482 Neb. Admin. Code, ch. 4, § 005

Current through June 17, 2024

Section 482-4-005 - CORE BENEFITS PACKAGE GENERAL PROVISIONS

All services provided under managed care must meet the requirements of Title 471 NAC unless specifically waived by the Department. The health plan must apply the same guidelines for determining coverage of services for the Heritage Health member as the Department applies for other Medicaid members. The plan must base the actual provision of a service included in the core benefits package on whether the service could have been covered under Medicaid fee-for-service basis under Title 471 NAC.

005.01PRIOR AUTHORIZATIONS. Family planning services (see 482 NAC 4-005.04), emergency services, and Native Americans seeking tribal clinic or Indian Health hospital services do not require prior authorization or provision by the primary care physician or participating network provider. All covered emergency services (see 482 NAC 4-005.05) must be available twenty-four (24) hours per day, seven (7) days per week, and are not to be limited to plan-network providers. The member may access these services from any Medicaid-enrolled provider of their choice, and the member may access these services without a referral.

005.01(A)REIMBURSEMENT. The Department requires the health plan to reimburse providers, network and out-of-network, for appropriate medical screening performed during an emergency room visit. The payment of claims to out-of-network providers are subject to the requirements in 482 NAC 4-006.07(A). Electronic referral and authorization must be provided in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996.

005.01(B)EXCEPTION. In addition to the health plans provision, abortions must be prior authorized by the Department.

005.02SERVICES IN THE CORE BENEFITS PACKAGE. Services provided in the core benefits package are as follows and represent covered services under Heritage Health. The health plan is responsible for working with the Department to ensure the member has access to all services.

005.02(A)PHYSICAL HEALTH SERVICES. The physical health services include those listed below as covered by Title 471 NAC:

(i) Inpatient hospital services, including transitional hospital services and transplant services (see 471 NAC 10-000);

(ii) Outpatient hospital services (see 471 NAC 10-000);

(iii) Ambulatory surgical center (ASC) services (see 471 NAC 10-000 and 471 NAC 26-000);

(iv) Physician services, including services provided by nurse practitioners, certified nurse midwives, and physician assistants, and clinic-administered injections or medications, and anesthesia services including those provided by a certified registered nurse anesthetist (see 471 NAC 18-000);

(v) Services provided in federally-qualified health centers and rural health clinics (see 471 NAC 29-000 and 471 NAC 34-000);

(vi) Services provided in Indian Health Service facilities (see 471 NAC 11-000);

(vii) Clinical and anatomical laboratory services, including the administration of blood draws completed in the physician's office or an outpatient clinic for a behavioral health diagnosis (see 471 NAC 10-000, 471 NAC 18-000, 471 NAC 20-000, 471 NAC 26-000, 471 NAC 32-000);

(viii) Radiology services (see 471 NAC 10-000);

(ix) Health Check services (see 471 NAC 33-000);

(x) Home health services (see 471 NAC 9-000);

(xi) Private duty nursing services (471 NAC 13-000);

(xii) Therapy services (physical therapy, occupational therapy, and speech pathology and audiology) (see 471 NAC 14-000, and 471 NAC 23-000);

(xiii) Durable medical equipment and medical supplies, including hearing aids, orthotics, prosthetics, and nutritional supplements (471 NAC 7-000, 471 NAC 8-000, 471 NAC 19-000, 471 NAC 15-000);

(xiv) Podiatry services (471 NAC 19-000);

(xv) Chiropractic services (471 NAC 5-000);

(xvi) Vision services (471 NAC 24-000)

(xvii) Free standing birth center services (471 NAC 42);

(xviii) Hospice services, except when provided in a nursing facility (471 NAC 36-000 and 471 NAC 12-000);

(xix) Skilled or rehabilitative and transitional nursing facility services (471 NAC 21-000, 471 NAC 12-000, and 471 NAC 13-000);

(xx) Ambulance services (471 NAC 4-000);

(xxi) Non-emergency transportation services (471 NAC 27-000);

(xxii) Transplant services; and

(xxiii) Pharmacy services (471 NAC 16-000)

005.02(B)BEHAVIORAL HEALTH SERVICES. The behavioral health services include those listed below as covered by Title 471 NAC:

(i) Services for individuals age twenty (20) and under, see Title 471 NAC 32:

(1) Crisis stabilization services (includes treatment crisis intervention);

(2) Inpatient psychiatric hospital (acute and sub-acute); and

(3) Psychiatric residential treatment facility (age 19 and under).

(4) Outpatient assessment and treatment:

(a) Partial hospitalization;

(b) Day treatment;

(c) Intensive outpatient;

(d) Medication management;

(e) Outpatient therapy (individual, family, or group);

(f) Injectable psychotropic medications;

(g) Substance use disorder treatment;

(h) Psychological evaluation and testing;

(i) Initial diagnostic interviews;

(j) Sex offender risk assessment;

(k) Community treatment aide services;

(I) Comprehensive child and adolescent assessment addendum;

(m) Hospital observation room services (up to 23 hours and 59 minutes in duration);

(n) Parent child interaction therapy;

(o) Child-parent psychotherapy;

(p) Applied behavioral analysis;

(q) Multi-systemic therapy; and

(r) Functional family therapy.

(5) Rehabilitation services:

(a) Day treatment and intensive outpatient;

(b) Community treatment aid services;

(c) Professional resource family care; and

(d) Therapeutic group home.

