alternative benefit planprovider.indianamedicaid.com/ihcp/stateplan/suffix/abp/abp1-5.pdf ·...

Alternative Benefit Plan

Attachn1ent 3.1-L-D OMB Control Number: 0938-1148

OMB Expiration date: 10/31/2014

Benefits:.µescription

The state/territory proposes a "Benchmark-Equivalent" benefit package.~

Benefits Included in Alternative Benefit Plan

Enter the specific name of the base benchmark plan selected:

Base Benchmark Commercial HMO Advantage HMO Basic Plan

Enter the specific name of the section 193 7 coverage option selected, if other than Secretary-Approved. Otherwise, enter ''Secretary-Approved."

Secretary-Approved

TN#: 15-0024

Indiana

ABP 5 Approval Date:10/29/15

Effective Date: October 1, 2015

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1. Essential Health Benefit: Ambulatory patient services Collapse All D

Benefit Provided: Source:

!Primary Care Physician (PCP) Services Office Visit 1 IBase Benchmark Commercial HMO 11 Re1n0Ve I

Authorization: Provider Qualifications:

Other I !Medicaid State Plan I Amount Li1nit: Duration Limit:

None I !None

Scope Limit

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Office visit services include supplies for treatment of the illness or injury, medical consultations, procedures performed in the physician's office, second opinion consultations and specialist treatment services provided by a PCP. For second opinion consultations, the Managed Care Entities (MCEs) n1ay require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the 1nember and a planned course of treatment, if applicable, as related to the number of services provided and duration of treat1nent.


!specialty Physician Visits I !Base Benchmark Conu11ercial HMO 11 RemOve I


Other I !Medicaid State Plan I Amount Liinit: Duration Limit:

None I INone

Scope Limit:

None

Other information regarding this benefit, including the specific naine of the source plan if it is not the base bench1nark plan:

Referral Physician Office Visit included. For authorization, Managed Care Entities (MCEs) may require prior authorization require1nents, such as general n1ember information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nu1nber of services provided and duration of treattnent.


!Home Health Services I !secretary-Approved Other I Authorization: Provider Qualifications:

I other I !Medicaid State Plan I

ABP 5 TN#: 15-0024

Indiana

Approval Date:10/29/15

Effective Date: October 1, 2015 of 43


Amount Li1nit: Duration Limit:

I 100 visits per year. I JNone I Remove

Scope Lin1it:

Services covered only if not considered custodial care and are prescribed in writing by a participating physician as medically necessary, in place of inpatient hospital care or convalescent nursing home and services provided under physician's care.

Other information regarding this benefit, including the specific natne of the source plan if it is not the base benchmark plan:

Services include skilled medical services; nursing care given or supeIVised by RN; nutritional counseling furnished or supervised by RD; home hospice services; home health aides; laboratory services, drugs, and medicines prescribed by a physician in connection with home health care; and medical social services. Home hospice services are considered a separate service. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nun1ber of services provided and duration of treatment.


!outpatient Surgery I !Base Benchmark Co1nmercial HMO 11

Remo-Ye


Other 1 IMedicaid State Plan I Amount Limit: Duration Li1nit:

None I !None

Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base benchn1ark plan:

Outpatient 1nedical and surgical hos pita! services are covered when medically necessary. Includes diagnostic invasive procedures that may or niay not require anesthesia. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general me1nber information, a justification of services rendered for the medical needs of the me1nber and a planned course of treatment, if apphcable, as related to the number of services provided and duration of treatn1ent.


!Allergy Testing I IBase Benchmark Commercial HMO I Authorization: Provider Qualifications:

None 1 IMedicaid State Plan I

An1ount Limit: Duration Li1nit:

None I !None

TN#: 15-0024

Indiana



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Scope Limit:

None I R61nove I Other information regarding this benefit, including the specific nan1e of the source plan if it is not the base benchmark plan:

Includes allergy procedures-administration of serum.


!chemotherapy-Outpatient I

!Base Bench1nark Co1nmercial HMO 11

Remove I Authorization: Provider Qualifications:

Other 1 IMedicaid State Plan I

Amount Limit: Duration Limit:

None I !None

Scope Limit:

None

Other inforn1ation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Includes outpatient therapeutic injections which are medically necessary and may not be self-administered. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization require1nents, such as general men1ber infonnation, a justification of services rendered for the 1nedical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


Irv Infusion Services I

!Base Benchmark Commercial HMO 11


Other I !Medicaid State Plan I

A1nount Limit: Duration Liinit:

None I !None

Scope Limit:

None


Includes coverage for outpatient infusion therapy. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general 1nember info1mation, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nun1 ber of services provided and duration of treat1nent.

TN#: 15-0024 ABP5

Indiana





!Radiation Therapy- Outpatient I !Base Benchmark Cornn1ercial HrvfO 11 Remove I


Other I !Medicaid State Plan I Ainount Limit: Duration Li1nit:

None I !None

Scope Lirnit:

None

Other infonnation regarding this benefit, including the specific na1ne of the source plan if it is not the base benchmark plan:

Includes coverage for outpatient services. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!Dialysis I !Base Benchmark Commercial HMO 11


Other I !Medicaid State Plan I Amount Limit: Duration Limit:

None I !None

Scope Limit:

None

Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Coverage provided for outpatient (including home) dialysis services provided by a participating provider. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member infonnation, a justification of services rendered for the 1nedical needs of the men1ber and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!outpatient Services I IBase Benchmark Con1n1ercial HMO I Authorization: Provider Qualifications:

Other 1 IMedicaid State Plan I Amount Litnit: Duration Limit:

IN one I INone

TN#: 15-0024

Indiana

ABPS Approval Date:10/29/15



Scope Limit:

None I Reino Ve

Other information regarding this benefit, including the specific nmne of the source plan if it is not the base benchmark plan:

Includes colonoscopy and pacemaker. Benefits provided are PCP, specialty and referTal for all physician services in an outpatient facility. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general 1ne1nber information, a justification of services rendered for the n1edical needs of the 1nember and a planned course of treatn1ent, if applicable, as related to the number of services provided and duration of treat1nent.


!clinical Trials for Cancer Treatment I !Base Benchmark Commercial Hl\110 11 Remove


Other I !Medicaid State Plan I Atnount Limit: Duration Li1nit:

None \\None

Scope Lin1it:

Items and services that are not routine care costs or unrelated to the care method will not be covered.

Other info1mation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

The clinical trial must be approved or funded by one of the following: National Institute of Health; cooperative group of research facilities that have an established peer review progra1n that is approved by a National Institute of Health or center; FDA; United States Depart1nent of Veterans Affairs; United States Department of Defense; institutional review board of an institution located in Indiana that has a multiple project assurance contract approved by the National Institute of Health Office for Protection from Research Risks; and research entity that meets eligibility criteria for a support grant from a National Institutes of Health center. Coverage provided for routine care costs that are incun·ed in the course of a clinical trial. For authorization, Managed Care Entities (MCEs) inay require prior authorization requirements, such a~ general men1ber infonnation, review of clinical trial to ensure qualified, review of routine costs related to clinical trial and a justification of services rendered for the medical needs of the member.


