assumes responsibility for the member’s care through transfer; iii. A PASSE representative and the treating physician reach an agreement concerning the member’s care; or iv. The member is discharged.