1. SCOPE OF SERVICES
Hospital: Inpatient services include semi-private accommodations for routine care, intensive and coronary care, surgical care, obstetrics and newborn nurseries, and behavioral health emergency/ crisis stabilization. If the member’s medical condition requires isolation; private inpatient accommodations are covered. Nursing services, dietary services and ancillary services such as laboratory, radiology, pharmaceuticals, medical supplies, blood and blood derivatives, etc. are also covered." Arizona Contract, pages 10, 13.
C - Covered Services...
B. Hospital Services
1. Inpatient Hospital
Services furnished in a licensed, certified hospital." Arizona Contract, page C1.
The following terms as used in this Contract shall be construed and interpreted as follows unless the context otherwise expressly requires a different construction and interpretation: ...
AP. 'Hospital Services' shall mean those Medically Necessary Covered Services (as described in Exhibit A) for registered bed patients which are generally and customarily provided by acute care general hospitals. Hospital Services shall also include services rendered in the emergency room and/or the outpatient department of any Hospital. Except for Medical Emergency or written referral, Hospital Services are Covered Services only when performed by Participating Providers." Colorado Contract, page 7.
Hospital, Outpatient Hospital, Clinics and Dialysis Centers
(a) Hospital Room and Board, Nursing Care
Room and Board...
Intensive care unit, special nursing and equipment
Delivery and labor rooms, and equipment...
Services And Supplies...
Blood and blood products...
Durable medical equipment...
Oxygen and its administration
Room & Related Services
Operating room services...
(e) Other Hospital
Ambulatory surgical care
Dressings, splints, casts and other supplies for medical treatment...
Surgical Services: ...
Surgical procedures include: ...
Hemic and lymphatic systems
Male genital system
Laporascopy, peritoneoscopy, hysteroscopy
Female genital system…" Colorado Contract, Exhibit A, pages 1-7, 21.
A. Covered Services included in the Capitation Payment
1. Hospital Inpatient Care (acute care hospitals) - Medically necessary and medically appropriate hospital inpatient acute care, procedures, and services, as authorized by the responsible physician(s) or dentist, and covered under Department of Social Services (DSS) policies and regulations...
4. Chronic Disease Hospital Inpatient Care - Such medically necessary care, procedures, and services as covered under DSS policy and regulation…" Connecticut Contract, Appendix A, pages 3-4.
The DHSSHP will provide standard benefits similar to the acute care benefits that are currently provided under Delaware's Medicaid program. At a minimum, MCOs must agree to assume responsibility for all covered medical conditions within the Basic Benefit Package for each member. The package will include inpatient..." Delaware RFP, page II.37.
Overview Medicaid Covered Services
BASIC BENEFIT PACKAGE...
Hospital Inpatient/ Covered…" Delaware RFP, Appendix H, page 1.
"6.2 The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a))
The following services marked with an 'X' are covered by the State Child Health Insurance Program as part of a basic MCO benefit package when medically necessary with exceptions/limitations noted:
6.2.1. 'X' Inpatient services (Section 2110(a)(1))" Delaware RFP, Appendix A (SCHIP), page A.18.
1. Covered services
a. This contract provide for coverage and provision by Provider of all medical assistance benefits and services that are listed in Attachment I, which is incorporated herein as part of this contract…" District of Columbia Contract, page 21
Classes of Covered Benefits
Coverage of all benefits by Provider shall conform to the definition of the benefit set forth in federal statue and regulation. The following general categories of benefits are included in the state plan and are not otherwise exempt under this contract.
1. Inpatient hospital services (other than services in institutions for mental diseases, as defined in federal law 42 U.S.C. §1396d). Inpatient hospital care includes cosmetic surgery, limited to services required to correct the following conditions: (a) a condition resulting from surgery or disease; (b) an accidental injury; [(c)] a congenital deformity; and (d) correction of a functional problem, i.e. a condition that impairs the normal function of a part of the body. Covered dental surgery is limited to emergency repair of accidental injury to the jaw and related structures." District of Columbia Contract, Attachment I, page 1.
