1. PWS Attachment 001 Health Services List 3.19.24.pdf

Attachment 0001 - Healthcare Services List

RRMB - Healthcare Delivery Services

*Healthcare Services Required **Description

Abdominal Aortic Aneurysm Screenings

This screening requires a doctor referral and is only if the AIC is at risk and will only be approved one time per AIC.

Air-Fluidized Beds Available with a doctor's order and BOP approval for the treatment of chronic wounds.

Ambulance Services

Ground ambulance services are available for AICs if the condition is serious enough that other ways of getting to a place of care could risk their life or health. Emergency ambulance transportation in a fixed wing or rotary wing aircraft is only available for rapid ambulance transport, for life threatening illnesses or injuries, that ground transportation cannot provide. In cases that are not emergencies, ambulance services are available if the AIC's condition is serious enough that other ways of getting to a place of care could risk life or health, such as in the case of End-Stage Renal Disease (ESRD).

Ambulance services for routine appointments, such as AIC with ESRD, require pre-approval from the BOP

Ambulatory Surgical Centers

Coverage for approved surgical procedures provided in an ambulatory surgical center. These centers are an outpatient facility center where surgical procedures are performed and the AIC will be released from the surgical center within 24 hours. All surgeries will require the BOP's approval.

Anesthesia

Anesthesia is covered if ordered by the physician for surgery as well as diagnostic and screening tests. Coverage includes anesthetic supplies as well as the anesthesiologist's fee. Coverage includes general anesthesia, local anesthetics, and sedation.

Audiologist Services

This covers hearing and balance tests done by the primary provider. If further testing is ordered, the

BOP will have final approval of the services. If hearing aids are approved, the following will be covered: providing and dispensing hearing aids, batteries, and accessories; instruction in the care, use, and management of hearing aids; ear molds and ear impressions; (1) set of the least expensive medically approved hearing aids every five years.

Blood, including processing & handling

Coverage includes whole blood, packed red cells, and all other parts of blood. If the provider obtains the blood from a blood bank at no cost there shall be no charge to the Government for the replacement of the blood. Payment for services for blood processing and handling services for each unit of blood the AIC receives is allowed.

Breast Prostheses Breast prostheses that replicates the size, shape, feel, and weight of the AIC's breast(s) following a partial, full, or double mastectomy due to cancer.

Cardiac Rehabilitation

Services are available if prescribed by a doctor's order if the AIC meets at least one of these conditions: recent heart attack (past 3 months), coronary artery bypass surgery, heart valve repair or replacement, coronary angioplasty or coronary stenting, heart or lung transplant, or stable chronic heart failure. Additionally, intensive cardiac rehabilitation programs may be prescribed.

Cardiovascular Disease Screenings

Screenings include blood tests for cholesterol, lipid, and triglyceride levels to help detect conditions that may lead to a heart attack or stroke. These blood tests are covered once every 5 years.

Additional services that are covered are education on using aspirin and tips for healthy meals.

Cervical & Vaginal Cancer Screenings

Coverage includes pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the pelvic exam, coverage also includes a clinical breast exam to check for breast cancer. These services are covered once every 24 months or once every 12 months if the AIC is considered high risk for cervical or vaginal cancer, or, if there has been an abnormal pap test in the past 36 months for AICs of child-bearing age. Additionally, HPV tests are covered once every 5 years for AICs between the ages of 30-36 without HPV symptoms.

Chemotherapy Chemotherapy for cancer is covered in a physician's office, freestanding clinic, or hospital outpatient setting. The BOP must approve chemotherapy in an inpatient hospital setting.

Chronic Care Management Services

Services are available if the AIC has 2 or more serious chronic conditions, such as arthritis and diabetes, that are expected to last at least a year. Coverage includes a comprehensive care plan that details health problems and goals, medications, and community resources available.

Clinical Laboratory Tests

Clinical diagnostic laboratory tests for AICs are covered for medically necessary routine testing.

These tests must be ordered by the provider are considered covered services with the initial approved visit and require no further approval by the BOP. These tests may include blood tests, urinalysis, testing on tissue specimens, and routine screening tests. Clinical laboratory tests that are not considered routine by community standards will require BOP approval.