\Dental- Limited Covered Services- Accident/Inju1y \ lsase Benchmark Commercial HMO I Authorization: Provider Qualifications:

I other I !Medicaid State Plan I A1nount Limit: Duration Li1nit:

jTreatn1ent co1nplete within 1 year fron1 initiation. I !None

Scope Limit:

!coverage not provided for orthodontia, dental procedures, repair of inju1y caused by an intrinsic force,

TN#: 15-0024

Indiana

ABP5 Approval Date:10/29/15


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such as the torce ot t11e upper and lower Jaw 1n chewing, repair ot artJt1c1a1 teeth, dentures or bndges and j other dental services.

1 Remove I Other info1mation regarding this benefit, including the specific name of the source plan if it is not the base

benchmark plan:

Injury to sound and natural teeth including teeth that have been filled, capped or crowned. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, to report injury to insurer and receive follow-up care within specified time-frame, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nun1 ber of services provided and duration of treatment.


!urgent Care- Walk-ins \ !Base Benchn1ark Com1nercial HMO I I Ren10Ve I Authorization: Provider Qualifications:

None [ !Medicaid State Plan I Amount Lin1it: Duration Limit:

None [ INone

Scope Limit:

None

Other infonnatlon regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

!Coverage includes after hours care. I Benefit Provided: Source:

fRoutine Foot C.are I !secretary-Approved Other I I ·Remove I Authorization: Provider Qualifications:

Other 1 IMedicaid State Plan I An1ount Limit: Duration Lilnit:

16 visits per year. I [None

Scope Li111it:

Coverage not provided for supportive devices of the feet, including but not limited to foot orthotics, co1rective shoes, arch supports for the treatment of plantar fasciitis, flat feet, fallen arches, weak feet, chronic foot strain, corns, bunions

Other infonnation regarding this benefit, including the specific nan1e of the source plan if it is not the base benchn1ark plan:

Scope limit continued- and calluses. Covered when 1nedically necessary for the treatment of diabetes and lower extretnity circulatory diseases. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the 1nember and a planned course of treatment, if applicable, as related to the number of services provided and duration of treattnen t.

TN#: 15-0024 ASP 5

Indiana





!Voluntary Stetilization for Males J lstate Plan 1905(a) 11



None I !None

Scope Limit:

None

Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base bench1nark plan:

For authorization, Managed Care Entities (MCEs) tnay require prior authorization require1nents) such as general member information, a justification of services rendered for the medical needs of the me1nber and a planned course of treatment, if applicable, as related to the nu1n ber of services provided and duration of treatment.

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TN#: 15-0024

Indiana



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2. Essential Health Benefit: Emergency services Collapse All D Benefit Provided: Source:

!Emergency Department Services I

jBase Benclunark Com1nercial HMO 11

Remove'


None I !Medicaid State Plan I

Amount Li1nit: Duration Limit:

None I !None

Scope Limit:

Medical care provided outside of the U.S. is not covered.

Other information regarding this benefit, including the specific naine of the source plan if it is not the base benchmark plan:

!Emergency room included. I Benefit Provided: Source:

!Emergency Transportation: Ambulance/Air Ambulance l IBase Benclunark Con11nercial 1™0 11

Remove


Other l IMedicaid State Plan I

Amount Litnit: Duration Limit:

None I !None

Scope Lin1it:

None


Other medically necessary ambulance transport (ambulance, n1edi-van or similar medical ground, air or water transpo1i to or fron1 the hospital or both ways and transfer from a hospital to a lower level of care) is covered. For other medically necessary transportation, authorization inay be required in which the Managed Care Entities (MCEs) may require other details, such as general me111ber infonnation, to contact PCP for other types of transportation related services and a justification of services rendered for the inedical needs of the metnber.

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TN#: 15-0024

Indiana



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3. Essential Health Benefit: Hospitalization Collapse All D Benefit Provided: Source:

!General Inpatient Hospital Care I !Base Benchmark Commercial HMO 11 Remove


Other I !Medicaid State Plan I Amount Lin1it: Duration Limit:

None I !None

Scope Limit:

Benefit does not include personal comfort items, including those services and supplies not directly related to care, such as guest meals, acco1nmodations or personal hygiene products, and room and board when tetnporary leave permitted.

Other infonnation regarding this benefit, including the specific na1ne of the source plan if it is not the base benchmark plan:

Services include serni~private room and board (private roon1 provided when 1nedically necessary); intensive care unit/coronary care unit; inpatient cardiac rehabilitation and rehabilitation therapy; general nursing care; use of operating roon1 or delivery suite; surgical and anesthesia services and supplies; ordinary casts; splints and dressings; drugs and oxygen used in hospital; laboratory and x-ray examinations; electrocardiogran1s; special duty nursing (when requested by a physician and certified as medically necessary); and inpatient specialty pharmaceuticals. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization requirements, such as general member infonnation, review of medical necessity, authorization by acting physician, a justification of services rendered for the medical needs of the member and a planned course of treat1nent, if applicable, as related to the number of services provided and duration of treat1nent.


!Inpatient Physician Services I !Base Benchmark Commercial HMO 11 Remove


Other 1 IMedicaid State Plan I Atnount Limit: Duration Li1nit:

None I !None

Scope Limit:

None


Benefit includes PCP, specialty and may require a referral for physician services in the hospital. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member info1mation, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of se1vices provided and duration of treat1nent.

TN#: 15-0024

Indiana

ABP5 Approval Date: 10/29/15


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!Inpatient Surgical Services I IBase Benchmark Com1nercial HMO 11 Remove


Other 1 IMedicaid State Plan I Amount Limit: Duration Limit:

None I INone

Scope Limit:

Benefit does not include bariatric surgery, surgical and nonsurgical treat1nent ofTMJ, personal comfort items, including those services and supplies not directly related to care, such as guest meals, accommodations or personal hygiene products,

Other information regarding this benefit, including the specific na1ne of the source plan if it is not the base benchmark plan:

Scope Limit continued~ and room and board when temporary leave permitted. Surgical hospital services are covered when medically necessary. Services include semi-private room and board (private room provided when 1nedical1y necessary); intensive care unit/coronary care unit; general nursing care; use of operating room or delivery suite; surgical and anesthesia services and supplies; ordinary casts; splints and dressings; drugs and oxygen used in hospital; laboratory and x-ray examinations; electrocardiogran1s; special duty nursing (when requested by a physician and certified as tnedically necessary); and inpatient specialty pharmaceuticals. Surgical operations may include replace1nent of diseased tissue removed while a member. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


tNon-Cosmetic Reconstructive Surgery \ IBase Benchmark Com1nercial HMO I Authorization: Provider Qualifications:

Other \ !Medicaid State Plan I Amount Lin1it: Duration Limit:

Services begin within 1 year of the accident. I \None

Scope Limit:

Benefit does not include personal comfort items, including those services and supplies not directly related to care, such as guest meals, accommodations or personal hygiene products, and rootn and board when tetnporary leave pennitted.

