STATE COVERAGE INSURANCE (SCI) BENEFIT PACKAGE
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Defines the SCI benefit package services, limitations, prior authorization requirements, and coverage rules for members and MCOs under New Mexico's SCI program. Applies to the general public and managed care organizations administering SCI benefits.
No material clinical or coverage changes in this revision.
SCI Coverage Rules and Limits
SCI core coverage requirements
Covered when ALL of the following are met
From general provisions and service lists.
Inpatient / rehabilitation / home health limits
Coverage is limited as follows
Applies to inpatient hospital, inpatient physical rehabilitation, and home health.
Behavioral health and substance abuse coverage
Behavioral health and substance abuse services are covered with limits
Prior authorization required.
Prior authorization required.
Cardiovascular rehabilitation
Post-cataract surgery vision materials
One set per surgery; contact lenses and eyeglasses not both covered.
Covered services with limits
Covered services are subject to medical necessity and specified service limits; total benefits per member per benefit year are capped.
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Long-term rehabilitative therapy for chronic or incurable conditions is not routinely covered under the SCI benefit package. Short-term physical, occupational, and speech therapy are covered only when they are expected to produce significant and demonstrable improvement within a two-month period from the initial date of treatment. Therapy must be ordered by the member's PCP or another appropriate treating provider to whom the member has been referred; requests from therapists will not be approved. A one-time extension of up to two additional months may be granted only if the MCO medical director determines continued significant improvement is expected and therapy records document compliance and goal attainment for the preceding two-month period.
The SCI benefit package expressly excludes services and supplies that are not listed as covered, those not coordinated through the member's PCP (or authorized referral) or lacking required prior authorization, and a broad set of named services. Exclusions include, but are not limited to: acupuncture and chiropractic; many behavioral health residential and non‑standard behavioral programs; cosmetic procedures and related services; most general dental services, orthodontics, endodontics and dental prosthetics; many durable medical equipment, prosthetic and orthotic items; routine eyeglasses and refractions (except post‑cataract materials as specified); most genetic testing except for diagnosis/treatment of current illness; health club fees; hearing aids except where specifically defined; hospice care; travel and lodging expenses; vocational rehabilitation; weight loss surgery and medications; services covered by workers' compensation; and miscellaneous items such as copying charges, holistic medicine, bone density screening with ultrasound, telephone visits for which a charge is made, and devices or treatments for hair removal or hair loss.
Services that fail the SCI definition of medically necessary are considered not medically necessary and therefore not covered. Medically necessary services must be essential to prevent, diagnose, or treat medical conditions or to attain, maintain, or regain functional capacity, delivered in a clinically appropriate amount, duration, scope and setting, and provided within professionally accepted standards and national guidelines. Services that are not essential, are provided in inappropriate amount/duration/setting, fall outside accepted standards, or are primarily for convenience do not meet coverage criteria.
The SCI benefit package excludes services that are not medically necessary, experimental, or investigational. This includes treatments, procedures, drugs, devices, or supplies that are not standard medical practice, as well as drugs or devices that are not FDA‑approved or not approved for the proposed use. Experimental or investigational medical, surgical or other health care procedures, including use of experimental drugs or biologicals, are not covered except for routine patient costs associated with certain cancer clinical trials as specified.
Coding and Equipment Thresholds
Prior Authorization, Documentation, and Coordination
Obtain prior authorization for listed admissions, rehab, home health, DME, oral surgery, and some behavioral services
Prior authorization is required for hospital admissions, inpatient physical rehabilitation, home health services, durable medical equipment with allowable charges of $200 or more per item, limited oral surgery, and certain inpatient behavioral health and substance abuse services. Hospital admissions and inpatient physical rehabilitation must be provided under the direction of the member's PCP or a consulting provider to whom the member is referred. Any service or procedure not outlined in the inpatient hospital services section requires prior authorization.
- Hospital admissions must have prior authorization and be provided under the direction of the member's PCP or a consulting provider to whom the member is referred by his PCP.
- Inpatient physical rehabilitation services require prior authorization.
- Home health services are provided with prior authorization; home health in lieu of hospitalization must be preceded by inpatient hospitalization or a PCP statement indicating hospitalization would be necessary.
- Durable medical equipment, medical supplies, orthotic appliances and prosthetic devices with allowable charges of $200 or more per item require prior authorization.
- Limited oral surgery benefits are covered with prior authorization.
Services requiring prior authorization must have authorization in place or they will not be covered
Prior authorization is required for services when specified by the plan; services and supplies that require prior authorization will not be covered if prior authorization is not obtained.
- Any services or supplies that require a prior authorization are not covered if a prior authorization is not obtained.
- Services must be provided by or under the direction of the member's PCP or by a provider to whom the member has been referred; services not coordinated through the PCP may be excluded unless a prior authorization is in place.
Document accidental dental injuries and treat within 72 hours
For accidental injury to sound natural teeth, initial treatment must be sought within 72 hours of the injury and the injury must be properly documented at the initial treatment; services must be completed within 12 months of the date of injury and the MCO will require dental x‑rays.
- Teeth with crowns or restorations are not considered sound natural teeth.
- Services must be completed within 12 months of the date of injury.
- MCO will require dental x‑rays as part of documentation.
Document accidental dental injuries and meet home health prerequisites
For accidental dental injury coverage, document the injury at initial treatment and ensure initial treatment is sought within 72 hours; the MCO will require dental x‑rays. For home health services, ensure inpatient hospitalization precedes home health coverage or obtain a PCP statement that hospitalization would be necessary absent home health services.
- Initial treatment for accidental injury must occur within 72 hours and be documented; complete services within 12 months.
- Home health in lieu of hospitalization is limited to 25 days per benefit year and must be preceded by inpatient hospitalization or a PCP statement supporting home health.
- MCO requires dental x‑rays for accidental dental injury claims.
Prior authorization required for inpatient admissions and unspecified outpatient services
Any inpatient hospital admission and outpatient services not explicitly outlined require prior authorization; inpatient admissions must have prior authorization and be provided under the direction of the member's PCP or a consulting provider to whom the member is referred.
- Any service or procedure not outlined in the inpatient hospital services section requires prior authorization.
- Inpatient hospital admissions must have prior authorization and be under the direction of the member's PCP or an authorized consulting provider.
Failure to obtain prior authorization or coordinate through PCP risks denial
Services and supplies that require prior authorization will not be covered if prior authorization is not obtained; services not coordinated through the member's PCP or lacking prior authorization may be excluded.
- Health services and supplies must be provided by or under the direction of the member's PCP or a provider to whom the member has been referred by his PCP, or have a prior authorization for non-participating providers.
- Failure to obtain required prior authorization may result in denial of coverage.
Scope and Purpose
The SCI benefit package defines the scope of medically necessary clinical and rehabilitative services that are required to prevent, diagnose, or treat medical conditions and to enable or restore functional capacity. Covered services must meet the SCI standards for medical necessity: they must be essential to the member's care, delivered in a clinically appropriate amount, duration, scope and setting, and provided within professionally accepted standards and national guidelines. The policy emphasizes coordination of care under the member's PCP or an authorized consulting provider and specifies service limits, combined benefit day caps, annual dollar limits, and out‑of‑pocket thresholds that govern coverage.
Key Definitions
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