A. Services To Be Provided
1. Services. The plan shall insure the provision of the following covered services as defined and specified in Attachment II:
Inpatient Hospital Services...X" Florida Contract, page 5.
SERVICE DEFINITONS AND REQUIREMENTS...
B. Required Services. These services shall be provided under the Medicaid guidelines.
1. Inpatient Hospital Services. These services are medically necessary serviced ordinarily furnished by a state licensed hospital for the medical care and treatment of impatient provided under the direction of a physician or dentist in a hospital maintained primarily for the care and treatment of patients with disorders other than mental diseases. Inpatient hospital services include but are not limited to medical supplies, diagnostic and therapeutic services, use of facilities, drugs and biological, room and board, nursing care and all supplies and equipment necessary to provide adequate care...
Inpatient hospital services include rehab hospital care. Rehab inpatient care days are also counted as inpatient hospital days. This service also includes care provided by nursing homes as a downward substitution for inpatient hospital services...
The service also includes the following medically necessary and appropriate transplants; bone marrow, all ages and kidney, all ages. The service includes physical therapy services when necessary and provided during a member's inpatient stay...
a. The plan shall be at risk of the provision of up to 45 days of inpatient hospital care for each enrolled member...
b. The plan shall provide up to 45 days of inpatient coverage per member from July 1 or the initial date of enrollment whichever comes later, continuing through June 30…" Florida Contract, pages 74-75.
* Hospital services…" Hawaii RFP, page 9.
One of the primary focuses of Quest is preventive care; therefore, preventive and diagnostic services are important benefits of the basic health plan. The services include all medically necessary and preventive services. The health plan shall provide, at a minimum, whatever services are currently covered by the Hawaii Medicaid program...
inpatient hospital services for medical, surgical, psychiatric, and maternity/newborn
- Room and board
- Nursing care
- Medical supplies, equipment and drugs
- Diagnostic services
- Physical, occupational, speech and language therapy services
- Other medically necessary services…" Hawaii RFP, pages 16-17.
of services - QUEST-NET...
* 10 inpatient hospital days (there is no benefit for maternity, nursery, rehabilitation, or skilled nursing level of care)…" Hawaii RFP, pages 40-42.
Services Other Than Services in Institutions for Mental Diseases.
A. For Adults
1. All services medically necessary for the diagnosis and treatment of acute and/or serious medical conditions of sufficient severity to be furnished in a hospital and under the direction of a licensed physician:
a. These services include room and board, nursing care, drugs, medical supplies and equipment, diagnostic and therapeutic procedures, and other medically necessary ancillary services.
b. Service categories include but are not limited to Medical/Surgical, Maternity and Newborn, Psychiatric, and Rehabilitative...
1. Inpatient hospital coverage for children follows the same requirements as for adults.
2. All Plans must ensure that newborns discharged less than 48 hours after vaginal delivery and 96 hours after cesarean-section delivery receive follow-up services which meet current guidelines, standards, and/or criteria for early newborn discharge as established by the American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG).
3. Inpatient hospital coverage for children also includes all medically necessary non-experimental diagnostic and/or therapeutic services allowed under federal Medicaid rules and regulation…" Hawaii RFP, Appendix F, pages 1-2.
The following is a listing of required components of the provider network. It is not meant to be an all-inclusive listing of the components of the network and additional components may be required based on the needs of the members.
• Hospital services…" Hawaii Behavioral Health RFP, page 15.
(2) Medically Necessary Covered Services
The following services and benefits shall be included as Covered Services under this Contract and will be provided to Beneficiaries whenever medically necessary:
• Inpatient hospital services (including dental hospitalization and acute medical detoxification);
• Inpatient psychiatric care…" Illinois HMO Contract, page 19.
Medicaid Covered Services
The Indiana Medicaid program covers the following services for all eligible recipients. The specific services covered under the managed care initiative are specified in Section 4.4 of this RFP.
* Inpatient hospital services…" Indiana RFP, page 3-3.
Of Managed Care Services
4.4.1 Hoosier Healthwise RBMC Covered Services...
The following is a general list of covered services under the RBMC program, listed by general categories; an abbreviated list of covered services within each category also is provided...
