Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SCHOOL-BASED  HEALTH  CENTERS 
AND  MANAGED  CARE: 
EXAMPLES  OF  COORDINATION 
DECEMBER  1993  OFFICE OF INSPECTOR GENERAL 
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REGION V  HEADQUARTERS 
JosephL.Penkrot( ProjeLceta
 der)  MaryBethClarke

EllenR
.Meara(LeadAnalyst)

JeffreJy.D
 onarski
 Department  of Health and Human Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SCHOOL-BASED  HEALTH  CENTERS  AND

MANAGED  CARE:

EXAMPLES  OF  COORDINATION 
DECEMBER  1993  05-92-00681
 TABLE  OF  CONTENTS 
PAGE 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

ExAMPm  . . . . . . . ..  o........  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

Multnomah  County,  Oregon...  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


St. Paul,  Minnesota  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6

.Baltimore,  Maryland  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7

Minneapolis,  Minnesota  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11

Brooklyn,  New York  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13

Hillsborough  County,  Florida..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...15

.San  Francisco,  California  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...18

APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  A-l 
AOregon  Senate  Bi11760 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  A-1

B  Contract  Between  Multnomah  County  and  Good  Health  Plan  . . . . . . . . . . . .  B-1

(2  Contract  Between  Health  Start  and  RamseyCare  . . . . . . . . . . . . . . . . . . . ..C-1
 INTRODUCTION 
PURPOSE 
The  purpose  of this report  is to describe  a variety  of ways school-based  health  centers 
coordinate  services  with managed  care  providers.  The  examples  described  here  were 
found  while  collecting  data  for our  report,  School-basedHealth Centersand Managed 
Care,  0EI-05-92-O0680.  That  report  examined  the  relationship  between  school-based 
health  centers  and  managed  care  providers. 
BACKGROUND 
Both  school-based  health  centers  and  managed  care  were  created  to increase  access  to

health  care  services.  Some  managed  care  providers  recognize  the  special  expertise

school-based  health  centers  can  provide  to meet  the  compelling  health  needs  of

adolescents.  A number  of these  managed  care  providers  have  entered  into

agreements  with school-based  health  centers  so adolescents  covered  by their  plan  have

the  advantages  of medical  treatment  at both  sites.

This  report  describes  seven  examples  of coordination  between  school-based  health

centers  and  managed  care  providers.  In our  earlier  report,  after  we reviewed  current

literature  and  consulted  with  experts  on this topic,  we visited  all known  sites where

coordination  exists.  During  on-site  visits we used  in-depth,  structured  personal

interviews  with representatives  from  the  school-based  health  centers  and  managed

care  providers.  The  seven  examples  cited  here  represent  different  methods  of

coordination.  Because  agreements  are  new and  still being  developed,  this report  does

not  represent  a comprehensive  list of agreements  between  managed  care  providers

and  school-based  health  centers.  Nor  does  it address  all operational  and  policy

related  questions  which  present  themselves  in discussions  of this topic,  such  as the

appropriateness  of funding  streams  between  managed  care  organizations  and  school-

based  health  centers.  For  further  background  information  on school-based  health

centers  and  managed  care,  consult  the  companion  report,  School-basedHealth

Centersand Managed Care.

The  level  of coordination  between  managed  care  providers  and  school-based  health

centers,  where  it exists at  all, varies  widely across  the  country.  The  agreements

described  in this report  represent  cooperation  at different  points  along  a spectrum,

ranging  from  school-based  health  centers  being  reimbursed  for all services  they

perform  for managed  care  plan  children,  to school-based  health  centers  needing  prior

authorization  from  a managed  care  plan  before  providing  a very limited  number  of

services.  Managed  care  plans  and  school-based  health  centers  are  still evolving;

agreements  between  them  are  embryonic.

