Table 2. State Definitions of Medical Necessity ...

[Pages:33]Table 2. State Definitions of Medical Necessity: Comparison with State Contract Language

(N/A=No information pertaining to state pediatric medical necessity standard in Medicaid MCO contracts)1

State AL

AK

Enabling Law or Regulation

Alabama Administr ative Code Alabama Medicaid Agency Ch. 560X-44. Quality Assurance (Ala. Admin. Code r. 560-X44.02) Alaska Administr ative Code Title 7. Health and Social Services Part 3. Public Assistance and Medical Assistance Chapter 43. Medical

Statutory/ regulatory definition Regulation

Regulation

Definition Medical necessity is th e need or condition documented in the medical record by a physician which indicates the level of care required.

Preventive standard in statute or rule (y/n) No

Medically necessary and appropriate

Yes

means a course of diagnosis or treatment

that is (A) reasonably calculated to

diagnose, correct, cure, alleviate or

prevent the worsening of medical

conditions that endanger life, cause

suffering or pain, result in illness or

infirmity, threaten to cause or aggravate a

disability, or cause physical deformity or

malfunction; and (B) used because there

is no equally effective more conservative

or substantially less costly course of

medical diagnosis or treatment available

or suitable for the Medicaid recipient

requesting the service; "course of

treatment" may include mere observation

Existence of MCO Contracts (y/n) N/A

N/A

Contract Definition -

-

Variation in Contract/State definitions (y/n) N/A

N/A

1 These states were not included in the database for Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts (3rd Ed., 1999).

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State AZ

Enabling Law or Regulation

Statutory/ regulatory definition

Assistance Article 20. Federally Qualified Health Centers (7 Alaska Admin. Code 43.874) Arizona Administr ative Code Title 9. Health Services Ch. 22. Arizona Health Care Cost Containme nt System (AHCCCS) Administr ation Article 1. Definitions (Ariz. Admin. Code R922-101)

Regulation

Definition

or, if appropriate, no treatment at all.

Medically necessary means a covered service provided by a physician or other licensed practitioner of the healing arts and within the scope of practice under state law to (a) prevent disease, disability, and other adverse health conditions or their progression; or (b) prolong life.

Preventive standard in statute or rule (y/n) Yes

Existence of MCO Contracts (y/n) Yes

Contract Definition No provision for Pediatric Medical Necessity

Variation in Contract/State definitions (y/n) N/A

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State AR

CA

Enabling Law or Regulation Welfare and Institution s Code Division 9. Public Social Services Part 3 Aid and Medical Assistance Chapter 7. Basic Health Care

Statutory/ regulatory definition Yes

Statute

Definition

A service, drug, supply, or article necessary for the diagnosis of an illness or injury in accord with generally accepted standards of medical practice at the time the service, drug, or supply is provided. When specifically applied to a confinement it further means the diagnosis or treatment of the covered person's medical symptoms or condition cannot be safely provided to that person as an outpatient. A service, drug or supply or article shall not be medically necessary if it: (i) is investigational, experimental, or for research purposes; or (ii) is provided solely for the convenience of the patient, the patient's family, physician, hospital, or any other provider; or (iii) of care that is needed to provide safe, adequate and appropriate diagnosis or treatment; or (iv) could have been omitted without adversely affecting the covered person's condition of a medical device, drug, or substance not formally approved by the United States Food and Drug Administration. A service is medically necessary or a medical necessity when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.

Preventive standard in statute or rule (y/n) No

Yes

Existence of MCO Contracts (y/n) N/A

Contract Definition -

Yes

EPSDT Supplemental Services, including

case management service...EPSDT

supplemental services are defined in Title

22, CCR Section 51184 and include

medically necessary health services that

would not otherwise be covered by the

Medi-Cal program...." California

Contract, pages 91-92

Variation in Contract/State definitions (y/n) N/A

Yes

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State CO

CT

Enabling Law or Regulation

Statutory/ regulatory definition

Article 2. Definitions (Cal. Welf. & Inst. Code ?14059.5) The Code of Colorado Regulation s Departme nt Of Health Care Policy And Finance Medical Services Board Medical Assistance 8.205.11. Definitions (10 CCR Medical Assistance 8.205.11)

Regulation

Conn. General Statutes Ann. Title 17B. Social Services Chapter

Statute

Definition

A covered service shall be deemed medically necessary if, in a manner consistent with accepted standards of medical practice, it: 1. Is found to be an equally effective treatment among other, less conservative or more costly treatment options, and 2. Meets at least one of the following criteria: (a) The service will, or is reasonably expected to prevent or diagnose the onset of an illness, condition, primary disability or secondary disability; (b) The service will, or is reasonably expected to cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury or disability; (c) The service will, or is reasonably expected to reduce or ameliorate the pain or suffering caused by an illness, injury or disability; (d) The service will, or is reasonably expected to assist the individual to achieve or maintain maximum functional capacity in performing Activities of Daily Living. Appropriate and medically necessary means the standard for health services as determined by health care providers in accordance with the prevailing practices and standards of the medical profession and community.