Other infonnation regm·ding this benefit, including the specific na1ne of the source plan if it is not the base benchmark plan:

Surgical hospital services are covered when medically necessary and approved by physician. Reconstructive procedures perfonned to restore or in1prove impaired physical function or defects resulting fro1n an accident. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as genera\ member infonnation, a justification of services rendered for the medical needs of the metnber and a

TN#: 15-0024

Indiana



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pJannea course or treatment, IT appl!caote, as re1atea to tne num oer ot services provided ana ouratton at treatment.

I Remove


jMastecto1ny- Reconstmctive Surgery j jBase Benchmark Commercial HJvIO 11 Remove



None I !None

Scope Limit:

Benefit does not include personal comfort items, including those services and supplies not directly related to care, such as guest n1eals, accommodations or personal hygiene products, and roon1 and board when te1nporary leave permitted.

Other information regarding this benefit, including the specific nan1e of the source plan if it is not the base bench1nark plan:

Surgical hospital services are covered when medically necessary and approved by physician. Covered services include reconstruction of the breast upon which the mastecton1y was performed; surgery and reconstruction of the other breast to produce a sy1nmetrical appearance; and prostheses and physical complications at all stages ofmastecto1ny, including lyn1phedemas. For authorization, Managed Care Entities (M_CEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatinent.


!Transplants I IBase Benchn1ark Co1n1nercial HMO I Authorization: Provider Qualifications:

Other 1 IMedicaid State Plan I Amount Limit: D1rration Limit:

None I !None

Scope Litnit:

None


Hun1an organ and tissue transplant services for both the recipient and the donor, when the recipient is a me1nber. No coverage is provided for the donor or the recipient when the recipient is not a nien1ber. Specialty Care Physician (SCP) provides pre-transplant evaluation. Non-experimental, non-investigational organ and other transplants are covered. Donor1s 1nedical expenses covered if the person receiving the transplant is a n1ernber, and donor's expenses are not covered by another issuer. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the 1nedical needs of the me1nber and a

TN#: 15-0024

Indiana



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s Alternative Benefit Plan

p1annea course 01 treatment, IT appncaote, as relatea to the number or services provtaed and duration ot treatment.

I Remove I Benefit Provided: Source:

jcongenital Abnormalities \ !Base Benclunark Commercial Hl\10 11


Other J IMedicaid State Plan I A1nount Limit: Duration Limit:

None I ~one I Scope Limit:

Benefit does not include personal comfort items, including those services and supplies not directly related to care, such as guest tneals, acco1nrnodations or personal hygiene products, and roon1 and board when te1nporary leave permitted.

Other information regarding this benefit, including the specific natne of the source plan if it is not the base benchmark plan:

Surgical hospital services are covered \Vhen medically necessary and approved by physician. For authorization, Managed C-are Entities (MCEs) n1ay require prior authorization require1nents, such as general n1ernber inforn1ation, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nutnber of services provided and duration of treatn1ent.


!Anesthesia I !Base Benchmark Commercial HMO 11 .Remo~e I Authorization: Provider Qualifications:

Other I !Medicaid State Plan I Ainount Limit: Duration Lin1it:

None I INone

Scope Limit:

None


Coverage includes anesthesia services and supplies. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the mcn1ber and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!Hospice Care ! !Base Benchn1ark Co1n1nercial HMO I

TN#: 15-0024 ABP 5

Indiana





Other 1 IMedicaid State Plan 11 Remove I

Amount Limit: Duration Limit:

None I INone

Scope Limit:

Room and board services are not covered when temporary leave pennitted.

Other info1111ation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

This benefit 1nay be provided in hospitals, skilled nursing facilities, and freestanding hospice centers. Covered services include semi-private roo1n (private room provided when n1edically necessa1y). Hospice care provided ifte1minal illness, in accordance with a treat1nent plan before ad1nission to the progra1n. Treatment plan must provide statement fro1n physician that life expectancy is 6 months or less. Concu1Tent care is provided to children (19 & 20 year olds). For authorization, Managed Care Entities (MCEs) inay require prior authorization requirements, such as general me1nber information, a justification of services rendered for the n1edical needs of the 1nember and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!Medical Social Services I

jBase Benchmark Comn1ercial HM.:O 11


None I !Medicaid State Plan I Amount Limit: Duration Limit:

None I !None

Scope Limit:

None

Other information regarding this benefit, including the specific naine of the source plan if it is not the base benchmark plan:

Ilospital services to assist member and family in understanding and coping with the emotional and social problems affecting health status.

Benefit Provided:

!Dialysis

Authorization:

I other

Atnount Limit:

!None

TN#: 15-0024

Indiana

Source:

I !Base Benchmark Commercial HMO I Provider Qualifications:

1 IMedicaid State Plan

Duration Li1nit:

I !None

ABP 5

I




Scope Limit:

None I Remo Ve

Other information regarding this benefit, including the specific nan1e of the source plan if it is not the base benchmark plan:

Inpatient dialysis services provided by a participating provider. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned co~rse of treatment, if applicable, as related to the number of services provided and duration of trcahnent.


!chemotherapy ! !Base Benchmark Commercial HMO 11 Rerriove


Other !Medicaid State Plan I An1ount Limit: Duration Limit:

None I !None

Scope Lin1it:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base bench1nark plan:

Includes coverage for inpatient services. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!Radiation Therapy I !Base Bench1nark Com1nercial HMO I Authorization: Provider Qualifications:

Other I !Medicaid State Plan I Amount Lhnit: Duration Limit:

None ) jNone

Scope Limit:

None I Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Includes coverage for inpatient services. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general me1nber information, a justification of services rendered for the n1edical needs of the n1ernber and a

TN#: 15-0024

Indiana



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!planned course of treatment, 1t appllcable, as related to the nu1nber of services provided and duration ot treatment.

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TN#: 15-0024 ABP 5

Indiana



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4. Essential Health Benefit: Maternity and newborn care Collapse All 0


jobstetric Care I !state Plan 1905(a) 11 Remove


Other I !Medicaid State Plan I Amount Lin1it: Druation Limit:

ILimits equivalent to State Plan. I !None

Scope Limit:

None

Other info1mation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan:

Coverage is provided fron1 the State Plan under the physician benefit and includes various obstetrical services such as antepartum and postpartum visits, laboratory and x-ray (ultrasound) services and other services as n1edical\y necessary and appropriate. The benefit provides for antepartum senrices up to 14 visits for noimal pregnancies. High-risk pregnancies may allow for additional visits. Postpartum services includes 2 visits within 60 days of delivery.

