A. Individual and
families enrolled in RIte Care receive the full scope of services covered under
the Medicaid State Plan and the State's Section 1115 waiver, unless otherwise
indicated. Covered services may be provided through the MCO or through the
fee-for-service delivery system if the service is "out-of-plan" - that is, not
included in the MCO but covered under Medicaid. Fee-for-service benefits may be
furnished by any participating provider. Rules of prior authorization apply to
any service required by EOHHS. Each RIte Care member selects a primary care
provider (PCP) who performs the necessary medical care and coordinates
referrals to specialty care. The primary care provider orders treatment
determined to be medically necessary in accordance with MCO policies.
Beneficiaries in the Extended Family Planning (EFP) coverage group do not
require a PCP. The extended family planning group is entitled only to family
planning services.
1. Access to Benefits -
Unless otherwise specified, members of all RIte Care coverage groups (MACC,
Non-MAGI) are entitled to a comprehensive benefit package that includes both
in-plan and specific out-of-plan services. Categories of eligibility for the
extended family planning benefit package are as follows:
a. Women otherwise Medicaid ineligible. The
package of services is available without the comprehensive benefit package.
Women who have given birth and are not eligible for Medicaid under another
coverage group lose the full scope of covered services twelve (12) months
postpartum or post-loss of pregnancy. Women in this category are eligible for
RIte Care for a period of up to twenty-four (24) months for the full family
planning benefit package. The benefit package includes interpreter services but
does not include transportation benefits. Renewal is required at twelve (12)
months.
b. Women who are otherwise
eligible for Medicaid. Women enrolled in RIte Care are eligible for family
planning services. Participation is voluntary. Members continue to be enrolled
with the same MCO they selected or were assigned to for comprehensive health
service delivery but for family planning services only for a twelve (12) month
period. Upon renewal at twelve (12) months, a participant may qualify for up to
an additional twelve (12) months. Services are covered on an outpatient basis
only. Non-prescription contraceptives are covered for members in this category
with a provider's order (i.e., prescription).
2. Delivery of Benefits - The coverage
provided through RIte Care is categorized as follows:
3. Medical necessity - The standard of
"medical necessity" is used as the basis for determining whether access to
Medicaid-covered services is required and appropriate. A "medically necessary
service" means medical, surgical or other services required for the prevention,
diagnosis, cure, or treatment of a health-related condition including any such
services that are necessary to prevent a detrimental change in either medical
or mental health status or substance use disorder or services needed to achieve
age-appropriate growth and development or to attain, maintain, or regain
functional capacity. Medically necessary services must be provided in the most
cost-efficient and appropriate setting and must not be provided solely for the
convenience of the member or service provider.
4. Early Periodic Screening, Diagnosis and
Treatment (EPSDT) -- The EPSDT provision in Title XIX mandates that state
Medicaid programs must provide coverage for all follow-up diagnostic and
treatment services deemed medically necessary to ameliorate or correct defects
and physical and mental illnesses and conditions discovered through screening
or at any other occasion, whether or not those services are covered by the
State Medicaid Plan or the State's Medicaid Section 1115 waiver. This applies
to members of the MACC group up to age nineteen (19), SSI-eligible children and
young adults up to age twenty-one (21), including adults aging out of foster
care up to age twenty-one (21). A young adult over age nineteen (19) who
transitions from the MACC group for children and young adults to the MACC group
for adults from age nineteen (19) to sixty-four (64) also receives EPSDT
services until age twenty-one (21).
