Investigational Services. This plan covers certain experimental or investigational services as described in this section. This plan covers clinical trials as required under R.I. General Law § 27-20-60. An approved clinical trial is a phase I, phase II, phase III, or phase IV clinical trial that is being performed to prevent, detect or treat cancer or a life-threatening disease or condition. In order to qualify, the clinical trial must be: • federally funded; • conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or • a drug trial that is exempt from having such an investigational new drug application. To qualify to participate in a clinical trial: • you must be determined to be eligible, according to the trial protocol; • a network provider must have concluded that your participation would be appropriate; and • medical and scientific information must have been provided establishing that your participation in the clinical trial would be appropriate. If a network provider is participating in a clinical trial, and the trial is being conducted in the state in which you reside, you may be required to participate in the trial through the network provider. Coverage under this plan includes routine patient costs for covered healthcare services furnished in connection with participation in a clinical trial. The amount you pay is based on the type of service you receive. Coverage for clinical trials does not include: • the investigational item, device, or service itself; • items or services provided solely to satisfy data collection and that are not used in the direct clinical management; or • a service that is clearly inconsistent with widely accepted standards of care.
Investigational Services. This plan covers certain experimental or investigational services as described in this section. This plan covers clinical trials as required under R.I. General Law § 27-20-60. An approved clinical trial is a phase I, phase II, phase III, or phase IV clinical trial that is being performed to prevent, detect or treat cancer or a life-threatening disease or condition. In order to qualify, the clinical trial must be: federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or a drug trial that is exempt from having such an investigational new drug application. To qualify to participate in a clinical trial: you must be determined to be eligible, according to the trial protocol;
Investigational Services. Contractor shall provide investigational services as defined in Title 22 CCR Section 51056.1(b) when a service is determined to be investigational pursuant to Section 51056.1(c), and that all requirements in Section 51303(h) are clearly documented.
1. Comprehensive Case Management Including Coordination of Care Services Contractor shall ensure the provision of Comprehensive Medical Case Management to each Member. Contractor shall maintain procedures for monitoring the coordination of care provided to Members, including but not limited to all Medically Necessary services delivered both within and outside the Contractor's provider network. These services are provided through either basic or complex case management activities based on the medical needs of the member.
A. Basic Case Management Services are provided by the Primary Care Provider, in collaboration with the Contractor, and shall include:
1) Initial Health Assessment (IHA);
2) Individual Health Education Behavioral Assessment (IHEBA);
3) Identification of appropriate providers and facilities (such as medical, rehabilitation, and support services) to meet Member care needs;
4) Direct communication between the provider and Member/family;
5) Member and family education, including healthy lifestyle changes when warranted; and
6) Coordination of carved out and linked services, and referral to appropriate community resources and other agencies.
B. Complex Case Management Services are provided by the Contractor, in collaboration with the Primary Care Provider, and shall include, at a minimum:
1) Basic Case Management Services
2) Management of acute or chronic illness, including emotional and social support issues by a multidisciplinary case management team
3) Intense coordination of resources to ensure member regains optimal health or improved functionality
4) With Member and PCP input, development of care plans specific to individual needs, and updating of these plans at least annually
C. Contractor shall develop methods to identify Members who may benefit from complex case management services, using utilization data, the Health Information Form (HIF)/Member Evaluation Tool (MET), clinical data, and any other available data, as well as self and physician referrals. Complex case management services for SPD beneficiaries must include the concepts of Person-Centered Planning.
D. Person-Centered Planning for SPD Beneficiaries
1) Upon the enrollment of a SPD beneficiary, Contractor shall provide, or ensur...
Investigational Services. Contractor shall provide investigational services as defined in Title 22 CCR Section 51056.1(b) when a service is determined to be investigational pursuant to Section 51056.1(c), and that all requirements in Section 51303(h) are clearly documented.
Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam $30 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered
Investigational Services. Contractor shall provide investigational services as defined in 22 CCR 51056.1(b) when a service is determined to be investigational pursuant to Section 51056.1(c), and that all requirements in Section 51303(h) are clearly documented.
1. Comprehensive Case Management Including Coordination of Care Services
A. Basic Case Management Services are provided by the Primary Care Provider, in collaboration with the Contractor, and shall include:
1) Initial Health Assessment (IHA);
2) Individual Health Education Behavioral Assessment (IHEBA);
3) Identification of appropriate providers and facilities (such as medical, rehabilitation, and support services) to meet Member care needs;
4) Direct communication between the provider and Member/family;
5) Member and family education, including healthy lifestyle changes when warranted; and
6) Coordination of carved-out and linked services, and referral to appropriate community resources and other agencies.
B. Complex Case Management Services are provided by the Contractor, in collaboration with the Primary Care Provider, and shall include, at a minimum:
1) Basic Case Management Services;
2) Management of acute or chronic illness, including emotional and social support issues by a multidisciplinary case management team;
3) Intense coordination of resources to ensure member regains optimal health or improved functionality;
4) With Member and PCP input, development of care plans specific to individual needs, and updating of these plans at least annually.
C. Contractor shall develop methods to identify Members who may benefit from complex case management services, using utilization data, the Health Information Form (HIF)/Member Evaluation Tool (MET), clinical data, and any other available data, as well as self and physician referrals. Complex case management services for SPD beneficiaries must include the concepts of Person-Centered Planning.
D. Person-Centered Planning for SPD Beneficiaries
1) Upon the enrollment of a SPD beneficiary, Contractor shall provide, or ensure the provision of, Person-Centered Planning and treatment approaches that are collaborative and responsive to the SPD beneficiary’s continuing health care needs.
2) Person-Centered Planning shall include identifying each SPD beneficiary’s preferences and choices regarding treatments and services, and abilities.
3) Contractor shall allow or ensure the participation of the SPD beneficiary, and any family, friends, and professionals of their choosing, to participate...
