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EXHIBIT A

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					EXHIBIT P OUT-OF-PLAN SERVICES

Out of Plan Services include, but are not limited to: A) Transitional Care Homes The PH-MCO will only be responsible to provide medical services to children upon the child leaving the transitional care home to reside with family or other caretakers living within the HealthChoices Zone. The PH-MCO must ensure continuity of care, as well as coordination with necessary Providers and interagency teams once they are notified that the child has become enrolled in the PH-MCO. B) Medical Foster Care Services Medical foster care services are provided to children with special or chronic medical conditions or physical disabilities in the custody of the County Children and Youth Agency and placed in foster family care. Medical foster care services enable the child to be treated by a licensed practitioner on an outpatient rather than an inpatient or institutional basis. Medical foster care services include both supportive and supervisory activities as well as direct care of children. Such tasks include but are not limited to: medical management, nutritional care, hygiene and personal care and developmental education Medical foster care services are provided by both county and private children and youth social service agencies. The foster parents who are under contract with the agency provide direct care. The licensed foster care agency is enrolled as a Provider Type 40, Specialty 400, Medically Fragile Foster Care, and claims reimbursement is through the Medical Assistance Fee-for-Service Program according to the maximum daily fees for the four levels of medical foster care as established by the Office of Medical Assistance Programs. Even though the PHMCO is responsible to provide Medically Necessary services to children residing in medical foster care homes, the PH-MCO is not responsible for the medical foster care services identified in the four levels of care. These four levels of medical foster care are described as Level(s) I - IV with each level progressively requiring increased care.  Level I o The Child has one or more medical conditions or physical disabilities that can be relieved, alleviated, or controlled by a regimen of medical supervision and consistent non-specialized care. No life threatening situations are anticipated. o Some specialized training may be required for the foster parent to care for the child, such as the preparation and control of special diets and the administration of non-oral medications.

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o Wheel chairs, ramps, and/or prostheses may be required but sophisticated technological equipment usually will not be necessary. Few special medical supplies are necessary. Level II o The child has one or more acute medical conditions or physical disabilities that can be relieved, alleviated, or controlled by specialized intervention and a regimen of medical supervision and consistent care. No immediate life threatening situations are anticipated. o Some special medical procedures training may be required for the foster parent for the management of tracheostomies, ileostomies, NG feeding tubes, catheters, etc. o Use of sophisticated technological equipment will be minimal. Some special medical supplies will be necessary. o The child will usually require special therapeutic interventions and special social, educational, and vocational planning. Level III o The child has a combination of acute temporary, chronic, or permanent medical conditions or physical disabilities which require intensive, home-based medical intervention on a constant basis to sustain life. Life threatening situations are anticipated. o Considerable special medical procedures training will be required for the foster parent. o Use of sophisticated technological equipment will be necessary. Special medical supplies will be necessary. o Because the child will usually be home-bound, all developmental areas will require special planning. Level IV o The child has a combination of acute, chronic, or permanent medical conditions or physical disabilities whose life can be sustained only by intensive, home-based medical intervention on a 24-hour basis. Life threatening situations are constantly present. o Extensive special medical procedures training will be required for the foster parent. o Use of a variety of sophisticated technological equipment will be necessary. Special medical supplies will be necessary. o Because the child will be home-bound, all developmental areas will require special planning.