1
 As health  care  reform  takes  shape,  it is crucial  to examine  how these  two types  of 
medical  providers  coordinate.  Both  managed  care  and  school-based  health  centers 
have  important  roles  in providing  universal  access  to health  care  services. 
2
 EXAMPLES

For  each  example,  we describe  the  community  where  the  agreement  originated,  the 
conditions  that  promoted  coordination,  and  the  mechanism  for coordinating. 
Mtitnomah County,Oregon:  State  law requiring  Medicaid  managed  care  providers  to 
coordinate  with  school-based  health  centers 
St. Pad  Minnesotix Legal  contract  between  managed  care  provider  and  school-based 
health  center 
Baltimore,Maryland  Protocol  for referral  and  treatment  between  managed  care 
provider  and  school-based  health  center 
Minneapolis,Minnesota: Including  managed  care  providers  in coalitions  which  fund 
and  develop  school-based  health  centers 
Brooldyq New York  Publice ntititehsa tadministebro thschool-basehdealthcenters 
and managed careplans 
Hillsboro@  County,Floridz  Managed  care  providers  authorize  school-based  health 
centers  to provide  care  and  bill Medicaid  directly  for service 
San Francisco,California: Managed caregivesexpeditepda tiencta reon school-based
healthcenterreferrals 
3
 Multnomah  County,  Oregon 
Statelaw requiringMedicaidmanagedcareprovidersto coordinatewithschool-based 
healthcenters 
State  laws are  playing  a major  role  in increasing  coordination  between  school-based 
health  centers  and  managed  care  providers  in Oregon.  First,  in  1991, Oregon  enacted 
Senate  Bill 760 (SB 760) affecting  county  health  departments  and other  publicly 
supported  programs  that  provide  services  to children  and  adolescents.  (Appendix  A 
contains  a copy of SB 760.)  The  bill requires  prepaid  Medicaid  health  providers  to 
contract  with these  public  health  providers  for certain  types  of services.  Since  all 
Oregon  school-based  health  centers  are  publicly  funded,  they  are  included  under  this 
statute.  Then  in 1992, Oregon  passed  the  Oregon  Health  Plan,  a State  health  care 
reform,  setting  a February  1, 1994 deadline  for agreements  between  managed  care 
providers  and  public  health  providers. 
Under  SB 760, Medicaid  prepaid  health  plans  are  required  to pay public  health 
providers  for immunizations,  diagnosis  and  treatment  of sexually  transmitted  diseases, 
and  testing  and  treatment  of tuberculosis.  The  managed  care  providers  are  also 
encouraged  to contract  with these  providers  for maternity  case  management,  well-child 
care,  and  pre-natal  care.  Under  this law, public  health  providers  bill Medicaid  directly 
on a fee-for-service  basis  for HIV  counseling  and  family planning  services. 
In response  to SB 760 and  the  Oregon  Health  Plan,  negotiations  are  underway 
between  the  Multnomah  County  health  department  and  the  12 managed  care  plans  in 
Multnomah  County.  In addition  to the  community  based  clinics operated  by 
Multnomah  County,  the  County  also  operates  seven  school-based  health  centers. 
Services  provided  at the  school-based  health  centers  are  considered  part  of the 
Countys  primary  care  clinic system. 
While  mandated  contracts  have  begun  to open  lines of communication  between 
managed  care  providers  and  school-based  health  centers,  school-based  health  centers 
still will not  receive  reimbursement  for services  they  provide  that  are  not  specifically 
covered  by SB 760. 
One  managed  care  plan,  Good  Health  Plan  of Oregon,  has  contracted  with 
Multnomah  County  to meet  the  requirements  of SB 760.  (Appendix  B contains  a 
copy of this contract.)  Although  this fee-for-service  contract  runs  through  1993, no 
bills have  been  submitted  to the  managed  care  plan  for  any Multnomah  County 
semices  to  date.  Multnomah  County  is working  with  all managed  care  plans  to agree 
to terms  so they  may establish  common  billing  protocols,  procedures  and 
communications.  Without  this standardization,  receiving  reimbursement  from 
managed  care  plans  may result  in prohibitive  costs  to the  county. 
4
 Unlike  other  areas  where  school-based  health  centers  have  negotiated  with  managed 
care  providers,  Oregons  school-based  health  centers  face  few obstacles  when  keeping 
certain  health  care  services  confidential.  Under  Oregon  law, children  who  have 
reached  age  15 have  control  over  their  medical  care. 
5
 St. Paul,  Minnesota 
Legal contractbetweenmanagedcareproviderandschool-basedhealthcenter 
Comprehensive  school-based  health  centers  and  managed  health  care  emerged  in the 
early  1970s in St. Paul.  Today,  Health  Start,  a nonprofit  corporation,  operates  school-
based  health  centers  in six St. Paul  high schools,  seining  over  3,000 students  annually. 
Approximately  half  of the  students  treated  at the  St. Paul  school-based  health  centers 
are  covered  by Medicaid.  Health  Start  has been  a Medicaid  fee-for-service  provider 
and  obtains  a sizable  amount  of its funding  from  Medicaid  billings. 
In the  spring  of 1993, the  Minnesota  State  Medicaid  agency  required  Medicaid 
recipients  in Ramsey  County,  where  St. Paul  is located,  to choose  a managed  care 