For autho1ization, Managed Care Entities (MCEs) n1ay require prior authorization requiren1ents, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nu1nber of services provided and duration of treatment.

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TN#; 15-0024

Indiana



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5. Essential Health Benefit: Mental health and substance use disorder services including Collapse All D behavioral health treatment


\Mental/Behavioral Health Inpatient \ lBase Bench1nark Commercial HMO \I Remove l Authorization: Provider Qualifications:


None I !None

Scope Lirnit:

Benefit does not include hypnotherapy, behavioral n1odification, or milieu therapy when used to treat conditions that are not recognized as 1nental disorders; persona] comfort items; and room and board when temporary leave available.


Benefits include evaluation and treatment in a psychiatric day facility and electroconvulsive therapy. Coverage may also include partial hospitalization depending on the type of services provided. These services are not provided tlu·ough institutions of mental disease (IMDs). For authorization, Managed Care Entities (MCEs) 1nay require prior authorization require1nents, such as 'general 1nember infonnation, a justification of services rendered for the 1nedical needs of the me1nber and a planned course of treatment, if applicable, as related to the nutnber of services provided and duration of treatinent


!Mental/Behavioral Health Outpatient I !Base Benchmark Commercial HMO 11

Rvmove I Authorization: Provider Qualifications:

Other 1 IMedicaid State Plan I

Ainount Limit: Duration Lin1it:

None I jNone

Scope Limit:

Coverage does not include self-help training or other related fonns of non-1nedical self care; marriage counseling; hypnotherapy, behavioral modification, or milieu therapy when used to treat conditions that are not recognized as n1ental disorders.

Other information regarding this benefit, including the specific nan1e of the source plan if it is not the base benchmark plan:

Coverage applies to individual therapy and group therapy sessions. Benefit 1nay also include partial hospitalization depending on the type of services provided. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general niember information, a justification of services rendered for the medical needs of the 1nember and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatn1ent.

TN#: 15-0024 ASP 5

Indiana

Approval Date: 10/29/15

Effective Date: October 1, 2015 of43



!substance Abuse Inpatient Treatment I !Base Benchmark Commercial HMO 11 Re1nove I


Other [ jMedicaid State Plan I Amount Lin1it: Duration Lilnit:

None [[None

Scope Limit:

Benefit does not include services and supplies for the treatment of co-dependency or caffeine addiction; personal comfort ite1ns; and roo1n and board when temporary leave permitted.

Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchn1ark plan:

Benefit includes detoxification for alcohol or other drug addiction. Coverage may also include partial hospitalization depending on the type of services provided. These services are not provided through institutions of mental disease (llvIDs). For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general 1nember infonnation, a justification of services rendered for the tnedical needs of the n1ember and a planned course of treattnent, if applicable, as related to the number of services provided and duration of treatment.


f substance Abuse Outpatient Treatment ! f Base Benchmark Commercial HMO 11 Remove I


Other [ jMedicaid State Plan I Amount Limit: Duration Limit:

None [!None

Scope Limit

Benefit does not include services and supplies unrelated to mental health for the treat1nent of co-dependency or caffeine addiction.


Coverage includes detoxification for alcohol or other drug addiction. Benefit may also include partial hospitalization depending on the type of services provided. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member infonnation, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nu1nber of services provided and duration of h·eatn1ent.

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TN#: 15-0024

Indiana

ABP5 Approval Date: 10/29/15


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6. Essential Health Benefit: Prescription drugs

Benefit Provided:

Coverage is at least the greater of one drug in each U.S. Pharmacopeia (USP) category and class or the sa1ne nu1nber of prescription drugs in each category and class as the base benclunark.

Prescription Drug Limits (Check all that apply.): Authorization: Provider Qualifications:

IZl Limit on days supply IYes I ~tate licensed I IZl Limit on number of prescriptions

IZl Li1nit on brand drugs

IZl Other coverage I ilni ts

IZl Preferred drug list

Coverage that exceeds the minimum requirements or other:

The prescription dntg benefit will cover at least one drug in every catego1y and class or the number of d1ugs covered in each category and class as the base benclunark, whichever is greater. The fom1ulary must support the coverage and non-coverage requirements for legend drugs by Indiana Medicaid, found in 405 !AC 5-24-3. In addition, the exact drugs covered under the formulary may vary by the Managed Care Entities (MCEs). Prescription supply is limited to 30 days.

For authorization, Managed Care Entities 1nay require prior authorization requirements, such as general men1 ber infonnation, a justification of need for Rx related to the medical needs of the member and a planned course of treatment, if applicable, as related to the number Rx provided and duration of treatn1ent. Prior authorization require1nents for prescription drugs may vary by MCE, but will comply with Mental I1ealth Parity require1nents. MCEs will be required to have a process in place to allow drugs that are medically necessary, but not included on the fonnulary to be accessed by members.

TN#: 15-0024

Indiana

ASP 5 Approval Date:10/29/15


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7. Essential Health Benefit: Rehabilitative and habilitative services and devices Collapse All D


!Physical Therapy, Occupational Therapy, Speech The 1 lsecretaiy-Approved Other 11 Remo Ve I



160 combined visits annually. I IN one

Scope Limit:

Rehabilitative and habilitative services are offered at parity and share the same, comparable benefit limits. Coverage does not include nonsurgical treatment of TMJ.

Other information regarding this benefit, including the specific na1ne of the source plan if it is not the base bench1nark plan:

Amount limit continued- As an outpatient benefit, coverage is limited to 60 combined visits annually for PT, OT, ST, cardiac and pulmonmy rehabilitation. For authorization, Managed Care Entities (MCEs) tnay require prior authorization requiretnents, such as general 1ne1nber infon11ation, a justification of services rendered for the 1nedical needs of the n1ernber and a planned course of treat1nent, if applicable, as related to the number of services provided and duration of treatment.


!Durable Medical Equipment (DME) I I secretary-Approved Other \ [ . ·. Remove I Authorization: Provider Qualifications:


15 mo rental cap;! eve1y 5 yr per member- replaceol INone

Scope Limit:

DME does not include con·ective shoes, arch supports, dental prostheses, deluxe equipn1ent, common first aid supplies and non-durable supplies. Other non-covered services include but not li1nited to equipment not suitable for home use.