When children in the custody of the County Children and Youth Agency are placed in medical foster care homes, the PH-MCO's Special Needs Unit must work with the medical foster care agency to ensure that necessary medical and ancillary services are provided in the amount and level that enable the child to be maintained in the foster care home and minimize hospitalization/institutionalization of the child. C) Early Intervention Services An infant or toddler may receive services under both the HealthChoices Program and the Early Intervention Program, but the services are separate and distinct.
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The HealthChoices Program consists of Medically Necessary services prescribed by the Primary Care Practitioner. Early intervention services consist of a range of family-centered habilitation services and supports as defined by each family's individualized family service plan. D) The Home and Community Based Waiver Program for Nursing Facility Residents With Other Related Conditions (OSP/OBRA Waiver) The Department's Office of Social Programs currently operates a Home and Community Based Waiver that provides services to nursing facility and special rehabilitation facility residents with Other Related Conditions who need specialized services. Persons with Other Related Conditions are persons who have physical disabilities such as cerebral palsy, epilepsy, spina bifida or similar conditions which occurred before the age of 22, the conditions are likely to continue indefinitely, and result in three or more substantial functional limitations. Recipients receiving these home and community-based services through the OSP/OBRA Waiver will be enrolled in the HealthChoices Program. The PH-MCO is responsible for providing Medically Necessary services to these individuals with the exception of those services covered under the OSP/OBRA Waiver. The PHMCO must coordinate with the waiver service providers to promote a seamless continuum of care. The PH-MCO is also not responsible to provide any medical services that are determined to fall under the scope of Behavioral Health Services or is the responsibility of the Behavioral Health MCOs. A description of these services is addressed in the MA Eligibility Handbook. E) The Home and Community Based Waiver Program for Nursing Facility Applicants with Other Related Conditions (OSP-Independence Waiver) This waiver provides supports and services to persons with Other Related Conditions (those with severe physical disabilities, age 18 and above, who acquired their disability prior to age 22) and prevents these persons from entering long-term care facilities. Services include service coordination, personal assistance services (attendant care), respite services and environmental accessibility adaptations. Some therapies, limited visiting nursing services and special medical equipment and supplies that are above and beyond those provided by the MA fee Schedule, can also be obtained with the required medical documentation. The Department’s Office of Social Programs manages this waiver. Recipients receiving these home and community-based services through the OSPIndependence Waiver will be enrolled in the HealthChoices Program. The PH-MCO is responsible for providing Medically Necessary services to these individuals with the exception of those services covered under the OSP-Independence Waiver. The PHMCO must coordinate with the waiver service providers to promote a seamless continuum of care. The PH-MCO is also not responsible to provide any medical services that are determined to fall under the scope of Behavioral Health Services or are the responsibility of the Behavioral Health MCOs.

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F)

The Home and Community Based Waiver Program for Attendant Care Services (OSP/AC Waiver) The Department's Office of Social Programs currently operates a Home and Community Based Services Waiver which provides attendant care to mentally alert adults 18 through 59 years of age with physical disabilities who require nursing facility level of care but who choose to remain in their own home or community living arrangement. Recipients receiving these home and community-based services through the OSP/AC Waiver will be enrolled in the HealthChoices Program. The PH-MCO is responsible for providing Medically Necessary services to these individuals with the exception of those services covered under the OSP/AC Waiver. The PH-MCO must coordinate with the waiver service providers to promote a seamless continuum of care. The PH-MCO is also not responsible to provide any medical services that are determined to fall under the scope of Behavioral Health Services, or are the responsibility of the Behavioral Health MCOs. A description of these services is addressed in the MA Eligibility Handbook.

G)

The Home and Community Based Waiver Program for Persons with Mental Retardation The Department's Office of Developmental Programs currently operates a Community Based Services Waiver that provides services in the community to persons who would otherwise need care in an ICF/MR/ORC. Recipients receiving community-based services through this waiver will be enrolled in the HealthChoices Program. The PH-MCO is responsible for providing Medically Necessary services to these individuals with the exception of those services covered under this waiver. The PH-MCO must coordinate with the waiver service providers to promote a seamless continuum of care. The PH-MCO is also not responsible to provide any medical services that fall under the scope of Behavioral Health Services, or are the responsibility of the Behavioral Health MCOs. A description of these services is addressed in the MA Eligibility Handbook .

H)

The COMMCARE Waiver for Persons with a Primary Diagnosis of Traumatic Brain Injury The Department’s Office of Social Programs operates a Home and Community Based Waiver that provides services in the community to persons age twentyone (21) and older who experience a medically determinable diagnosis of traumatic brain injury and require a Special Rehabilitation Facility (SRF) level of care. Recipients receiving community-based services through this waiver will be enrolled in the HealthChoices Program. The PH-MCO is responsible for providing Medically Necessary services to these individuals with the exception of those services covered under this waiver. The PH-MCO must coordinate with the waiver service providers to promote a seamless continuum of care. The PH-MCO is also not

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responsible to provide any medical services that fall under the scope of Behavioral Health Services, or are the responsibility of the Behavioral Health MCOs. A description of these services is addressed in the MA Eligibility Handbook .

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