* Hospital services
* Inpatient care..." Indiana RFP, page 4-4.
Service: Inpatient Hospital Services*+
Indiana Medicaid Benefits: Inpatient and outpatient services are covered when such services are provided or prescribed by a physician and when the services are medically necessary for the diagnosis or treatment of the recipient's condition. Does not include services that are not medically or clinically reasonable or necessary, post-stabilization services that are not prior authorized, experimental services; personal comfort or convenience items; services for remediation of learning disabilities; amphetamines when prescribed for weight control; fallopian tuboplasty for infertility or vasovasostomy, air fluidized suspension type hospital beds; cybex services; autopsy; cryosurgery for chloasma; conray dye injection supervision; day care or partial day care or partial hospitalization; pulmonary exercises and rehabilitation programs; cognitive rehabilitation; telephone consultation; nonlegend stop smoking aids; artificial insemination; private duty nursing.
CHIP Benefit Package: Inpatient and outpatient services are covered when such services are provided or prescribed by a physician and when the services are medically necessary for the diagnosis or treatment of the recipient's condition. Coverage is subject to the same limitations as Medicaid.
*Prior Approval Required Under Certain Circumstances
+Federally Required CHIP Benefits" Indiana CHIP Amendment, Attachment C-1, page 1.
Following service categories shall be covered under this contract:
- Hospital inpatient…" Iowa Contract, page 17.
SERVICES NOT INCLUDED IN THE CONTRACT
The following services are non-covered under the terms of this contract, but are covered under Fee-For-Service in the Medicaid Program: ...
• Inpatient hospital costs of heart, liver and bone marrow transplants…" Kansas Contract, pages 3-4.
SERVICES INCLUDED IN THE CONTRACT…
• Inpatient hospital services (includes Acute Medical Detoxification) based on medical necessity…" Kansas Contract, pages 4-6.
to Be Provided
1. Covered Services
The Contractor shall provide Covered Services in accordance with Section 7.9.1 and Attachment VIII of the RFA." Kentucky Contract, page 21.
Inpatient Hospital Services." Kentucky RFA, Attachment VIII, page 57.
Services (907 KAR 1:012 & 1:376)
If preadmission utilization review results in approval for inpatient services, coverage of inpatient hospital services includes: …" Kentucky RFA, Attachment VIII, page 75.
D. DESCRIPTION OF SERVICES
The Contractor will provide, either directly or through contract, a benefits package to Medicaid recipients enrolled through a process administered by the Department and its Health Benefits Advisor ('HBA')... As further described below, the capitated benefits package includes inpatient...hospital care..." Maine Contract, page 1.
• Hospital: Inpatient and Outpatient (includes days waiting placement)…" Maine Contract, page 20.
.07 Benefits-Inpatient Hospital Services.
A. An MCO shall provide to its enrollees medically necessary and appropriate inpatient hospital services as specified in this regulation.
to Long-Term Care Facility.
(1) An MCO shall provide to its enrollees medically necessary and appropriate long-term care facility services for:
(a) The first 30 continuous days following the enrollee's admission; and
(b) Any days following the first 30 continuous days of an admission until the date the MCO has obtained the Department's determination that the admission is medically necessary and appropriate as specified in B(2) of this regulation...
C. The Department shall render a determination with respect to the medical necessity and appropriateness of a stay in a long-term care facility as specified in §B of this regulation within 3 business days of receipt of a complete application from the MCO.
of Stay and Home Visits.
(1) Except as provided in D(2) and (3) of this regulation, the criteria and standards used by an MCO in performing utilization review of hospital services related to maternity and newborn care, including length of stay, shall be in accordance with the medical criteria outlined in the Guidelines for Perinatal Care, which is incorporated by reference in COMAR 10.09.65.01." Maryland COMAR 10.09.67.07.
MCO COVERED SERVICES
Exhibit 1: MCO Covered Services for MassHealth Standard Enrollees...