Colorectal Cancer Screenings

Colorectal cancer screenings are used to aid in the detection of precancerous growths. The following methods of colorectal cancer screenings are approved: Barium enema - For AICs over 50 coverage includes testing once every 48 months. Coverage is extended to once every 24 months for high risk AICs if the physician uses a barium enema in lieu of a sigmoidoscopy or colonoscopy;

Colonoscopies - Coverage for colonoscopies is one test every 120 months or one test every 24 months for high risk AICs. Colonoscopies are also available for AICs 48 months from their previous flexible sigmoidoscopy. There is no minimum age requirement for colonoscopies. Coverage also includes the removal and laboratory testing of polyps; Flexible sigmoidoscopy - Coverage includes a testing once every 48 months for AICs 50 or older, or 120 months after a previous screening colonoscopy if the AIC is not high risk. Coverage also includes the removal and laboratory testing of polyps; Fecal occult blood tests - Coverage is available for one testing every 12 months for AICs 50 or older; Multi-target stool DNA & blood-based biomarker tests - These tests are considered "at-home" lab tests and will be conducted at the AIC's place of residence. Coverage for these tests are available once every 3 years if: the AIC is between the ages of 50-85, the AIC shows no signs of colorectal disease such as blood in stool and other clinical symptoms, the AIC is at an average risk for the development of colorectal cancer, and there is no family history of colorectal cancer.

Continuous Positive Airway Pressure

(CPAP) Devices, Accessories, & Therapy

Coverage for AICs is available if the AIC has been diagnosed with obstructive sleep apnea by medical provider. The AIC will be required to follow-up with a doctor and the doctor must document in the AIC's medical records that the CPAP machine therapy is helping the AIC.

Coronavirus Disease 2019 (COVID-19)

The President of the United States has declared the public health emergency over for COVID-19.

Testing in the form of diagnostic tests and antibody tests will still be offered to the AICs if free testing kits are not available at the AIC's residence. Additionally, monoclonal antibody treatments are covered for AICs with moderate to severe symptoms related to COVID-19 after a positive test.

Defibrillators

Coverage includes an implantable automatic defibrillator is the AIC has been diagnosed with heart failure and the procedure is approved by the BOP. The preferred method of surgery for this procedure would be in an outpatient setting.

Dental Services

Dental services for AICs are NORMALLY only provided for dental emergencies. Routine dental care is limited to criteria determined by the BOP (e.g. length of community residence, Care Level, etc) and shall be preapproved by BOP. A dental emergency is defined as any dental problem that requires immediate treatment in order to save a tooth, stop ongoing tissue bleeding or alleviate severe pain. A severe infection or dental abscess in the mouth can be life-threatening and should be death with as such. Non-emergency dental care is routinely not approved by the BOP. Dentures for

AICs require pre-approval from the BOP. Upon request, diagnostic x-rays and comprehensive dental exam notes shall be provided.

Diabetes Screenings The BOP will cover up to (2) blood glucose laboratory tests screening each year if determined medical necessary by a physician. The tests can be with or without a carbohydrate challenge.

Diabetes Self-Management Training

For AICs diagnosed with diabetes, self-management training is available, if ordered by a doctor. The program will include tips for healthy meals, exercise, monitoring blood glucose, the importance of taking prescriptions as prescribed, and reducing risks associated with diabetes.

Diagnostic Non-Laboratory Tests

The BOP will cover X-Ray's, Ultrasounds, MRI's, CT Scans, EKG/ECG's, and some other rare diagnostic tests. All diagnostic tests with the exclusion of X-Ray's and EKG's require the approval of the BOP.

Doctor & Other Health Care Provider

Services

Medically necessary doctor services that include outpatient- services and some inpatient hospital doctor services are covered preventative services. Services from other medical professionals are covered also including physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, physical therapists, and occupational therapists.

Durable Medical Equipment (DME)

Coverage

Coverage includes certain items ordered by a provider for personal use at the AIC's dwelling.

Examples of DME include, but are not limited to, are bedside commodes, patient lifts, pressure-reducing support surfaces, glucose control solutions and supplies, braces that are medically prescribed, canes, crutches, diabetic monitors and supplies, hospital beds as prescribed by a provider, IV and infusion pumps, suction pumps, traction equipment, nebulizers, oxygen equipment and supplies, speech generating devices, hearing aids, walkers, and wheelchairs. Other DME items may be covered including assistive/adaptive technology. Coverage may also include the AIC learning to use, modify, or repair the DME item. All DME's require the BOP's approval.

