met the out-of-pocket maximum a letter stating that the Enrollee shall not incur any responsibilities for the remainder of the Contract Year. Insurer shall not avoid costs for services covered under this Contract, including immunization requirements, by referring Enrollees to publicly supported health care resources and requiring the Enrollee to utilize those resources. Insurer shall not object or otherwise refuse to provide a or service covered under this Contract on moral or religious grounds. Insurer shall ensure that services provided are sufficient in amount, duration and scope to reasonably achieve the purpose for which the services are furnished. Insurer shall not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of diagnosis, type of illness or Enrollee condition. This provision does not prohibit Insurer from placing appropriate limits on services or implementing utilization management controls. Utilization Management Insurer establish utilization management controls to ensure Enrollees receive appropriate care. Insurer’s utilization management controls shall allow for consideration of factors specific to individual Enrollees such as age and medical history. Insurer shall not compensate individuals or entities conducting utilization management activities in a way that provides incentives for the individual or entity to deny, limit or discontinue Medically Necessary services to an Enrollee. Utilization management activities, including prior authorization reviews, shall be conducted by individuals with clinically appropriate backgrounds in a manner that results in interrater reliability sufficient to indicate the appropriateness and validity of the process, including the training given to the reviewers. Behavioral Health; Substance Use Disorder Benefits Insurer shall adopt Section 394.491 and Chapter 397, Florida Statutes, as guiding principles in the delivery of services and supports to Enrollees with behavioral health care needs, including substance use disorder services. Insurer shall maintain policies and procedures that support: Early identification of behavioral health care needs through the use of valid assessments; The use of services that enhance the Enrollee’s likelihood of positive outcomes, improved ability to function at home, school and in the community, and to live
met the out-of-pocket maximum a letter stating that the Enrollee shall not incur any responsibilities for the remainder of the Contract Year. Insurer shall not avoid costs for services covered under this Contract, including immunization requirements, by referring Enrollees to publicly supported health care resources and requiring the Enrollee to utilize those resources. Insurer shall not object or otherwise refuse to provide a or service covered under this Contract on moral or religious grounds. Insurer shall ensure that services provided are sufficient in amount, duration and scope to reasonably achieve the purpose for which the services are furnished. Insurer shall not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of diagnosis, type of illness or Enrollee condition. This provision does not prohibit Insurer from placing appropriate limits on services or implementing utilization management controls. Utilization Management Insurer establish utilization management controls to ensure Enrollees receive appropriate care. Insurer’s utilization management controls shall allow for consideration of factors specific to individual Enrollees such as age and medical history. Insurer shall not compensate individuals or entities conducting utilization management activities in a way that provides incentives for the individual or entity to deny, limit or discontinue Medically Necessary services to an Enrollee. Utilization management activities, including prior authorization reviews, shall be conducted by individuals with clinically appropriate backgrounds in a manner that results in interrater reliability sufficient to indicate the appropriateness and validity of the process, including the training given to the reviewers. Behavioral Health; Substance Use Disorder Benefits Insurer shall adopt Section 394.491 and Chapter 397, Florida Statutes, as guiding principles in the delivery of services and supports to Enrollees with behavioral health care needs, including substance use disorder services. Insurer shall maintain policies and procedures that support: Early identification of behavioral health care needs through the use of valid assessments; The use of services that enhance the Enrollee’s likelihood of positive outcomes, improved ability to function at home, school and in the community, and to live
Attachment1DraftContract.docx