Table 2. State Definitions of Medical Necessity ...

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).

1

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

2

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

3

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

4

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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