Emergency Department Services

Services are covered for AICs when they have a sudden illness, an injury, or an illness that quickly gets much worse, and is life-threatening, or could endanger the long-term health of the AIC. A medical emergency is a medical condition that anyone with an average knowledge of health and medicine could expect is so serious that if it doesn't get immediate medical attention, it would result in a serious risk to the AICs health or serious harm to bodily functions or serious dysfunction of any bodily organ or part. If the AIC receives emergency care at an out-of-network hospital and needs inpatient care after the emergency is stabilized, the AIC must return to an in-network hospital for the continuance of care to be a covered expense. The AIC can stay in the out-of-network hospital with the approval of the BOP.

Eye Exams

Coverage is available for comprehensive eye exams, including diabetic eye exams. Coverage is also available for age-related macular degeneration and the related treatments as prescribed by a physician. Eye exams require the approval of the BOP.

Eyeglasses & Contact Lenses

Eyeglasses & contact lenses for AICs must be approved by BOP. A current prescription must be submitted with the request for eyeglasses or contact lenses. Contact lenses are generally not approved by the BOP unless special conditions are met.

Federally Qualified Health Center (FQHC) services

Federally Qualified Health Centers provide many services for outpatient primary care and preventative care. Since the cost of these services are generally free or reduced based on income, it is the BOP's preference to use these services if available.

Glaucoma Tests

Coverage is available for glaucoma tests once every 12 months for AICs at a high risk of developing glaucoma. High risk factors include diabetics, a family history of glaucoma, are African American and 50 or older or are Hispanic and 65 or older.

Hepatitis C Screening Tests

Services covered include one Hepatitis C screening test if ordered by a doctor and the AIC is: high risk because of using illicit injection drugs; or the AIC had a blood transfusion before 1992; or the

AIC was born between the years of 1945-1965.

HIV Screenings HIV screening is covered for AICs once every 12 months for AICs between the ages of 15 - 65.

Additionally, screenings are available for high-risk AICs younger than 15 and older than 65.

Home Health Agency Care and Aide

Services

Home health services must be approved by the BOP. The services must be certified by a physician as medically necessary and at least one of the following services must be needed: intermittent skilled nursing care other than drawing blood; physical therapy, speech-language pathology, or continued occupational therapy services. The services are only covered when the services are safe, specific, and an effective treatment for the AIC's condition. The amount, frequency and time period of the of the services need to be complex or only qualified therapists can do them safely and effectively; you must be homebound and a doctor must certify that you're homebound. To be eligible, either: the AIC's condition must be expected to improve in a reasonable and generally predictable period of time; or the AIC will need a skilled therapist to safely and effectively make a maintenance program for their condition; or the AIC will need a skilled therapist to safely and effectively do maintenance therapy for their condition.

Home Infusion Therapy Services &

Supplies

Coverage includes equipment and supplies (like pumps, IV poles, tubing, and catheters) for home infusion therapy to administer certain IV infusion drugs at the AICs residence. These supplies are also covered under DME. Coverage also includes services such as nurse visits and patient monitoring. These services and supplies require approval by the BOP.

Hospice Care

Hospice care is available if the medical provider and BOP determine the AIC has a terminal prognosis, with a life expectancy of six months or less. Coverage includes drugs to treat symptoms and pain, short-term respite care, and in-home care (limited instances). Hospice care can also be given in a nursing facility if approved by the BOP.

Hyperbaric Oxygen Therapy

Services must be pre-approved by the BOP. Services are limited to a one-person unit for the following conditions: acute carbon monoxide intoxication, decompression illness, gas embolism, gas gangrene, acute traumatic peripheral ischemia, crush injuries and storing of severed limbs, progressive necrotizing infections, acute peripheral arterial insufficiency, preparation and preservation of compromised skin grafts, chronic refractory osteomyelitis that is unresponsive to conventional treatment, osteoradionecrosis as an adjunct to conventional treatment, soft tissue radionecrosis as an adjunct to conventional treatment, cyanide poisoning, actinomycosis as an adjunct to conventional therapy, and diabetic wound of the lower extremities for a wound classified as Wagner grade III or higher and standard wound therapy is unsuccessful.

