Effective for dates of service beginning Jan. 1, 2024, in support of recent legislation from the State of Maine, Point32Health is making some coverage changes and associated medical policy/medical necessity guideline (MNG) updates applicable to Harvard Pilgrim commercial members in Maine.
Assisted reproductive technology services: new MNG
In response to the recent Maine mandate entitled “An Act to Provide Access to Fertility Care” (H.P. 1144 – L.D. 1539), we’ve developed dedicated Medical Necessity Guidelines for Assisted Reproductive Technology Services – Maine Products.
Similar to the existing Massachusetts and New Hampshire versions, the MNG outlines coverage effective Jan. 1 for Harvard Pilgrim members residing in Maine or with a Maine plan for assisted reproductive technology.
Prior authorization will be required, and coverage will be granted based on the criteria specified on the MNG. These services may also be covered when:
- The member is unable to conceive as an individual due to the lack of necessary gametes for conception
- The member is unable to conceive with a partner due to the lack of necessary gametes for conception
- The member or the member’s partner is at an increased risk of transmitting a serious inheritable genetic or chromosomal abnormality to a child
For complete information, please refer to the new Assisted Reproductive Technology Services – Maine Products MNG.
Coverage of an additional prosthetic device
In accordance with Maine House Bill 1003 (An Act to Improve Outcomes for Persons with Limb Loss), Point32Health will cover an additional prosthetic device for sports or recreational use for eligible Harvard Pilgrim commercial members residing in Maine or with a Maine plan.
This coverage will apply for members under age 18 who require an additional prosthetic device for sports or recreational use, and coverage will be offered for the most appropriate model for medical necessity. Devices considered experimental/investigational will not be covered.
Harvard Pilgrim’s commercial Lower Limb Prostheses Medical Policy, Upper Limb Prostheses Medical Policy, and Orthotic and Prosthetic Devices Payment Policy have been updated to reflect this change in coverage.
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