Acute Inpatient Hospital -- all inpatient services such as daily physician intervention, surgery, obstetrics, radiology, laboratory, and other diagnostic and treatment procedures…
Exhibit 4: MCO Covered Services for MassHealth Basic Enrollees...
Acute Inpatient Hospital -- inpatient services such as daily physician intervention, surgery, obstetrics, radiology, laboratory, an other diagnostic and treatment procedures…
Exhibit 8: MCO Covered Services for MassHealth Family Assistance Enrollees...
Acute Inpatient Hospital -- all inpatient services such as daily physician intervention, surgery, obstetrics, radiology, laboratory, and other diagnostic and treatment procedures…" Massachusetts Contract, Appendix C, pages 1, 14, 21."
OF COMPREHENSIVE BENEFIT PACKAGE
1. Services Included...
The services provided to Enrollees under this Contract include, but are not limited to, the following:
*Inpatient… hospital services…" Michigan Contract, pages 20-21."
"Section 2.23. Inpatient Hospitalization. Includes inpatient medical, mental health and chemical dependency services." Minnesota Contract, page 12.
"Section 6.1. MA and MinnesotaCare/MA Covered Services. The HEALTH PLAN shall provide, or arrange to have e provided to MA and MinnesotaCare/MA Enrollees comprehensive preventive, diagnostic, therapeutic and rehabilitative health care services as defined in Minnesota Statutes… These services shall include but are not limited to, the following…
Section 6.1.10. Inpatient Hospital Services. Coverage for inpatient hospital services shall not exceed the actual semi-private room rate, unless a private room is determined to be Medically Necessary by the HEALTH PLAN." Minnesota Contract, pages 48-49, 53.
"Section 6.2. GAMC Covered Services. The HEALTH PLAN shall provide, or arrange to have provided to Enrollees comprehensive preventive, diagnostic, therapeutic and rehabilitative health care services as defined in Minnesota Statutes, Section 256D.03. Except for Section 6.2.16, these services shall be provided to the extent that this law was in effect on the effective day of this contract. These services shall include, but are not limited to, the following…
Section 6.2.7. Inpatient and Outpatient Hospital Services. Coverage for inpatient hospital services shall not exceed the actual semi-private room rate, unless a private room is determined to be Medically Necessary by the HEALTH PLAN." Minnesota Contract, pages 59-60.
"Section 6.3.2. MinnesotaCare Enrollees. The HEALTH PLAN shall provide, or arrange to have provided to MinnesotaCare Enrollees the same services described in Section 6.1. above with the following modifications.
A. Inpatient hospital service billings covered up to a $10,000 per calendar year benefit limit.
1) Parents (including Legal Guardians) whose income is less than or equal to 175% of Federal Poverty Guidelines (FPG), shall not be subject to a limit on inpatient hospital services.
2) For Enrollees who change health plans during the calendar year, charges submitted toward the $10,000 inpatient limit and out of pocket expenses incurred toward the inpatient limit, that were submitted or incurred prior to the change in health plans are disregarded." Minnesota Contract, page 60.
1) Inpatient hospital services" Missouri RFP, page 8.
Services shall include:
a. Inpatient hospital services" Missouri RFP, page 17.
benefit package includes:
a. Inpatient hospital services…" Missouri RFP, page 48.
Inpatient hospitalization...services for physical health needs are the responsibility of the health plan for members, based on medical necessity including charges for the pretransplant and post discharge follow-up for transplant recipients. (See Transplants). Inpatient stop loss limits will apply when the health plan's payment exceeds $50,000/person/contract year…" Missouri RFP, Attachment Five
2.5.1 COVERED SERVICES...
Hospital Services [Inpatient] (all persons)/services offered in a hospital, limited to medically necessary stays, including inpatient drug and alcohol detoxification; ARM 46.12.503 & 504." Montana Contract, page 41.
Definitions: The following definitions apply under this contract: ...
4.1.3 The term 'Basic Benefits Package,' means the following medical/surgical services, representing a minimum benefits package, as defined in this contract and 471 Nebraska Administrative Code (NAC), that shall be provided by the plan to clients enrolled in the NHC:
(a) Inpatient hospital services (See 471 NAC 10-000)...