provider.  The  State  also encouraged  Medicaid  managed  care  providers  to coordinate 
with school-based  health  centers.  By the  end  of 1994, Health  Start  estimates  that  75 
percent  of school-based  health  center  enrollees  will be  covered  by managed  care 
plans. 
Anticipating  the  considerable  impact  Medicaid  managed  care  would  have  on their 
ability  to continue  providing  sexvices and  the  reduction  in their  largest  funding  stream, 
Health  Start  began  negotiations  with RamseyCare,  the  largest  Medicaid  managed  care 
provider  in Ramsey  County.  Both  parties  agreed  to a contract  that  made  the  school-
based  health  centers  primary  care  clinic providers  and  care  coordinators  for 
adolescents  enrolled  in RamseyCare.  (Appendix  C contains  a copy of this contract.) 
Under  the  contract,  RamseyCare  reimburses  Health  Start  on a fee-for-semice  basis, 
using Medicaid  reimbursement  rates  plus  15 percent.  Health  Start  also bills 
RamseyCare  for Early,  Periodic,  Screening,  Diagnostic,  and  Treatment  (EPSDT) 
services  provided  to patients. 
This  contract  allows Health  Start  to receive  reimbursement  for confidential  services 
the  school-based  health  centers  provide  (e.g. mental  health  sexvices).  In the  past,  the 
school-based  health  centers  would  not  bill certain  services  to Medicaid  because  of the 
Medicaid  requirement  to noti~  the  parents  by an  explanation  of benefits  of services 
provided  to their  children.  This  requirement  had  the  potential  to inhibit  students  from 
using services,  so the  school-based  health  centers  chose  not  to bill for  these  services. 
Medical  information  is exchanged  between  Health  Start  and  RamseyCare.  The 
school-based  health  centers  provide  medical  information  to RamseyCare  through  their 
billing  for services.  In addition,  RamseyCare  must  give prior  authorization  for  all 
specialty  semices.  In turn,  RamseyCare  notifies  their  primary  care  clinics whenever 
emergency  room  visits are  used. 
Quality  of care  is also  addressed  in the  contract.  Health  Start  school-based  health 
centers  participate  in RamseyCare  quality  assurance  and  utilization  review  programs. 
6
 Baltimore.  Maryland 
Protocolfor referralandtreatmentbetweenmanagedcareproviderand school-based 
healthcenter 
The  Baltimore  City Health  Department  began  operating  school-based  health  centers 
in 1985.  It now operates  7 of the  10 school-based  health  centers  in middle  and  high 
schools  throughout  the  city.  The  centers  provide  a range  of primary  and  preventive 
care  aimed  at improving  primary  care  for children,  promoting  positive  health 
behaviors,  and  increasing  health  knowledge  and  decision  making  skills.  The  full time 
staff  at most  school-based  health  centers  includes:  a nurse  practitioner,  a school  nurse, 
a mental  health  counselor,  a health  educator,  a medical  office  assistant,  and  a health 
aid.  Part  time  staffing  includes  supervisory  physicians,  additional  nurse  practitioners, 
substance  abuse  counselors,  case  managers,  social  workers,  and  nutritionists. 
As part  of services  delivered  at the  Baltimore  school-based  health  centers,  case 
managers  help  students  make  appointments  with primary  care  providers  for EPSDT 
screenings.  Many  children  are  enrolled  in both  a managed  care  program  and  a 
school-based  health  center.  When  the  case  managers  noticed  that  some  children  with 
managed  care  providers  waited  as much  as 6 months  for appointments,  the  school-
based  health  centers  began  providing  EPSDT  services  to students  assigned  to managed 
care  providers. 
In the  school-based  health  centers,  an  increasing  number  of children  changed  from 
fee-for-service  Medicaid  to managed  care  Medicaid.  Many  of the  students  the  school-
based  health  centers  were  treating  belonged  to Total  Health  Care,  a managed  care 
plan  operated  by a federally  funded  community  health  center.  The  school-based 
health  centers,  which  had  always provided  sexvices to some  of these  children,  initiated 
a relationship  with Total  Health  Care  to become  a sub-contractor  providing  EPSDT 
exams  for students  who were  not  using Total  Health  Care.  At first,  this was a 
contentious  issue  because  Total  Health  Care  viewed  this as the  school-based  health 
centers  taking  patients  away from  their  medical  home.  They  saw it as a threat  to 
continuity  of care.  Eventually,  both  providers  met  and  worked  out  an informal 
agreement  on how the  Total  Health  Care  enrollees  should  be  treated. 
The  agreement  defines  when  the  school-based  health  centers  should  see  patients  and 
when  they  should  be  referred  to Total  Health  Care.  They  devised  a referral  process 
with  a flow chart  outlining  different  situations  students  may present  and  what  actions 
should  be  taken  by the  school-based  health  center.  The  flow chart  on the  following 
page  gives detail  about  how and  where  Total  Health  Care  students  receive  semices 
depending  on the  situation.  In a letter  of agreement  to the  Baltimore  Health 
Department,  Total  Health  Care  guaranteed  reimbursement  at Medicaid  rates  for 
authorized  semices  provided  in school-based  health  centers. 
7
 CLIENTS

