Section 441.88.5. Covered services.

         88.5(1) Amount, duration, and scope of services. Except as provided for in the contract, PHPs shall cover as a minimum all services covered by the Medicaid program as set forth in 441—Chapter 78.

         88.5(2) Mandatory services.

            a.               Although the contract may specify additional services covered (with the exception of those defined in 88.5(3)), the PHP shall cover as a minimum the following services:

             (1)             Inpatient hospital services.

             (2)             Outpatient hospital services.

             (3)             Physician services.

             (4)             Family planning services.

             (5)             Home health agency services.

             (6)             Laboratory and X-ray services.

             (7)             Early periodic screening, diagnosis and treatment for persons under age 21.

             (8)             Rural health clinic services (where available).

             (9)             Advanced registered nurse practitioners.

            b.               PHPs shall attempt to subcontract with all local family planning clinics funded by Title X moneys and all maternal and child health centers funded by Title V moneys.

            c.               According to the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272, recipients enrolled in managed health care options (including PHPs) may seek family planning services anywhere without referral, even if they are minors. The PHP must pay any claims submitted by a provider of family planning services when the service has been provided to a recipient in a month for which a capitation rate has been paid on the recipient’s behalf to the PHP by the department.

         88.5(3) Excluded services. Unless specifically included in the contract, PHPs will not be required to cover long-term care (skilled nursing facilities, intermediate care facilities, residential care facilities, state resource centers, or intermediate care facilities for the mentally retarded), inpatient psychiatric care provided at the state-administered mental health institutes, services provided by the area education agencies, services provided at specialized adolescent psychiatric facilities, day treatment and partial hospitalization services for persons aged 20 or under, or the enhanced services provided to certain eligible recipients. Reimbursement to recipients for nonemergency medical transportation as described at rule 441—78.13(249A) will not be covered by the PHP; the department will continue to reimburse through its fee-for-service methodology for this service.

         88.5(4) Restrictions and limitations. If the PHP covers a type of service which is also covered under Medicaid, the PHP may not impose any restrictions or limitations on that service more stringent than those applicable in Medicaid according to the provisions at 441—Chapter 78. The PHP may, at its discretion, offer services to its enrolled recipients beyond the scope of Medicaid as defined at 441—Chapter 78.

         88.5(5) Recipient use of PHP services. An enrolled recipient must utilize PHP participating providers of service. No payment by the PHP will be made for services provided by non-PHP providers if the same type of service is available through the PHP under its contract with the department except as provided in subrule 88.5(2)“c,” and rule 441—88.6(249A).

[ARC 2358C, IAB 1/6/16, effective 1/1/16]