In Lieu of Services (ILOS) Coverage Criteria
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Governs the Plan's use, management, and oversight of In Lieu of Services (ILOS) for Carolina Complete Health Medicaid products; applies to Utilization Management, Quality, Compliance, Pharmacy and Member Service departments.
No material clinical or coverage changes in this revision.
Coverage Criteria for In Lieu of Services (ILOS)
General Coverage Criteria for ILOS
Covered when the Plan and DHHS have approved an ILOS and it meets the Plan's requirements:
Plan may offer alternative services and benefits as ILOS if they meet medical appropriateness and cost-effectiveness standards and are approved per contract
The Plan shall not require a beneficiary to utilize an In Lieu of Service (ILOS). The beneficiary cannot be forced to accept an ILOS in place of a State Plan covered service; use of an ILOS must be voluntary.
There are no specific conditions listed as not medically necessary for ILOS in this policy. Instead, ILOS coverage is governed by the requirement that any ILOS offered by the Plan be medically appropriate and a cost-effective alternative to a State Plan covered service.
Provider Responsibilities and Authorization Rules
Prior authorization noted in ILOS table; no PA rules provided
The procedure table for proposed ILOS includes a column labeled “PA (Y/N),” indicating whether prior authorization is required for each ILOS, but the policy text does not define specific prior authorization rules, criteria, or affected codes.
No step therapy requirements described
The policy explicitly states that no step therapy requirements are described for ILOS; there are no step-therapy rules or escalation sequences provided in the document.
Post ILOS policies publicly and monitor utilization/expenditures
The Plan must publish its ILOS policies on publicly available member and provider websites and must monitor the cost-effectiveness of each approved ILOS by tracking utilization and expenditures.
- Post ILOS policies on member and provider websites as publicly available documents.
- Monitor utilization and expenditures for each approved ILOS to assess cost-effectiveness.
No explicit provider authorization procedures specified
The document does not list explicit provider-level authorization requirements; it states the Plan may use ILOS services that are medically appropriate and cost-effective alternatives to State Plan services, leaving specific authorization processes undefined.
- No provider-level authorization procedures or requirements are specified in the policy text.
- Plan may offer ILOS when medically appropriate and cost-effective, subject to DHHS approval where required.
Background on In Lieu of Services (ILOS)
An In Lieu of Service (ILOS) is a service or setting not covered under the State Medicaid Plan that the Plan may offer as a medically appropriate, cost‑effective alternative to a State Plan covered service. The policy directs that the Plan may use ILOS when they meet standards of medical appropriateness and cost-effectiveness and clarifies that offering ILOS does not change Standard Plan coverage. The Plan must also follow DHHS approval and notification requirements when adding, reducing, or removing ILOS options.
Key Definitions
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