APPENDIX A

  • Appendix A is also available in Portable Document Format (PDF)

Administrative Services Agreement Between Managed Long Term Care Plan and Health Homes

Managed Long Term Care Plan Covered Services
(Covered by the Capitation 1, 2,
Services Provided as Medically Necessary)		 Check Needed Services Managed Long Term Care Plan Non-Covered Services (Excluded From The Capitation; Can Be Billed Fee-For-Service) Check Needed Services
Nursing Home Care ☐ Inpatient Hospital Services ☐
Home Care
  1. Nursing ☐
  2. Home Health Aide ☐
  3. Physical Therapy (PT) ☐
  4. Speech Pathology (OT) ☐
  5. Medical Social Services ☐
 ☐   ☐
Adult Day Health Care ☐ Outpatient Hospital Services ☐
Personal Care ☐ Physician Services including services provided in an office setting, a clinic, a facility, or in the home. 3 ☐
DME, including Medical/Surgical Supplies*, Enteral and Parenteral Formula#, and Hearing Aid Batteries, Prosthetics, Orthotics and Orthopedic Footwear** ☐ Laboratory Services ☐
Personal Emergency Response System ☐ Radiology and Radioisotope Services ☐
Non-emergent Transportation ☐ Emergency Transportation ☐
Podiatry ☐ Rural Health Clinic Services ☐
Dentistry ☐ Chronic Renal Dialysis ☐
Optometry/Eyeglasses ☐ Mental Health Services ☐
PT, OT, SP or other therapies provided in a setting other than a home. Limited to 20 visits of each therapy type per calendar year, except for children under 21 and the developmentally disabled. MLTC Plan may authorize additional visits. ☐ Alcohol and Substance Abuse Services ☐
Audiology/Hearing Aids ☐ OPWDD Services ☐
Respiratory Therapy ☐ Family Planning Services ☐
Nutrition ☐ Prescription and Non-Prescription Drugs, Compounded Prescriptions ☐
Private Duty Nursing ☐ Assisted Living Program ☐
Private Duty Nursing ☐ All other services listed in the Title XIX State Plan: ☐
Consumer Directed Personal Assistance Services ☐    
Home Delivered or Congregate Meals ☐    
Social Day Care ☐    
Social and Environmental Supports ☐    

1. The capitation payment includes applicable Medicare coinsurance and deductibles for benefit package services.  1

2. Any of the services listed in this column, when provided in a diagnostic and treatment center, would be included in and covered by the capitation payment.  2

3. Includes nurse practitioners and physician assistants acting as "physician extenders".  3

# Enteral formula limited to nasogastric, jejunostomy, or gastrostomy tube feeding; or treatment of an inborn error of metabolism.

** Prescription footwear and inserts are limited to use in conjunction with a lower limb orthotic brace, as part of a diabetic treatment plan, or if there are foot complication in children under age 21.