Medicaid Managed Care - U.S. Senate Special Committee on Aging

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legally binding requirement on the managed care plan. To achieve that
goal, the definition should directly reference the goals of services.
Each covered individual (Memner) shall be eligiblefor servicms, as deflsd in sec-
tion _ provided in suficient asount, duration and scope to enabeMembers
ofiunction at the bgheispossibk kvel, given the severizy of teir disorder, in the
least r ictivesetingoftheir, dbice, andfor chddren underage 21, o progress
develropmnetllyas individ appropriate.
Medically nec sayev
(a) are designed to promote recovering and healing, enhance quality of
life, promote wellness-and improvefunctioning.
(J are provided with tlh goal of ensuring tbat Menbers are sucaessfrld
and satisfied in the setting of teir choire, with rhe least amount of ongoing
professional intervention
.(c) reflect Member choice and are designed to achieve outcomes desired
by the Member;
(d) are offered in the most integrated settings appropriate to the Member's
needs;and
(e)for Members wnderage 21, enable the child to progress dlopmntally
as individually appropriate, designed to enable the child to live at
home or in tchomelihe setting. and address both the needs of the child and
the related needs of thefamily.
B. Purpose of Services
In addition to being directed towards the advancement of members'
life goals, services must be designed to accomplish certain objectives. Additionally,
the definition of medically necessary services must be explicitly
broad and encompass not only clinical treatment but also screening,
prevention and rehabilitation. Most state definitions address these issues
to some degree and the language below is based on language that appears
in several state definitions of 'medically necessasy.'
A medically ncessa-y service shal mean 4 service identifqed in Section_
(Benefit Package), and supplies and technologiesfumrnished by or under the supervision
of a physician or otr licensd practitionr of te healing am within the
scope of their practierider State law, that are provided consistent with the
Member's desire and wishes and in sufficint amount. duration and scope to ef
fectively:
(a) srreen and assess the preence of a mental illness condfition;
Defining 'Medically Necessary" Services to Protect Plan Members 1'Z
POLICY ANALYSIS BY THE SAZELON CENTER FOR MENTAL HEALTH LAW 1L