Common use of Basic Benefit Package Clause in Contracts

Basic Benefit Package. After consideration of third party liability including Medicare coverage pursuant to OAC rules 5160‐58‐01.1 and 5160‐26‐09.1, a MyCare Ohio Plan (MCOP) must ensure its members have access to all medically‐necessary medical, drug, emergency and post‐stabilization, behavioral health, nursing facility and home and community‐based waiver services covered by Medicaid pursuant to OAC rules 5160‐58‐ 03 and 5160‐58‐04 and in 42 CFR 438.114. This coverage must be with limited exclusions, limitations and clarifications (see OAC rule 5160‐58‐03 and below in this Appendix). An MCOP must also ensure that its members have access to any additional services specified in this Agreement. For information on Medicaid‐covered services, MCOPs must refer to the Ohio Department of Medicaid (ODM) website. Services covered by the MCOP benefit package include, but are not limited to the following: a. Inpatient hospital services; b. Outpatient hospital services; c. Rural health clinics (RHCs) and federally qualified health centers (FQHCs); d. Physician services whether furnished in the physician’s office, the covered person’s home, a hospital, or elsewhere; e. Laboratory and x‐ray services; f. Screening, diagnosis, and treatment services to children under the age of 21 under the Healthchek, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illness and conditions. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a) that are in excess of state Medicaid plan limits applicable to adults. An EPSDT screening is an examination and evaluation of the general physical and mental health, growth, development, and nutritional status of an individual under age 21. It includes the components set forth in 42 U.S.C. 1396d(r) and must be provided by plans to children under the age of twenty‐one; g. Children’s Intensive Behavioral Health Service (CIBS) upon OAC rule implementation (date to be determined); h. Family planning services and supplies; i. Home health and private duty nursing services; j. Podiatry; k. Chiropractic services; l. Physical therapy, occupational therapy, developmental therapy, and speech therapy;

Basic Benefit Package. After consideration of third party liability including Medicare coverage pursuant to OAC rules 5160‐58‐01.1 5160-58-01.1 and 5160‐26‐09.15160-26-09.1, a MyCare Ohio Plan (MCOP) must ensure its members have access to all medically‐necessary medically-necessary medical, drug, emergency and post‐stabilizationpost-stabilization, behavioral health, nursing facility and home and community‐based community-based waiver services covered by Medicaid pursuant to OAC rules 5160‐58‐ 5160-58- 03 and 5160‐58‐04 5160-58-04 and in 42 CFR 438.114. This coverage must be with limited exclusions, limitations and clarifications (see OAC rule 5160‐58‐03 5160-58-03 and below in this Appendix). An MCOP must also ensure that its members have access to any additional services specified in this Agreement. For information on Medicaid‐covered Medicaid-covered services, MCOPs must refer to the Ohio Department of Medicaid (ODM) website. Services covered by the MCOP benefit package include, but are not limited to the following: a. Inpatient hospital services; b. Outpatient hospital services; c. Rural health clinics (RHCs) and federally qualified health centers (FQHCs); d. Physician services whether furnished in the physician’s office, the covered person’s home, a hospital, or elsewhere; e. Laboratory and x‐ray x-ray services; f. Screening, diagnosis, and treatment services to children under the age of 21 under the Healthchek, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. These services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illness and conditions. Such services and items, if approved through prior authorization, include those services and items listed at 42 U.S.C. 1396d(a) that are in excess of state Medicaid plan limits applicable to adults. An EPSDT screening is an examination and evaluation of the general physical and mental health, growth, development, and nutritional status of an individual under age 21. It includes the components set forth in 42 U.S.C. 1396d(r) and must be provided by plans to children under the age of twenty‐onetwenty-one; g. Children’s Intensive Behavioral Health Service (CIBS) upon OAC rule implementation (date to be determined); h. Family planning services and supplies; i. Home health and private duty nursing services; j. Podiatry; k. Chiropractic services; l. Physical therapy, occupational therapy, developmental therapy, and speech therapy; m. Nurse-midwife, certified family nurse practitioner, and certified pediatric nurse practitioner services; n. Free-standing birth center services in free-standing birth centers as defined in OAC rule 5160-18-01; o. Prescribed drugs; p. Ambulance and ambulette services; q. Dental services; r. Durable medical equipment and medical supplies, including expedited wheelchair fitting, purchase, maintenance and repair, professional evaluation, home assessment, the services of skilled wheelchair technicians, pick-up and delivery, timely repairs, training, demonstration and loaner chairs; s. Vision care services, including eyeglasses; t. Nursing facility services; u. Hospice care;