BALTIMORE  CITY HEALTH  DEPARTMENT  SBHCS & TOTAL  HEALTH  CARE HMO 
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THC Medical Recmh  Under  the  agreement,  the  school-based  health  centers  recognize  the  managed  care 
provider  as the  medical  home  for the  child.  The  school-based  health  centers  try to 
arrange  for students  to receive  care  at Total  Health  Care.  When a Studenthas an 
acute  care  need,  the  nurse  practitioner  at the  school-based  health  center  calls Total 
Health  Cares  clinical  tracking  department  to try to arrange  for an appointment.  If 
Total  Health  Care  cannot  see  the  student  the  same  day, the  school-based  health 
center  is authorized  to provide  the  treatment  needed. 
For  regular  EPSDT  screenings,  if the  student  has never  been  to Total  Health  Care, 
the  school-based  health  center  performs  the  screening  and  sends  a copy of the 
information  to Total  Health  Cares  records  department.  The  school-based  health 
centers  learn  which  students  have  never  been  to Total  Health  Care  by sending  a 
computer  file with  students  registered  for the  school-based  health  centers  to Total 
Health  Care  and  having  Total  Health  Care  indicate  which  ones  are  members,  and 
which  of these  have  never  been  to Total  Health  Care.  In all other  instances,  Total 
Health  Care  performs  EPSDT  screenings.  The  school-based  health  centers  facilitate 
these  EPSDT  screenings  by making  appointments  for students  to be  screened  and  by 
sending  appointment  reminders  home  with  students. 
Whenever  the  school-based  health  center  provides  any service  to  a student  enrolled  in 
Total  Health  Care,  they  must  send  a bill for the  service  and  a medical  report  to be 
included  in Total  Health  Care  records.  This  helps  preserve  the  continuity  of care  for 
patients. 
In addition  to authorizing  and  reimbursing  the  school-based  health  centers  for services, 
Total  Health  Care  has  several  responsibilities  under  the  agreement.  When  scheduling 
appointments,  Total  Health  Care  gives priority  to students  referred  by the  school-
based  health  centers.  When  Total  Health  Care  sees  a patient  referred  by the  school-
based  health  centers,  a referral  form  is sent  back  to the  school-based  health  centers  to 
confirm  that  the  student  has  completed  the  referral. 
Both  Total  Health  Care  and  the  Baltimore  Health  Department  said  that  the  biggest 
barrier  they  had  to overcome  before  reaching  an agreement  was who would  have 
ownership  of the  patient.  At first, the  school-based  health  centers  did not  want  to 
recognize  the  managed  care  provider  as the  medical  home  for students.  At  the  same 
time,  Total  Health  Care  felt  they  should  be  responsible  for all care  of each  patient. 
They  looked  at visits to the  school-based  health  centers  as out-of-plan  utilization,  and 
did not  want  to authorize  screenings  or reimburse  the  centers  for the  bills submitted 
despite  their  long delays  in scheduling  EPSDT  screenings.  Each  provider  had  to 
develop  a mutual  respect  for the  other  and  see  how the  other  was concerned  for the 
patients. 
9
 One  way that  Total  Health  Care  and  the  Baltimore  Health  Department  are 
developing  a mutual  understanding  is through  special  events  that  expose  each  provider 
to the  other  and  teach  students  how to use services.  The  school-based  health  centers 
held  an educational  session  for all Total  Health  Care  physicians  to explain  school-
based  health  centers.  ~eyintited  physicians  tothehealth  center  site  andaUowed 
them  toseehow  andwhere  their  patients  would  retreated.  Theschool-based  health 
centers  sponsor  field  trips  to Total  Health  Care  for students  who have  never  been  to 
their  clinics before.  The  students  are  transported  to the  Total  Health  Care  clinics by 
bus,  and  Total  Health  Care  teaches  them  how to access  the  clinics, provides  lunch, 
gives a tour,  and  allows students  to meet  the  doctors.  Parents  may also join  this trip 
to Total  Health  Care. 
Duringthefirs5tm onthsoftheagreementT,o talHealthCarereimbursedt
he