Immunizations

Services are provided for immunizations for pneumonia, flu shots, hepatitis B vaccine, COVID-19 vaccine, shingles vaccine, T-DAP, and any other vaccines covered by Medicare services. The criteria for the vaccines approval will be based on community standards.

Inpatient Hospital Care

Inpatient hospital care services are available for AICs who are admitted to the hospital as an inpatient after an official doctor's order stating the AIC will need inpatient hospital care to treat their illness or injury. Inpatient hospital care includes semi-private rooms, meals, general nursing, medication and supplies. Private rooms will not be authorized unless they are considered medically necessary by a physician. Inpatient hospital care includes care received at acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and long-term care hospitals.

Inpatient Rehabilitation Care

Inpatient rehabilitation care must be approved by the BOP as well as certified as medically necessary by a physician. The AIC must have a medical condition that requires intensive rehabilitation, continued medical supervision, and coordinated care that comes from the doctors and therapists working together. Inpatient rehabilitation care includes rehab services including physical therapy, occupational therapy, and speech-language pathology; a semi-private room; meals; nursing services; prescription drugs; and other hospital supplies and services.

Long-term Care Hospital Services

Long-term care services are available for AICs who have more than one serious medical condition and who are hospitalized for 25 days or more and require services such as respiratory therapy, comprehensive rehabilitation, and pain management.

Lung Cancer Screenings

Lung cancer screening services are available for AICs using low dose computed tomography once each year if all of the following conditions are met: aged 50-77, no signs or symptoms of lung cancer, a current smoker or have quit in the past 15 years, have a history of smoking at least one pack of cigarettes each day for 20 years or more, and is ordered by a physician.

Mammograms

Coverage is available to AICs for a mammogram screening to check for breast cancer once every

12 months for women 40 or older. Coverage is available for a baseline mammogram for women between the ages of 35-39.

Mental Health Care (inpatient) Services are covered for inpatient mental health care when the AIC is admitted as a hospital patient due to mental health issues or concerns.

Newborn Care

Services include limited necessary postnatal care of the child born to an AIC. The services provided shall include the child’s medical expenses for the first three days after routine vaginal birth or up to seven days for a Cesarean section.

Nursing Hotline

Services as defined in this PWS include a 24 hour, 7 day per week nurse hotline. This hotline should be staffed by a registered nurse. The AICs will utilize the nurse hotline for non-life threatening medical issues to determine the appropriate medical course of action. Additional details concerning the nurse hotline are detailed in the PWS.

Nutrition Therapy Services

Coverage is available to AICs to cover nutritional diagnostic therapy and counseling services to help manage a medical condition such as kidney disease and diabetes. These services require the approval of the BOP.

OB/GYN Services include prenatal and postnatal care and gynecological services.

Occupational Therapy Services

If medically prescribed a physician and approved by the BOP, services covered will include medical necessary outpatient occupational therapy to help the AIC perform the activities of daily living such as dressing and bathing after an accident or illness.

Ophthalmology Consults Services are available for advanced eye medical conditions related to the eye. These services must be approved by the BOP.

Over the Counter (OTC) medications OTC medications that are not medically indicated are not permitted. Any request shall be approved by BOP.

Outpatient Hospital Services

All outpatient hospital services must be approved by the BOP except in emergency situations. The services covered must be medically necessary for the diagnosis or treatment of an injury or illness.

Coverages include: services in an emergency department or outpatient clinic, such as outpatient surgery or observation services; labs and diagnostic tests billed by the hospital; x-rays and other radiology services billed by the hospital; medical supplies such as splints and casts; preventative screenings; and some medicines that must be administered in a medical setting.

Outpatient Rehabilitation Services

Outpatient rehabilitation services must be approved by the BOP. The services must be ordered by a physician as medically necessary following an illness, accident, or major operation. The services provided under outpatient rehabilitation services may include, but are not limited to, physical therapy, social services, respiratory therapy, occupational therapy, speech therapy, and home environment evaluation services.

Physical Therapy Services

Physical therapy services must be approved by the BOP. The services must be ordered by a health care provider as a medically necessary treatment to aid in the recovery from an illness, accident, or major operation.

Podiatry, Routine and Diabetic

Services covered include the diagnosis and medical or surgical treatment of injuries and diseases of the foot. Additionally, routine foot care is available for AICs with conditions affecting the leg, such as diabetes.