Preventive standard in statute or rule (y/n) NA

No

Existence of MCO Contracts (y/n) Yes

N/A

Contract Definition No provision for Pediatric Medical Necessity

-

Variation in Contract/State definitions (y/n) N/A

NA

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State

Enabling Law or Regulation

Statutory/ regulatory definition

Definition

319V. Medical Assistance (C.G.S.A. ?17b-259)

Preventive standard in statute or rule (y/n)

Existence of MCO Contracts (y/n)

Contract Definition

Variation in Contract/State definitions (y/n)

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State DE

Enabling Law or Regulation

Statutory/ regulatory definition

Delaware Reg Administr ative Register Volume 2, Issue 7 January 1, 1999 Final Regulation s Departme nt Of Health And Social Services Division Of Social Services

Definition Medical Necessity is defined as: the essential need for medical care or services (all covered State Medicaid Plan services, subject to age and eligibility restrictions and/or EPSDT requirements) which, when prescribed by the beneficiary's primary physician care manager and delivered by or through authorized and qualified providers, will: . be directly related to the diagnosed medical condition or the effects of the condition of the beneficiary (the physical or mental functional deficits that characterize the beneficiary's condition), and be provided to the beneficiary only; . be appropriate and effective to the comprehensive profile (e.g. needs, aptitudes, abilities, and environment) of the beneficiary and the beneficiary's family; . be primarily directed to treat the diagnosed medical condition or the effects of the condition of the beneficiary, in all settings for normal activities of daily living, but will not be solely for the convenience of the beneficiary, the beneficiary's family, or the beneficiary's provider. . be timely, considering the nature and current state of the beneficiary's diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time; . be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds; . be the most appropriate care or service that can be safely and effectively provided to the beneficiary, and will not duplicate other services provided to the beneficiary;

Preventive standard in statute or rule (y/n) Yes (prevent the worsening of)

Existence of MCO Contracts (y/n) Yes

Contract Definition EPSDT requires coverage for all follow-up diagnostic and treatment services deemed medically necessary to ameliorate or correct a problem discovered during an EPSDT screen. Such medically necessary diagnosis and treatment services must be provided as long as they are Medicaidcovered services as defined in Delaware RFP, Appendix F. Delaware RFP, pages II.25- II.26.

Variation in Contract/State definitions (y/n) Yes

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State

Enabling Law or Regulation

Statutory/ regulatory definition

Definition . be sufficient in amount, scope and duration to reasonably achieve its purpose; . be recognized as either the treatment of choice (i.e. prevailing community or statewide standard) or common medical practice by the practitioner's peer group, or the functional equivalent of other care and services that are commonly provided; . be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay; and will be reasonably determined to: . diagnose, cure, correct or ameliorate defects and physical and mental illnesses and diagnosed conditions or the effects of such conditions; or . prevent the worsening of conditions or effects of conditions that endanger life or cause pain, or result in illness or infirmity, or have caused or threaten to cause a physical or mental dysfunction, impairment, disability, or developmental delay; or . effectively reduce the level of direct medical supervision required or reduce the level of medical care or services received in an institutional setting or other Medicaid program; or . restore or improve physical or mental functionality, including developmental functioning, lost or delayed as the result of an illness, injury, or other diagnosed condition or the effects of the illness, injury or condition; or

Preventive standard in statute or rule (y/n)

Existence of MCO Contracts (y/n)

Contract Definition

Variation in Contract/State definitions (y/n)

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State

Enabling Law or Regulation

Statutory/ regulatory definition

Definition . provide assistance in gaining access to needed medical, social, educational and other services required to diagnose, treat, or support a diagnosed condition or the effects of the condition, in order that the beneficiary might attain or retain independence, self-care, dignity, self-determination, personal safety, and integration into all natural family, community, and facility environments and activities

Preventive standard in statute or rule (y/n)

DC Weil's

Statute

Code Of

D.C.

Municipal

Regulation

s, Title 22.

Public

Health

And

Medicine

Chapter

60. Health

Benefits

Plan

Members

Bill Of

Rights

Cdcr 22-

60-6099

(2000)

22-60-

6099.

Definitions

Medically Necessary Care - means the

NA

care which, in the opinion of the treating

physician, is reasonably needed to (i)

prevent the onset or worsening of an

illness, condition, or disability; (ii)

establish a diagnosis; (iii) provide

palliative, curative, or restorative

treatment for physical and/or mental

health conditions; and (iv) assist the

individual to achieve or maintain

maximum functional capacity in

performing daily activities, taking into

account both the functional capacity of

the individual and those functional

capacities that are appropriate for

individuals of the same age

FL

Florida

Regulation Medically necessary or medical necessity Yes

Admin

means that the medical or allied care,

Code Ann

goods, or services furnished or ordered

Existence of MCO Contracts (y/n) Yes

Yes

Contract Definition

Variation in Contract/State definitions (y/n)

...In making medical necessity-related coverage determinations in the case of children under 21, Provider must authorize coverage if, taking into account the clinical evidence, as well as the recommendations of the child's PCP and other health, educational, and social services professionals caring for the child, Provider determines that a service covered under this contract is necessary to: (a) correct or ameliorate a physical or mental condition; or (b) prevent the onset or worsening of a disabling or chronic condition. ... In making medical necessity-related coverage determinations in the case of children with developmental disabilities, Provider shall provide coverage if, taking into consideration the clinical evidence, as well as the opinion of health, educational, and social services professionals furnishing care to such children, Provider determines that the care is necessary to correct or ameliorate the effects of a developmental disability. District of Columbia Contract, pages 21, 22,24-26 No provision for pediatric medical necessity

No N/A

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