BaltimorHee althDepartmentfor120EPSDT visitsT.h eyalsowillr eimburset
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fortheBaltimores chool-basehde althcentersI.n additiotno thisc,o ordinatihoans
 

improvedcontinuiotfyc aretostudentwsh o normallyw
ouldnothaveit.

Wliile  the  agreement  between  Total  Health  Care  and  Baltimores  Health  Department 
allows students  to receive  EPSDT  screening  at  the  school-based  health  centers,  it 
cannot  address  many  other  issues  regarding  the  school-based  health  centers  and 
managed  care  providers.  The  agreement  covers  a limited  number  of services,  omitting 
issues  such  as how confidential  reproductive  health  services  should  be  delivered  by 
school-based  health  centers.  It does  not  address  how services  other  than  EPSDT 
should  be  reimbursed,  and  State  Medicaid  managed  care  contracts  are  unclear  on this 
issue,  creating  dispute  over  which services  should  be  reimbursed  and  at what  rates. 
Also,  the  agreement  applies  only to interaction  with Total  Health  Care.  It cannot 
address  how the  school-based  health  centers  coordinate  with other  managed  care 
providers  in the  Baltimore  area. 
Even  with an  agreement,  Baltimore  school-based  health  centers  still face  barriers 
providing  services  to students  who need  them,  collecting  reimbursement  for these 
services,  and  keeping  patient  information  confidential. 
10
 Minneawlis.  Minnesota 
Includingmanagedcareprovidersincoalitionswhichfundand developschool-based 
healthcenters 
The  Minneapolis  Board  of Education  established  school-based  health  centers  in their 
high schools  14 years  ago.  Today  these  school-based  health  centers  serve  over  10,000 
students.  Hennepin  County,  the  city of Minneapolis,  the  Minneapolis  Childrens 
Medical  Center,  the  University  of Minnesota,  the  Robert  Wood  Johnson  Foundation, 
Maternal  and  Child  Health  block  grants,  and  the  local  health  department  provide 
major  funding  for the  school-based  health  centers. 
There  is broad  based  community  support  for the  Minneapolis  school-based  health 
centers.  Four  health  care  agencies  are  major  medical  sponsors  for the  school-based 
health  centers,  providing  medical  staff and  other  support.  In addition  to these 
sponsors,  numerous  other  agencies  co-locate  staff in the  school-based  health  centers. 
The  Minneapolis-St.  Paul  area  is home  to a very competitive  managed  care  market. 
As Minnesota  Medicaid  expanded  managed  care  into  Hennepin  County,  Medicaid 
recipients  were  required  to choose  a managed  care  plan  for themselves  and  their 
children.  Forty  percent  of the  school-based  health  center  patients  are  Medicaid 
managed  care  patients.  Of the  managed  care  plans,  Medics,  a primary  care  case 
manager  plan,  currently  covers  approximately  70 percent  of the  Minneapolis  Medicaid 
enrollees. 
In recent  years,  some  of the  school-based  health  centers  sponsoring  agencies 
attempted,  without  success,  to bring  together  all involved  in adolescent  health  to 
discuss the  role  of school-based  health  centers  in the  community  and  to obtain 
additional  funding  or support.  But in 1992, Medics  performed  a utilization  study  of 
their  members  and  found  that  adolescents  were  not  receiving  many  primary  care 
services  from  Medics  providers.  In February  1993, school-based  health  centers  and 
