[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-403263-105":3,"detail-sidebar-cat-0-en-105":81,"doc-detail-403263-en":130},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","cost-effective-alternative-services-in-lieu-of-effective-july-6-2016","Cost Effective Alternative Services (In Lieu of) - Effective July 6, 2016","","Cost Effective Alternative Services (In Lieu of) describe how Medicaid Managed Care Organizations (MMCOs) may offer medically appropriate, cost effective alternative services and settings that are not covered under the Medicaid State Plan. Effective July 6, 2016, MMCOs can propose “in lieu of services (ILS)” for State Approved or State Identified ILS categories, subject to State and CMS approval. Requirements cover enrollee and MMCO voluntariness, clinical target criteria, cost benefit calculation, limits on prohibited expenditures, contract amendment and public posting, consistent provider processes, encounter tracking, cost reporting, and termination and continuity of care rules.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/cost-effective-alternative-services-in-lieu-of-effective-july-6-2016/403263/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/cost-effective-alternative-services-in-lieu-of-effective-july-6-2016/403263.png","ImageObject",300,407,{"name":42,"@type":43},"noah","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-31","2026-09-27",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What are Cost Effective Alternative Services (In Lieu of) and when do they take effect?","Question",{"text":63,"@type":64},"They are alternative services or settings not included in the Medicaid State Plan but offered as medically appropriate, cost effective substitutes. The regulations take effect July 6, 2016.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does an MMCO offer ILS, and what approvals are required?",{"text":68,"@type":64},"The MMCO must apply to the State, obtain State and CMS approval, and demonstrate required conditions under the cited federal provisions. The proposed ILS must be added to the MMCO contract and reviewed and approved by CMS before implementation.",{"name":70,"@type":61,"acceptedAnswer":71},"Are enrollees required to use ILS instead of State Plan services?",{"text":72,"@type":64},"No. ILS are voluntary for enrollees; an MMCO cannot require an enrollee to use ILS in place of a State Plan covered service or setting, though it may offer options when medically appropriate and cost effective.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},403263,1790673660,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},9,"Religion & Spirituality",20,"religion-spirituality",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":121,"show_sort_weight":118,"slug":122},"World Cup","world-cup",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":55,"slug":125},"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":97,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":139,"language":140,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":12,"update_tm":144,"read_time":113,"preview_page_count":4},1099529839121,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Cost Effective Alternative Services (In Lieu of)  \nEffective July 6, 2016, federal regulations allowed and clarified the use of cost effective alternative services that are approved by the New York State (NYS or State) to be offered by Medicaid Managed Care Organizations (MMCOs) . These regulations encourage innovation and promote efficiency and quality by enabling MMCOs to offer their enrollees physical and behavioral health services that are not covered under the Medicaid State Plan.  \nMMCOs may, as a cost effective alternative to Medicaid State Plan services and settings, provide Medicaid Managed Care enrollees with alternative services and settings as permitted by 42 CFR  \n438.3(e)(2) and approved by the State and the Centers for Medicare and Medicaid Services (CMS) . These cost effective alternative services are often referred to as “in lieu of services” (ILS) . The cost of such services must be included in the development of the MMCO rates.  \nILS are defined as alternative services or settings that are not included in the Medicaid State Plan but are medically appropriate, cost effective substitutes for covered services or settings.1 “State Approved ILS” means ILS proposed by an MMCO that has been approved by the State. “State Identified ILS”means ILS that has been identified by the State as appropriate ILS for the Medicaid Managed Care program. Both State Approved and State Identified ILS will be posted on State agency websites.  \nRequirements for ILS Provision:  \n• MMCOs may not provide ILS pursuant to 42 CFR 438 .3(e)(2) without first applying to the State, obtaining State and CMS approval to offer the ILS, and demonstrating all of the following requirements will be met. Pursuant to 42 CFR 438 .3(e)(1), MMCOs may voluntarily agree to provide any service to an enrollee outside of an approved ILS construct, however the cost of such voluntary services may not be included in determining State premium rates.  \no Voluntary for Enrollee: A MMCO cannot require an enrollee to use an ILS instead of a State Plan covered service or setting but can offer enrollees the option of such services when doing so would be medically appropriate and cost effective.  \no Voluntary for MMCO: It is a MMCO’s option to offer ILS. A MMCO may apply to the State for approval if it chooses to provide an ILS.  \no Proposals for ILS must demonstrate that the alternate services are medically appropriate and cost effective. The plan is responsible to calculate the cost benefit analysis.  \no Proposal must clinically define target population and criteria for the alternate  \nservice(s) .  \n1 42 CFR 438 .3(e)(2), [https://www.ecfr.gov/cgi](https://www.ecfr.gov/cgi) bin/text   \nidx?SID=b91d306244cadc49c856f6b4539ec2b5&mc=true&node=se42 .4.438_ 13&rgn=div8 .  \no ILS may not include expenditures that are prohibited by CMS, such as training or equipment for law enforcement and room and board.2  \no ILS must be approvable through a State plan amendment authorized through the Social Security Act, including sections 1905(a), 1915(i), or 1915(k) of the Social Security Act, or a waiver under section 1915(c) of the Social Security Act.  \no The MMCO shall comply with all applicable requirements contained within the Medicaid  \nManaged Care/ Family Health Plus/ HIV Special Needs Plan/ Health and Recovery Plan Model Contract, including section 10.43 Cost Effective Alternative Services.  \n• Once the State approves an ILS application for an MMCO:  \no The ILS must be added to the MMCO’s Medicaid Managed Care contract (amendment to Appendix M), which must be reviewed and approved by CMS prior to implementation.  \no The ILS will be posted on State agency websites as a State Approved ILS.  \no The cost and utilization of ILS will be factored into the medical portion of the MMCO’s rates.  \no MMCO must inform enrollees of new ILS benefits and must post approved ILS publicly, including on MMCO website and in an updated member handbook or member handbook insert.  \no The MMCO will be re","cbCaibZ85boYUC56","https://ap.wps.com/l/cbCaibZ85boYUC56","pdf",418287,12,"English","# Cost Effective Alternative Services (In Lieu of)\n## Definition and purpose of ILS\n## Requirements for ILS provision\n## Post-approval contract, posting, and rate factors\n## Termination of ILS","[{\"question\":\"What are Cost Effective Alternative Services (In Lieu of) and when do they take effect?\",\"answer\":\"They are alternative services or settings not included in the Medicaid State Plan but offered as medically appropriate, cost effective substitutes. The regulations take effect July 6, 2016.\"},{\"question\":\"How does an MMCO offer ILS, and what approvals are required?\",\"answer\":\"The MMCO must apply to the State, obtain State and CMS approval, and demonstrate required conditions under the cited federal provisions. The proposed ILS must be added to the MMCO contract and reviewed and approved by CMS before implementation.\"},{\"question\":\"Are enrollees required to use ILS instead of State Plan services?\",\"answer\":\"No. ILS are voluntary for enrollees; an MMCO cannot require an enrollee to use ILS in place of a State Plan covered service or setting, though it may offer options when medically appropriate and cost effective.\"}]","Cost Effective Alternative Services (In Lieu of) - Effective July 6, 2016 | PDF",1790538445]