Other information regarding this benefit, including the specific naine of the source plan if it is not the base bench1nark plan:

Benefit includes but not limited to wheel chairs, crutches, respirators, traction equipment, hospital beds, monitoring devices, oxygen-breathing apparatus and insulin pu1nps. Training for use ofDME is also covered and applicable rental fees. Covered services are only for the basic type ofD:ME necessary to provide for medical needs and does not include non-durable supplies that are not an integral part of the DME set-up. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member info1mation, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nun1ber of services provided and duration of treatn1ent.

TN#: 15-0024 ABP 5

Indiana





!Prosthetics I jBase Benchmark Commercial HMO 11 Remove I


Other I !Medicaid State Plan I Amount Limit: Duration Li1nit:

None I INone

Scope Limit:

Benefit does not include foot orthotics, devices solely for comfort or convenience and devices fro1n a non-accredited provider.

Other information regarding this benefit, including the specific name of the source plan if it is not the base

benchn1ark plan:

A prosthetic device means an artificial arm or leg or any portion thereof. 01ihotic devices are also covered under this benefit as custom fabricated braces or suppo1is designed as a component of an artificial ann or leg. Covered services include the purchase, replacement or adjustment of artificial limbs when required due to a change in your physical condition or body size due to normal growth. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treattnent, if applicable, as related to the number of services provided and duration of treatment.


!corrective Appliances I !Base Benchmark Com1nercial HMO 11 ReinoVe I


Other I !Medicaid State Plan I Amount Lllnit: Duration Limit:

None I !None

Scope Limit:

Benefit does not include but not limited to artificial or prosthetic litnbs, cochlear frnplants, dental appliances, dentures, foot orthotics, con·ective shoes, arch supports for plantar fasciitis, flat feet, fallen arches and con1s.


Benefit must be medically necessary and used to restore function or to replace body parts. Benefit includes but not limited to hemodialysis equipment, breast prostheses, back braces, artificial eyes, one pair eyeglasses due to cataract surgery, ostomy supplies and prosthetics (all prosthetics except prosthetic limbs). Coverage not intended for non-durable appliances. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nu1nber of services provided and duration of treatment.

TN#: 15-0024

Indiana





!cardiac Rehabilitation I I secretary-Approved Other I i Remove I Authorization: Provider Qualifications:

Other I !Medicaid State Plan I Amount Lin1it: Duration Liniit:

!60 combined visits annually. I !None

Scope Limit:

Rehabilitative services are offered at parity and share the same, comparable benefit limits.

Other info1mation regarding this benefit, including the specific naine of the source plan if it is not the base bench1nark plan:

A1nount limit continued- As an outpatient benefit, coverage is limited to 60 combined visits annually for PT, OT, ST and pulmonary rehabilitation. Benefit includes services for the improvement of cardiac disease or dysfunction. For authorization, Managed Care Entities (1vlCEs) may require prior authorization requirements, such as general member infon11ation, a justification of setvices rendered for the n1edical needs of the 1nember and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!Medical Supplies I Jsase Benchmark Commercial HMO I i Remo've -, I Authorization: Provider Qualifications:

None [ !Medicaid State Plan I Amount Limit: Duration Lirnit:

None [!None

Scope Limit:

!Benefit does not include non-durable supplies and/or convenience ite1ns.

Other information regarding this benefit, including the specific na1ne of the source plan if it is not the base benchtnark plan:

Benefit includes casts, dressings, splints and other devices used for reduction of fractures and dislocations.

Benefit Provided:

!Puln1onary Rehabilitation

Authorization:

Jother

Amount Limit:

160 combined visits annually.

TN#: 15-0024

Indiana

Source:

J lsecretary-Approved Other

Provider Qualifications:

f IMedicaid State Plan

Duration Limit:

J JNone

ABP 5

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Scope Limit:

Benefit does not include formalized and pre-designed rehabihtation programs for pulmonary conditions. I Remove I Rehabilitative services are offered at parity and share the san1e, comparable benefit 1i1nits.


Amount limit continued- As an outpatient benefit, coverage is limited to 60 cotnbined visits annually for PT, OT, ST and cardiac rehabilitation. Benefit consists of services that are for the improve111ent of puhnonary disease or dysfunction that has a poor response to treatment. Examples of poor response include but are not limited to patients with respiratory failure, frequent emergency room visits, progressive dyspnea, hypoxemia or hypercapnia. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


I skilled Nursing Facility (SNF) I !Base Benchmark Commercial HJ\10 11



I 100 days per benefit period. I !None

Scope Limit:

A SNF does not include any institution or portion of any institution that is primarily for rest, the aged, non-skilled care, or care of mental diseases or substance abuse. Rootn and board services are not covered when tetnporary leave permitted.


Covered services include semi-private room (private room provided when medically necessary), drugs, specialty pharmaceuticals, 1nedical social services, short term physical, speech, occupational therapies (subject to limits) and other services generally provided. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization requiretnents, such as general inember information, a justification of services rendered for the medical needs of the member and a planned course of treat1nent, if applicable, as related to the nutnber of services provided and duration of treatn1ent.


!Autism Spectnnn Disorder Services I !secretary-Approved Other I Authorization: Provider Qualifications:

Other 1 IMedicaid State Plan I Atnount Limit: Duration Li1nit:

160 co1nbined visits annually. I !None

TN#: 15-0024

Indiana

ASPS Approval Date:10/29/15



Scope Li1nit:

None I Other information regarding this benefit, including the specific nan1e of the source plan if it is not the base benchmark plan:

Amount limit continued~ As an outpatient benefit, coverage is limited to 60 co1nbined visits annually for PT, OT, ST, cardiac and pulmonary rehabilitation. Benefit, formerly known as Pervasive Development Disorder (PDD), is a state mandate that must be covered as outlined in the lndiana insurance code. Benefit provides coverage for Asperger1s syndrome and autism. Coverage for services are provided as prescribed by the treating physician in accordance with the treannent plan. For authorization, Managed Care Entities (MCEs) n1ay require prior authorization requirements, such as general n1ember information, a justification of services rendered for the medical needs of the men1ber and a planned course of treat1nent, if applicable, as related to the nu1nber of services provided and duration of treatn1ent.


!Hearing Aids \ \state Plan 1905(a) 11


Other I !Medicaid State Plan I Amount Limit: Duration 'Li1nit:

f 1 per member every 5 years. \ jNone I Scope Limit:

None


Medically frail populations will receive State Plan benefits. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nun1ber of services provided and duration of treatment.


!Home Health:Medical Supplies, Equipment and Applia J IBase Benchmark Commercial HMO I Authorization: Provider Qualifications:

Other I !Medicaid State Plan I Amount Li1nit: Duration Limit:

None I /None

Scope Li1nit:

!Benefit does not include non-durable supplies and/or convenience items.

