N.H. Admin. Code § He-W 506.04

Current through Register No. 50, December 12, 2024

Section He-W 506.04 - Covered Services

(a) Covered services provided through an MCO shall include all covered state plan and ABP services except the following:

(1) Dental services provided in the dental setting;

(2) Intermediate care facility for individuals with intellectual disabilities;

(3) Medicaid to schools program;

(4) Skilled nursing facility;

(5) Skilled nursing facility atypical care;

(6) Inpatient hospital swing beds, intermediate care facility;

(7) Inpatient hospital swing beds, skilled nursing facility;

(8) Intermediate care facility nursing home;

(9) Intermediate care facility atypical care;

(10) Glencliff Home;

(11) Early supports and services;

(12) The following high-cost drugs when billed by a pharmacy:

a. Drugs used for the treatment of hemophilia;

b. Carbaglu, both brand and gneric;

c. Raviciti;

d. Crysvita ®;

e. Gattex®;

f. Procysbi®; and

g. Vijoice®;

(13) The following high-cost gene therapy and biological medications:

a. Zolgensma ®;

b. Zynteglo®;

c. Skysona®;

d. Hemegenix®;

e. Elevidys®; and

f. Roctavian®;

(14) The following services which are only offered to children involved with the division for children, youth, and families:

a. Home based therapy;

b. Child health support service;

c. Placement services;

d. Intensive home and community services;

e. Private non-medical institutional care for children; and

f. Crisis intervention; and

(15) Section 1915(i) of the Social Security Act, state plan home and community based services for high risk children with severe emotional disturbances.

(b) The services excluded in (a)(1) above shall be covered by medicaid on a fee-for-service basis except dental services which are covered as described in He-W 566.

(c) Covered services shall be provided by the MCO starting the same business day as a member's selection of or passive enrollment in an MCO.

(d) Covered state plan and ABP services provided through an MCO shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under fee-for-service.

(e) Covered services provided through a DO shall include all covered state plan, Section 1915(b) of the Social Security Act, Section 1915(c) of the Social Security Act, and Section 1115 of the Social Security Act, and ABP dental services.

N.H. Admin. Code § He-W 506.04

#10410, eff 9-13-13; ss by #10631, eff 7-1-14

Amended by Volume XXXVI Number 23, Filed June 9, 2016, Proposed by #11107, Effective 7/1/2016, Expires 7/1/2026.

Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12016, Effective 10/25/2016, Expires 12/25/2026.

Amended by Number 10, Filed March 7, 2024, Proposed by #13879, Effective 2/21/2024, Expires 2/21/2034.