(v) Transitional Hospitalization services (See 471 NAC 10-000, Section 9.13, 9.17, 9.18, and 9.19 of this contract)…" Nebraska Contract, pages 6-7.
in the Basic Benefits Package: Pursuant to this contract, services included
in the Basic Benefits Package are:
a) Inpatient hospital services (471 NAC 10-000)...
(w) Transitional Hospitalization services (See 471 NAC 10-000, Section 9.13, 9.18 and 9.19 of this contract)…" Nebraska Contract, pages 94-95.
DUTIES AND RESPONSIBILITIES
I. Medical Services
A. Contractor Mandatory Managed Care Benefit Package. Except as otherwise provided for in this contract, each Contractor must provide a comprehensive managed care benefit package to Medicaid participants…
Covered Services. At a minimum, the Contractor must provide directly
or by subcontract all medical services listed below: ...
13. Hospital Inpatient…" Nevada Contract, page 21.
I. Covered Services - General
B. Inpatient Hospital Services
1. Inpatient Hospital Services..." New Hampshire General Service Agreement, Exhibit A.3., page 3.
COVERED HEALTH CARE SERVICES
10.1 For enrollees who are Medicaid-eligible through Title XIX or the NJ KidCare Plan A program, the contractor shall provide or shall arrange to have provided comprehensive, preventive, diagnostic, rehabilitative, and therapeutic health care services to enrollees that include all services that Medicaid recipients are entitled to receive pursuant to Medicaid, subject to any limitations and/or excluded services as specified in Appendix A of this contract. DMAHS shall assure the continued availability and accessibility of Medicaid covered services not covered under this contract. All services provided shall be in accordance with the New Jersey State Plan for Medical Assistance, the New Jersey Medicaid Managed Care Plan, and all applicable statutes, rules, and regulations.
10.1.1 For beneficiaries eligible solely through NJ KidCare Plan B and Plan C, the contractor shall provide the same managed care services and products provided to enrollees who are eligible through Title XIX. However, non-HMO covered services (i.e., services that continue to be provided fee-for-service) will be limited to certain services for the NJ KidCare Plan B and C populations as indicated in Appendix A.
10.1.2 For beneficiaries eligible solely through NJ KidCare Plan D, the contractor shall provide the managed care services and products as delineated in Appendix S. Non-HMO covered services (i.e., services that will be provided fee-for-service by the Division of Medical Assistance and Health Services) will be limited to the services delineated in Appendix S…" New Jersey Contract, page 51.
BENEFITS PACKAGE-INCLUSIONS AND EXCLUSIONS MEDICAID ...
The health care services listed below shall be provided by the contractor to enrollees as covered benefits rendered under the terms of this contract. Provision of these services shall be equal in amount, duration, and scope as established by the Medicaid program, in accordance with medical necessity without any predetermined limits, unless specifically stated...
IN THE CONTRACTOR'S BENEFITS PACKAGE
The following services must be provided and case managed by the contractor...
5. Inpatient Hospital Services. The contractor shall be responsible for inpatient hospital costs of enrollees whose primary admitting diagnosis is not mental health or substance abuse related…" New Jersey Contract, Appendix A, pages 166-167.
NJ KIDCARE - PLAN D
The health care services listed below shall be provided by the contractor to enrollees as covered benefits rendered under the terms of this contract…
IN THE CONTRACTOR'S BENEFITS PACKAGE
The following services must be provided and case managed by the contractor: ...
6. Inpatient Hospital Services -- including general hospitals, special hospitals, and rehabilitation hospitals. The contractor shall not be responsible when the primary admitting diagnosis is mental health or substance abuse related." New Jersey Contract, Appendix S, pages 233-234.
The benefit package includes hospital inpatient acute care, procedures and services as set forth in Medical Assistance Division Program Manual Section MAD-721, HOSPITAL SERVICES." New Mexico Contract, page 36.
Hospital inpatient services "APPENDIX K-1
MANAGED CARE PLAN PREPAID BENEFIT PACKAGE
Inpatient Hospital Services
Plan Scope of Benefit
Up to 365 medically necessary days per year (366 for leap year).