TN#: 15-0024

Indiana



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Other information regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: i Benefits include n1edical supplies in connection with home health care. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


!Inpatient Cardiac Rehabilitation I !Base Benchmark Commercial HMO l i Authorization: Provider Qualifications:


190 days annual maxim11m. I !None

Scope Lilnit:

None


Benefit includes services for the improvement of cardiac disease or dysfunction. For authorization, Managed Care Entities (.MCEs) inay require prior authorization requirements, such as general member infonnation, a justification of services rendered for the medical needs of the 1nember and a p tanned course of treat111ent, if applicable, as related to the number of services provided and duration of treatment.


!Inpatient Rehabilitation Therapy I !Base Benchmark Commercial HMO Ii Authorization: Provider Qualifications:


190 days annual maxi1nu1n. I !None

Scope Limit:

Rehabilitative and habilitative services are offered at parity and share the san1e, comparable benefit 1i111its.

Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchn1ark plan:

Coverage includes physical, occupational, speech and pulmonary therapy of acute illness or injury to the extent that significant potential exists for progress toward a previous level of functioning. For authorization, Managed Care Entities (MCEs) may require prior authorization requiren1ents, such as general lnember information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nu1nber of services provided and duration of treatment.

TN#: 15-0024

Indiana

ASP 5 Approval Date:10/29/15


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TN#: 15-0024

Indiana




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~ 8. Essential I-Iealth Benefit: Laborato1y services Collapse All D Benefit Provided: Source:

!Lab Tests I !Base Benclunark Conunercial HMO 11


Other I !Medicaid State Plan I Amount Limit: Dwation Limit:

None I !None

Scope Lilnit:

Coverage does not include lab expenses related to physical exams when provided for employment, school, sports' programs, travel, i1nmigration, administrative purposes or insurance purposes.


Benefit provided as outpatient services when medically necessary. For authorization, Managed Care Entities (M_CEs) may require prior authorization requirements, such as general 1ne1nber information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


IX-Rays J lsase Benchmark Commercial HMO 11


Other I !Medicaid State Plan I A1nount Limit: Duration Limit:

None I !None

Scope Limit:

Coverage does not include x-ray expenses related to physical exams when provided for employment, school, sports' programs, travel, iln1nigration, administrative purposes or insurance purposes.


Benefit provided a') outpatient services when tnedically necessary. For authorization, Managed Care Entities (MCEs) may require prior authorization require1nents, such as general 1ne1nber infonnation, a justification of services rendered for the 1nedical needs of the in ember and a planned course of treatn1ent, if applicable, as related to the number of services provided and duration of treatment.


lrmaging- MRI, CT, and PET I !Base Benchmark Commercial HMO I Authorization: Provider Qualifications:

Other j \Medicaid State Plan I

TN#. 15-0024

Indiana

ABP 5 Approval Date.10/29/15


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Amount Lin1it: Duration I...irnit:

None \!None I Scope Limit:

None

Other information regarding this benefit, including the specific name of the source plan if it is not the base bench1nark plan:

Benefit provided as outpatient services when inedically necessary. Coverage also includes J\1RA and SPECT scan. For authorization, Managed Care Entities (MCEs) tnay require prior authorization requirements, such as general 1nen1 ber infonnation, a justification of services rendered for the tnedical needs of the in ember and a planned course of treatinent, if applicable, as related to the number of services provided and duration of treatment.


!Pathology ! !Base Benchmark Comn1ercial HMO 11


Other \ !Medicaid State Plan I Amount Limit: Duration Litnit:

None \!None

Scope Limit:

None


Benefit provided as outpatient services when medically necessary. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nun1ber of services provided and duration of treat1nent.


!Radiology J 'Base Benchtnark Co1nmercial HMO I Authorization: Provider Qualifications:

Other \ IMedicaid State Plan I Amount Limit: Duration Limit:

None \ INone

Scope Li1nit:

None

TN#: 15-0024

Indiana



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Other infonnation regarding this benefit, including the specific name of the source plan if it is not the base benchmark plan: I Remove Benefit provided as outpatient services \vhen medically necessary. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nu1n ber of services provided and duration of treatment.


IEKGandEEG I !Base Benchmark Connnercial Hr\.10 11 Remove



None I !None

Scope Limit:

None

Other information regarding this benefjt, including the specific name of the source plan if it is not the base benchmark plan:

Benefit provided as outpatient services when 1nedically necessary. For authorization, Managed Care Entities (MCEs) 1nay require prior authorization requiretnents, such as general 1nen1ber infonnation, a justification of services rendered for the 1ncdical needs of the member and a planned course of treat1nent, if applicable, as related to the number of services provided and duration of treat1nent.

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TN#: 15-0024

Indiana



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~ 9. Essential Health Benefit: Preventive and wellness services and chronic disease rnanage111ent Collapse All D TI1e state/te1Titory must provide, at a minin1u1n, a broad range of preventive services including: "A" and ''B" services recommended by the United States Preventive Services Task Force; Advisory Co1nmittee for hnrnunization Practices (ACIP) recommended vaccines; preventive care and screening for infants, children and adults reco1nmended by HRSA 's Bright Futures program/project; and additional preventive services for women recommended by the Institute of Medicine (!OM).


!Preventive Care Services J lsase Benchmark Commercial HMO


None 1 IMedicaid State Plan

Atnount Limit: Duration Lin1it:

None I !None

Scope Limit:

None


Physician services for wellness and preventive services include but are not litnited to routine physical exan1, routine total blood cholesterol screening, routine gynecological services and routine im1nunizations. Includes (1) all preventive items or services that have a rating of 'A' or 'B' by the United States Preventive Task Force (USPSTF); (2) Immunizations recommended for the individuals age and health status by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC); (3) for infants, children, adolescents and adults, preventive care and screenings included in the Health Resources and Services Administration's (HRSA) Bright Futures comprehensive guidelines; and (4) preventive screenings for women as reco1nmended by the Institute of Medicine (IOM).


!Diabetes Self Management Training I !Base Benchmark Commercial HMO


Other I !Medicaid State Plan

Atnount Limit: Duration Litnit:

None I !None

Scope Limit:

None


Covered services are Ii1nited to physician authorized visits after receiving a diagnosis of diabetes; after receiving a diagnosis that represents a significant change in sympto1ns or condition and there is a 1nedical\y necessary change in self-management; and for re-education or refresher training. For authorization, Managed Care Entities (NICEs) inay require prior authorization require1nents, such as general me1nber inforn1ation, a justification of services rendered for the tnedical needs of the 1nember and a planned course of treat1nent, if applicable, as related to the number of services provided and duration of

TN#. 15-0024

Indiana

ABP 5

11 Remove

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treatment.

I Benefit Provided: Source:

!Health Education I !Base Benchmark Commercial HMO 11


Other \ !Medicaid State Plan I Amount Limit: Duration Limit:

3 visits. [[None

Scope Limit:

Classes in nutrition or s1noking cessation will be approved up to 3 visits when referred by your physician.