Prescription Drugs (outpatient) Brand

Name

Prescription drug coverage for brand name drugs requires the approval of the BOP. All requests for prescription drugs must be in compliance with the BOP National Formulary List.

Prescription Drugs (outpatient) Generic

Prescription drug coverage is available for AICs with a current, unexpired prescription from a physician. The BOP's preference for all medicines is for a generic drug since the generic drug has the same active ingredients as brand name drugs. All requests for prescription drugs must be in compliance with the BOP National Formulary List.

Primary Care Provider (PCP) Services Routine medical care to include both urgent, well visits and chronic care.

Prostate Cancer Screenings Covered screenings include a digital rectal exam, a prostate specific antigen (PSA) test, and a biopsy if needed. Tests are available for AICs once every 12 months for AICs over 50.

Prosthetic and Orthotic Devices

Covered items include, but are not limited to arm, back, and neck braces, artificial limbs (and their replacement parts) and artificial eyes. Additional items covered include devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy.

Pulmonary Rehabilitation Programs Coverage includes a comprehensive pulmonary rehabilitation program if the AIC has: moderate to severe chronic obstructive pulmonary disease (COPD) and has a referral from the doctor.

Radiation Therapy Radiation services are available as ordered by a physician in the treatment of cancer.

Renal (Kidney) Disease Services and

Supplies

Services covered include: Inpatient dialysis treatments if the AIC is admitted as an inpatient to a hospital for special care; self-dialysis training; home dialysis equipment and supplies, in addition to home support services, if approved by the BOP. AICs with stage IV chronic kidney disease is eligible for coverage for six sessions of kidney disease education services.

Sexually Transmitted Infection Screenings

& Counseling

Services cover screenings for chlamydia, gonorrhea, syphilis, and hepatitis B. These screenings must be ordered by a physician. Services also include preventative services such as counseling that are held in a primary care setting, such as a doctor's office.

Skilled Nursing Facility (SNF) Care

Coverage is available if ordered by a physician for daily skilled care that is available from, or under the supervision of, skilled nursing or therapy staff. The skilled services must be for a medical condition that is either: a hospital-related medical condition treated during an inpatient hospital stay or the condition started while obtaining care in the SNF for a hospital related medical condition.

Sleep Studies If prescribed by a physician, sleep study services are available for AIC's with clinical signs and symptoms of sleep apnea. This coverage includes type I, II, III, and IV sleep tests and devices.

Speech-Language Pathology Services Services covered include outpatient speech-language pathology services if certified as medically necessary by a physician. This also requires approval by the BOP.

Surgery

All surgeries, except in emergency lifesaving situations, requires the approval of the BOP. Services are available for medically necessary surgeries given in places such as a physician's office, certified ambulatory surgical center, hospital outpatient department, or a hospital.

Surgical Dressing Services Services covered include the treatment of a surgical or surgically treated wound. These services must be requested with an order by a physician.

Swing Bed Services Swing bed services may be used if prescribed by a physician in critical access hospitals or skilled nursing facilities.

Therapeutic Shoes & Inserts

When prescribed by a physician and approved by the BOP, AICs are eligible for one pair of custom-molded shoes and inserts and one pair of extra depth shoes for diabetic foot disease. Additional coverage includes 2 additional pairs of inserts each calendar year for custom-molded shoes and 3 pairs of inserts each calendar year for extra-depth shoes.

Transitional Care Management Services

With a doctor's order, services are covered for AICs returning to their community after a stay at certain facilities, like a hospital or skilled nursing facility. A health care worker will work to coordinate and manage the AIC's care for the first 30 days after leaving the facility.

Urgently Needed Care

Urgently needed care is care for a sudden illness, injury, or condition that isn’t an emergency but still needs to be taken care of right away. For example, a flare-up of an existing condition that needs to be treated. Urgently needed care is covered if: the care is obtained from a participating provider, and the rules as established in the PWS are followed for obtaining the care.

Reimbursement for care from a non-participating provider will be handled in accordance to the rules specified in the PWS.

**Offerors may propose a variation in description based off their network.

*This list includes a diversity of medical and ancillary services covering a wide spectrum from inpatient and outpatient facility and physician services that may be routine, specialty or urgent/emergent, but may not be all-inclusive. Contractor shall discuss their plan for offering a diversity of services.