Includes inpatient detoxification services provided in Article 28 hospitals for all Enrollees. Inpatient dental services are covered…" New York Contract, Appendix K, page K-5.
MANAGED CARE PLAN PREPAID HEALTH ONLY BENEFIT PACKAGE
For SSI and SSI Related Recipients
Inpatient Hospital Services
Plan Scope of Benefit
Up to 365 medically necessary days per year (366 for leap year).." New York Contract, Appendix K, page K-9.
BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES
A. Medical Services
1. Inpatient Hospital Services
Inpatient hospital services, as medically necessary, shall include, except as otherwise specified, the care, treatment, maintenance and nursing services as may be required, on an inpatient hospital basis, up to 365 days per year (366 days in leap year). Among other services, inpatient hospital services encompass a full range of necessary diagnostic and therapeutic care including medical, surgical, nursing, radiological, and rehabilitative services. Services are provided under the direction of a physician, nurse practitioner, or dentist." New York Contract, Appendix K, page K-13.
Inpatient Hospital Services…
The Plan shall provide all Covered Services, except inpatient and related inpatient services, to hospitalized members commencing on the effective date of enrollment." North Carolina Contract, page 14.
Schedule of Benefits
* Inpatient Hospital - Except for Mental Health and Substance Abuse". North Carolina Contract, Appendix III, Amendment.
L: COVERED SERVICES...
9. Hospital Services, Inpatient - includes all medically necessary inpatient stays including rehabilitation and alcohol and drug detoxification and post-delivery coverage required under N.D.C.C. 26.1-36-09.8…" North Dakota Contract, Attachment L, pages 1-2.
BASIC BENEFIT PACKAGE BY SERVICE TYPE
The following types of services must be provided to covered persons by participating health plans and at least to the extent such services are covered by Ohio Medicaid. Additional covered services required under this contract are outlined in the RFP.
1. Inpatient hospital services…" Ohio RFP, Appendix A, page 1.
2. Description of Comprehensive Benefit Package
The HMO must agree to make available the comprehensive benefit package to program eligibles. The comprehensive benefits package includes inpatient…hospital services…" Pennsylvania RFP, pages 37-38.
The member's HealthChoices HMO has a comprehensive benefit package provided in a manner comparable to the amount, duration, and scope set forth in the Medical Assistance fee-for-service program, unless otherwise specified by the Department, The comprehensive benefit package includes inpatient…hospital services…" Pennsylvania Behavioral Health RFP, page 53.
Description Of Comprehensive Benefit Package
The comprehensive benefit package includes inpatient… hospital services…" Rhode Island RFP, page 21.
Inpatient Hospital Care
Up to 365 days per year based on medical necessity…" Rhode Island RFP, Attachment A, page 1.
Benefits For The South Carolina Medicaid HMO Program
Core benefits must be available to each Medicaid HMO Program member within the Contractor's service area and the Contractor must provide a mechanism to reduce inappropriate and duplicative use of health care services...
A summary listing
of the core benefits is as follows:
Inpatient Hospital Services…" South Carolina Contract, page 15.
FOR THE SOUTH CAROLINA MEDICAID HMO PROGRAM...
INPATIENT HOSPITAL SERVICES
Inpatient hospital services are those items and services, provided under the direction of a physician, furnished to a patient who is admitted to a general acute care medical facility for institutional and professional services on a continuous basis that is expected to last for a period greater than 24 hours. An admission occurs when the Severity of Illness/Intensity of Services criteria set forth by the review contractor and approved by DHHS is met. Among other services, inpatient hospital services encompass a full range of necessary diagnostic, therapeutic care including surgical, medical, general nursing, radiological and rehabilitative services in emergency or non-emergency conditions. Additional inpatient hospital services would include room and board, miscellaneous hospital services, medical supplies, and equipment." South Carolina Contract, page Appendix C, Tab 1, page 1.