Benefit provided by the PCP as part of preventive health care and other health education classes approved by the insurer. For authorization, Managed Care Entities (MCEs) n1ay require prior authorization require1nents, such as general 1nember information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the nutnber of services provided and duration of treatment.


!Routine Prostate Specific Antigen (PSA) Test I !Base Benchmark Commercial HMO 11


None 1 IMedicaid State Plan I A1nount L.imit: Duration Lilnit:

None I INone

Scope Limit:

One test annualJy for an individual who is at least 50 years old or less than 50 if at high risk for prostate cancer.


None

I

TN#: 15-0024

Indiana

ABPS Approval Date:10/29/15


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I 0. Essential Health Benefit: Pediatric services including oral and vision care Collapse All D Benefit Provided: Source: Medicaid State Plan EPSDT Benefits

!state Plan 1905(a) 11 Remove


None I !Medicaid State Plan I Amount Lilnit: Duration Limit:

IN one I !None

Scope Limit:

EPSDT is required in the ABP for 19 and 20 year olds.

Other information regarding this benefit, including the specific nmne of the source plan if it is not the base benchmark plan:

Services provided under EPSDT may include preventive and diagnostic services that are inedically necessary and n1ay need continued treatment. In accordance with CMS regulation, individuals covered under EPSDT are not subject to the ThID exclusion.

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TN#: 15·0024

Indiana



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D 11. Other Covered Benefits from Base Benchmark

TN#: 15-0024 ABP 5

Indiana

Collapse All IZ]



~


12. Base Benchn1ark Benefits Not Covered due to Substitution or Duplication Collapse All 0 Base Benchmark Benefit that was Substituted: Source:

!Infertility Diagnoses: substitution I Base Bench1nark

I I Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) ineluded above under Essential Health Benefits:

Infertility Diagnoses benefit offered in the base benchmark \Vas re1noved and replaced in EHB 1 by substitution with part of the actuarial value of Male Sterilization procedures which are not covered on the base benchn1ark. Coverage for voluntary Male Sterilization procedures comes fron1 the coverage provided on the State Plan.

Base Benchmark Benefit that was Substituted: Source:

!Routine Foot Care: substitution I Base Benchmark

I I Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

The benefit is covered. A more restrictive limit of 6 visits per year was added. In EHB 1, this has been substituted with the remaining actuarial value frotn the male sterilization benefit There is no limit on Routine Foot Care in the base benchmark.


IH01ne Health Services: substitution I Base Benchmark

I I Remove

Explain the substitution or duplication, including indicating the substituted benefit{s) or the duplicate section 1937 benchmark benefit( s) included above under Essential Health Benefits:

The benefit is covered. Within the benefit, training of family members to provide home health services is a non-covered benefit. In EHB 1, this sub-benefit was substituted \Vith the actuarial value remaining from the 1nale sterilization benefit.

Base Bench1nark Benefit that was Substituted: Source:

!Urgent Care-Walkins: substitution I Base Benchn1ark

I I Re1nove

Explain the substitution or duplication, including indicating the substituted benefit{s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

The benefit is covered, Within the benefit, physician home visits is a non-covered benefit. In ERB 1, this sub-benefit was substituted with the actuarial value re1naining from the male sterilization benefit.


!Maternity Services: duplication I Base Benchtnark

I I Remove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchtnark benefit(s) included above under Essential Health Benefits:

This benefit was duplicated with the Medicaid State Plan Obstetric benefit in EHB 4.


!Maternity ~ Delivery: duphcation I Base Benchmark

ABP 5 TN#: 15-0024

Indiana





I This benefit was duplicated with the Medicaid State Plan Obstetric benefit in EHB 4.


JDurable Medical Equipment (DME): substitution I Base Benchmark

I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

111e benefit is covered. The limits for a 15 1nonth rental cap and 5 year replacement for equip1nent were added. In EHB 7, this has been substituted with the actuarial value remaining from adding hearing aids as a benefit fro1n the State Plan. There is no li1nit on Durable Medical Equipment in the base benchmark.

Base Benchmark Benefit that \Vas Substituted: Source:

IPT, OT, ST: substitution I

Base Benchmark

I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 193 7 benchmark benefit( s) included above under Essential Health Benefits:

The benefit is covered. Within the benefit, the service limits are covered as an annual limit co1nbined for therapies. In EIIB 7, the service limits for limits per condition have been substituted with the actuarial value re1naining from adding hearing aids as a benefit from the State Plan. The base bench1nark allows for 60 combined visits per distinct condition or episode.


!cardiac Rehabilitation: substitution I Base Benclunark

I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

The benefit is covered. Within the benefit, the service limits are covered as an annual limit co1nbined for therapies. In EHB 7, the service limits for litnits per condition have been substituted with the actuarial value remaining fro1n adding hearing aids as a benefit from the State Plan. The base benchmark allows for 60 combined visits per distinct condition or episode.


IPuln1onary Rehabilitation: substitution I Base Bench1nark

I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section J 937 benchmark benefit(s) included above under Essential Health Benefits:

The benefit is covered. Within the benefit, the service lin1its are covered as an annual lin1it combined for therapies. In EHB 7, the service 1i1nits for limits per condition have been substituted with hearing aids. In addition, fonnalized and pre-designed rehabilitation progran1s for puhnonary conditions have also been substituted with hearing aids. Both substitutions were con1pleted with the actuarial value remaining fro1n adding hearing aids as a benefit from the State Plan. The base benchmark allows for 60 co1nbined visits per distinct condition or episode.

Base Bench1nark Benefit that was Substituted: Source:

!Autism Spectrum Disorder Services: substitution I Base Bench1nark

TN#: 15-0024

Indiana



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I Remove I The benefit is covered. Within the benefit, the service limits are covered as an annual li1nit combined for therapies. In EHB 7, the service limits for li1nits per condition have been substituted with the actuarial value remaining frotn adding hearing aids as a benefit from the State Plan. The base benchmark allows for 60 combined visits per distinct condition or episode.


!Applied Behavior Analysis: substitution I Base Benchmark

I I Reniove

Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under E5sential Health Benefits:

In EHB 7, ABA has been substituted with the actua1ial value remaining fro1n adding hearing aids as a benefit from the State Plan.

Base Benclunark Benefit that was Substituted: Source: Base Benchmark

!Non-Surgical Treatment Option Morbid Obesity: dupl I I Remove I Explain the substitution or duplication, including indicating the substituted benefit(s) or the duplicate section 1937 benchmark benefit(s) included above under Essential Health Benefits:

In EHB 9, the benefit is covered under preventive and wellness services. provides coverage above the benefit limits.