(ii) Services for individuals age twenty-one (21) and over, see Title 471 NAC 20:

(1) Crisis stabilization services (includes treatment crisis intervention);

(2) Inpatient psychiatric hospital services (acute and sub-acute);

(3) Outpatient assessment and treatment:

(a) Partial hospitalization;

(b) Social detoxification;

(c) Day treatment;

(d) Intensive outpatient;

(e) Medication management;

(f) Outpatient therapy (individual, family, or group);

(g) Injectable psychotropic medications;

(h) Substance use disorder treatment;

(i) Psychological evaluation and testing;

(j) Electroconvulsive therapy;

(k) Initial diagnostic interviews;

(I) Ambulatory detoxification; and

(m) In-home psychiatric nursing.

(4) Rehabilitation services:

(a) Dual-disorder residential;

(b) Intermediate residential for substance use disorder;

(c) Short-term residential;

(d) Halfway house;

(e) Therapeutic community for substance use disorder only;

(f) Community support;

(g) Psychiatric residential rehabilitation;

(h) Secure residential rehabilitation;

(i) Assertive community treatment and alternative community support; and

(j) Day rehabilitation.

005.02(C)AMOUNT, DURATION, AND SCOPE. The health plan must provide the above services in amount, duration and scope defined by the Department in Title 471 NAC. The health plan must provide care and services when medically necessary to ensure the member receives necessary services. The health plan must also ensure the services provided to the member are as accessible (in terms of timeliness, amount, duration and scope) as those services provided to the non-enrolled Medicaid client.

005.02(D)VALUE-ADDED SERVICES. The Department allows the health plan to provide medically necessary services to the member that are in addition to those covered under Medicaid. The Department allows the health plan to provide value-added services that are more cost effective than the covered service and the health status of the member is expected to improve or at least stay the same. If the plan provides additional or value-added services, the total payment to the health plan will not be adjusted but will remain within the certified rates agreed upon in any resulting contract and approved by the Centers for Medicare and Medicaid Services.

005.03EXCLUDED SERVICES. The following Medicaid coverable services are excluded from the Heritage Health core benefits package and are not the responsibility of the health plan. Members must access these services through Medicaid. For all Medicaid covered services, the health plan is required to coordinate the members care to promote the continuity of care. The health plan and enrollment broker must inform the member of the availability of these services and how to access them. Excluded services:

(A) Dental services (see Title 471 NAC 6 and 482 NAC 5);

(B) Services in Intermediate Care Facilities for Persons with Developmental Disabilities (see Title 471 NAC 31);

(C) Any institutional long-term care nursing facility services at a custodial level of care (see Title 471 NAC 12 and 471 NAC 13);

(D) School-based services (see Title 471 NAC 25);

(E) All home and community-based waiver services (see Title 404 and 480 NAC);

(F) Targeted case management (see Title 480 NAC); and

(G) Medicaid state plan personal assistance services (see Title 471 NAC 15).

005.04FAMILY PLANNING SERVICES. Approval by the member's primary care provider and health plan is not required for family planning services. The health plan and enrollment broker must inform Heritage Health members of their freedom of choice for family planning services and that they are not restricted to a provider participating in Heritage Health but they must use a Medicaid enrolled provider.

005.04(A)SERVICES COVERED UNDER FAMILY PLANNING. Family planning services are services to prevent or delay pregnancy, including counseling services and patient education, examination and treatment by medical professionals, laboratory examinations and tests, medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception. This includes tubal ligations and vasectomy. The health plan must reimburse treatment for sexually transmitted infections in the same manner as family planning services, without referral or authorizations.

(i) Family planning services do not include hysterectomies, other procedures performed for a medical reason (such as removal of an intrauterine device due to infection) or abortions.

(ii) Family planning services are to be paid by the health plan even if the provider is not part of the health plan's network.

005.05EMERGENCY SERVICES. Approval by the member's primary care provider and health plan is not required for receipt of emergency services. The health plan and enrollment broker must inform Heritage Health members that approval of emergency services is not required and must educate members regarding the definition of an "emergency medical condition," and how to appropriately access emergency services.

005.05(A) EMERGENCY SERVICES PROVIDED TO MANAGED CARE MEMBERS. The health plan must cover and pay for emergency services regardless of whether the provider that furnishes the services has contracted with the health plan.

(i) An emergency medical condition is a medical condition, which manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

(1) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(2) Serious impairment to bodily functions; or

(3) Serious dysfunction of any bodily organ or part.

005.06FEDERALLY QUALIFIED HEALTH CENTERS. The health plan must contract with any federally qualified health center located within the designated coverage area or otherwise arrange for the provision of federally qualified health center services:

(A) If a health plan reimburses a federally qualified health center on a fee-for-service basis, it cannot pay less for those services than it pays other providers;

(B) Federally qualified health center's electing to be reimbursed on a negotiated risk basis are not entitled to reasonable cost reimbursement. If the federally qualified health center requests reasonable cost reimbursement, the health plan must reimburse the federally qualified health center at the same rate it reimburses its other subcontractors of this provider type;

(C) The health plans must report to the Department the total amount paid to each federally qualified health center;

(D) Federally qualified health center payments include direct payments to a medical provider who is employed by the federally qualified health center; and

(E) The same reasonable efforts that are applied to the federally qualified health center, apply to rural health clinics and tribal clinics.

482 Neb. Admin. Code, ch. 4, § 005

Amended effective 7/29/2020

Amended effective 9/27/2021