"SECTION 2 -
2-2. CONTRACTOR Qualifications
The CONTRACTOR shall comply with the following requirements at the inception of this Agreement and at all times during the life of this Agreement:
health care services shall include, but not be limited to: ...
7. hospital services, including emergency services…" Tennessee Contract, pages 3-4.
Benefits/Service Requirements and Limitations
a. Covered Services
1. Medically Necessary Services
Inpatient Hospital Days (including days at a designated perinatal center)/As medically necessary. Preadmission approval and concurrent reviews allowed…" Tennessee Contract, pages 7-8.
If a CONTRACTOR provider admits an Enrollee for inpatient hospital care, the CONTRACTOR has the responsibility for all services needed by the Enrollee during the hospital stay that are ordered by the CONTRACTOR provider. Needed services include but are not limited to diagnostic tests, pharmacy, and physician services, including services provided by psychiatrists. If diagnostic tests conducted during the impatient stay reveal that the Enrollee's condition is outside the scope of the CONTRACTOR's responsibility, the CONTRACTOR remains responsible for the Enrollee until the Enrollee is discharged or until responsibility is transferred to another appropriate entity and the appropriate entity agrees to take financial responsibility, including negotiation a payment for services..." Utah Contract, Attachment B, page 19.
C - Covered Services
1. In General
The CONTRACTOR will provide the following benefits to Enrollees in accordance with Medicaid benefits as defined in the Utah State Plan subject to the exception or limitations as noted below. The DEPARTMENT reserves the right to interpret what is in the State plan. Medicaid services can only be limited through utilization criteria based on Medical Necessity. The CONTRACTOR will provide at least the following benefits to Enrollees...
1. Inpatient Hospital
Services furnished in a licensed, certified hospital..." Utah Contract, Attachment C, page 1.
The Contractor shall cover inpatient hospital stays in general acute care and rehabilitation hospitals for all enrollees.
The Contractor must use Department prior authorization criteria, as set forth in 12 VAC 30-50-100 and 12 VAC 30-50-220, or use other criteria approved by the Department.
The Contractor shall cover inpatient rehabilitation services in facilities certified as rehabilitation hospitals and rehabilitation hospitals which have been certified by the Department of Health to meet the requirements to be excluded from the Medicare Prospective Payment System, as set forth in 12 VAC 30-50-200." Virginia Contract, page 47.
The following services are covered by this agreement when medically necessary except for the exclusions specifically provided.
Inpatient Services: Provided by acute care hospitals (licensed under chapter 70.41 RCW), or nursing facilities (licensed under chapter 18.51 RCW) when nursing facility services are not covered by the Department's Aging and Adult Services Administration and the PCP and Contractor's Medical Director determine that nursing facility care is more appropriate than acute hospital care. Inpatient physical rehabilitation services are included…" Washington Contract, Exhibit 6, Attachment 1, page 1.
HMO Covered Services...
The HMO must promptly provide or arrange to make available for enrollees all medically necessary services listed below and assume financial responsibility for the provision of these services...
OF BENEFITS/LIMITATION ON SERVICES
Hospital Services, Inpatient/All inpatient services and organ transplant coverage or kidney,liver, bone marrow, corner, heart, heart-lung, lung both single and double./Unlimited medically necessary days based on diagnosis related groups. Transplant services must be in a facility approved as a transplant center by Medicare and prior authorized by Medicaid. Prior authorizationrequired for all inpatient admissions." West Virginia Contract, Exhibit A, pages 1-2.
The following charts present as explanation of the medical services which the MCP is required to provide...
The MCP must promptly provide or arrange to make available for enrollees all medically necessary services listed below and assume financial responsibility for the provision of these services...
SCOPE OF BENEFITS/ LIMITATION ON SERVICES
Hospital Services, Inpatient/ All inpatient services and organ transplant coverage of kidney, liver, bone marrow, cornea, and heart./ Excludes those adults in institutions for mental diseases. Unlimited medically necessary days for children. Transplant services must be in a facility approved as a transplant center by Medicare and prior authorized by Medicaid. Prior authorization required for all inpatient admissions." West Virginia RFA, Appendix A, pages A1, A3.