TN#: 15-0024

Indiana

ABPS

The ACA preventive services

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13. Other Base Benchmark Benefits Not Covered Collapse All D

Base Benchmark Benefit not Included in the Alternative Source:

Benefit Plan: Base Benchtnark

I I IAdult Vision

I

_Remove

Explain why the state/ten·itory chose not to include this benefit:

Adult vision is covered in the base benchmark plan, but it is an excepted benefit and therefore not an Essential Health Benefit.


Benefit Plan: Base Benchmark

I Re1nove I IN ewbom Child Coverage I

Explain why the state/territory chose not to include this benefit:

Benefit is excluded since the ABP is for ages 19-64. Newborns born to members will be covered through Medicaid for children. The newborn coverage includes the initial newborn examinations.



I Remove I !Emergency Services Outside the U.S. I


Emergency care provided outside the U.S. is covered in the base benchmark plan. Non-emergency services I are not covered. To conform with Medicaid standards, the benefit will not be covered in the ABP.



I Remove 1 !Lodging and Transportation for Transplants (Donor)


Transportation and lodging services for the donor are covered under the base benchmark plan subject to a dollar limit, these services are not considered an EHB and are considered a non-covered benefit for the ABP.

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TN#: 15-0024 ABP 5

Indiana



IZl


14. Other 1937 Covered Benefits that are not Essential Health Benefits Collapse All D

Other 1937 Benefit Provided: Source:

!Chiropractic Care - Pregnancy Benefit I Section 1937 Coverage Option Benchmark Benefit

I Remove I Package


Other I !Medicaid State Plan I Amount Lin1it: Duration Limit:

!Limits equivalent to State Plan. I !None

Scope Limit:

None

Other:

Benefit is only offered to women who beco1ne pregnant while enrolled in HIP and include State Plan equivalent benefits which are more generous than the benefits offered in the base bench1nark plan. Coverage provided is subject to program restrictions.

For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.


I.Non-emergency Transportation - Pregnancy Benefit I Section 1937 Coverage Option Benchtnark Benefit

I Reri1.ove I Package


Other I !Medicaid State Plan I A111ount Limit: Duration Limit:

None I !None

Scope Limit:

None

Other:

Benefit is only offered to women who become pregnant while enrolled in HIP and include State Plan equivalent benefits which are more generous than the benefits offered in the base benchmark plan. Coverage provided is subject to program restrictions.

For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the member and a planned course of treat1nent, if applicable, as related to the number of services provided and duration of treatment.


!Medicaid Rehabilitation Option (MRO)- Pregnancy Be I Section 1937 Coverage Option Benchmark Benefit Package

ABP 5 TN#: 15-0024

Indiana





Other 1 IMedicaid State Plan 11

Remove I Amount Litnit: Duration Limit:

None I !None

Scope Limit:

None

Other:

Benefit is only offered to women who become pregnant while enrolled in HIP and include State Plan equivalent benefits which are more generous than the benefits offered in the base benchmark plan. MRO services are designed to assist in the rehabilitation of the consumer's optilnu1n functional ability in daily living activities.

Other 193 7 Benefit Provided: Source:

!Dental Services - Pregnancy Benefit I Section 1937 Coverage Option Benchmark Benefit

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Other I !Medicaid State Plan I Ainount Limit: Duration Lin1it:

ILilnits equivalent to State Plan. I !None

Scope Limit:

None

Other:

Benefit is only offered to women who become pregnant while enrolled in HIP and include State Plan equivalent benefits which are 1nore generous than the benefits offered in the base benchmark plan. The dental benefits include State Plan equivalent benefits. For authorization, the dental insurer may require prior authorization requirements, such as general member information and a justification for the type of dental services rendered based on the 1nedical needs of the member.


!™J -Pregnancy Benefit I Section 1937 Coverage Option Bench1nark Benefit Package


Other 1 IMedicaid State Plan I Ainount Limit: Duration Lin1it:

None I !None

Scope Limit:

!None

TN#: 15-0024

Indiana




Other:

Benefit is only offered to women who become pregnant while enrolled in HIP and include State Plan I Remove I equivalent benefits which are more generous than the benefits offered in the base benchn1ark plan. Coverage includes treatment of te111poromandibular joint (TMJ) disorder. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general inernber information, documentation of non-surgical treatment and duration prior to surgery and a justification of services rendered for the medical needs and circumstances of the member.


!Adult Vision - Pregnancy Benefit I Section 193 7 Coverage Option Bench1nark Benefit

I Remove I Package


Other I !Medicaid State Plan I Amount Litnit: Duration Limit:

!Limits equivalent to State Plan. I !None

Scope Lin1it:

None

Other:

Benefit is only offered to vvomen who become pregnant while enrolled in HIP and include State Plan equivalent benefits \Vhich are n1ore generous than the benefits offered in the base benchmark plan. The benefits include State Plan equivalent benefits. For authorization, the vision insurer may require prior authorization requirements, such as general metnber information and a justification for the type of vision services rendered based on the medical needs of the me1nber.


!Health Education - Smoking Cess -Pregnancy Benefit I Section 193 7 Coverage Option Benchmark Benefit

I Remove I Package


Other I !Medicaid State Plan I Amount Lilnit: Duration Limit:

112 week course. I !None

Scope Lin1it:

IN one

Other:

Benefit is only offered to wo1nen who beco1ne pregnant while enrolled in HIP and include State Plan equivalent benefits which are more generous than the benefits offered in the base benchmark plan. The benefit includes up to 12 weeks in a smoking cessation course providing treatment and counseling. For authorization, the Managed Care Entity (1\1CE) may require prior authorization requirements, such as general member infotmation and a justification for the type of services rendered based on the inedical needs of the member.

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I I Section 193 7 Coverage Option Benchmark Benefit

LO_s_te_o_p_a_t1_1i_c_M_a_n_i_p_ul_a_ti_v_e_T_r_ea_t_m_e_n_t _(O_M_T_l ____ ~ Package


LO_t_h_e1_· ----------------~I !Medicaid State Plan

Ainount Limit: Duration Litnit:

Scope Li1nit:

None

Other:

State Plan benefit. For authorization, Managed Care Entities (MCEs) may require prior authorization requirements, such as general member information, a justification of services rendered for the medical needs of the metnber and a planned course of treatment, if applicable, as related to the number of services provided and duration of treatment.

TN#: 15-0024

Indiana

ABP 5 Approval Date: 10/29/15


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Add

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D


15. Additional Covered Benefits (This category of benefits is not applicable to the adult group under section 1902( a)(l O)(A)(i)(VIII) of the Act.)

PRA Disclosure Statement

Collapse All D

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control nu1nber for this information collection is 0938-1148. The time required to con1plete this infonnation collection is estimated to average 5 hours per response, including the ti1ne to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this fonn, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maiyland 21244-1850.

TN#: 15-0024

Indiana



V.20131219

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