their  community  sponsors  began  negotiating  with Medics  and  other  managed  care 
providers  to address  school-based  health  centers  providing  services  to adolescents 
covered  by managed  care  providers. 
As a result  of these  meetings,  Medics,  through  a foundation,  is underwriting  the  full 
cost  of the  Minneapolis  school-based  health  center  at Southwest  High  School  for a 
year.  During  this year,  this school-based  health  center  will not  bill Medics  for any 
treatments  provided  to children  enrolled  with  Medics. 
The  other  managed  care  plans  are  collaborating  with  the  school-based  health  center 
program  and  are  considering  pledging  $1 million  to fund  the  other  Minneapolis  school-
based  health  centers.  By November  22, 1993, these  managed  care  providers  will 
announce  their  contributions  to this effort.  In the  interim,  Medics  is providing  an 
additional  $110,000  to keep  the  school-based  health  centers  operating. 
11
 After  thisschoolyear,Medics andtheothermanagedcareproviderswillevaluate 
theirexperiencesand collaboratewithschool-basedhealthcentersto decidewhich 
healthsewicesshouldbe deliveredinschool-basedhealthcentersandwhichsemices 
shouldbe deliveredelsewhere. 
12
 Publicentitiesthatadministerboth school-basedhealthcentersand managedcare 
plans 
We visited  three  communities  where  federally  funded  community  health  centers 
operate  school-based  health  centers  as well as managed  care  plans.  To  illustrate  this 
example,  we will discuss  one  of these  community  health  centers,  the  Sunset  Park 
Family  Health  Center  of Lutheran  Medical  Center  in Southwest  Brooklyn,  New York. 
Sunset  Park  Family  Health  Center  is a federally  funded  community  health  center  that 
operates  10 school-based  health  centers  in elementary  and  middle  schools  in the 
Brooklyn  area.  They  also provide  an array  of community-based  outreach  and 
education  programs,  a mental  health  and  substance  abuse  program,  and  two satellite 
health  centers  in Brooklyn.  They  have  incorporated  their  school-based  health  centers 
into  the  overall  system  at Sunset  Park. 
The  school-based  health  centers  serve  large  numbers  of Medicaid  eligible  children. 
Sunset  Park  Family  Health  Center  bills about  41 percent  of the  visits to the  school-
based  health  centers  to Medicaid.  Sunset  Park  recently  started  Health  Care  Plus,  a 
managed  care  plan  for Medicaid  clients,  and  students  enrolled  in Health  Care  Plus 
may choose  a school-based  health  center  as a primaxy  care  provider. 
When school-based  health  centers  are  the  primary  care  providers  for students,  they 
need  no authorization  to treat  patients  enrolled  in Health  Care  Plus,  and  they will be 
reimbursed  through  Sunset  Park  for the  services  provided.  Because  the  school-based 
health  centers  are  part  of the  managed  care  network  continuity  of care  is not  an issue 
for these  students. 
Until  recently,  Sunset  Park  faced  barriers  to integrating  the  school-based  health 
centers  into  their  managed  care  network.  One  problem  Sunset  Park  had  to address 
was how to ensure  that  other  providers  in the  Family  Health  Center  network  could 
access  patient  information  when  necessary.  Sunset  Park  has  created  a database  system 
that  should  address  this issue.  An Active  Patient  Identification  System  contains 
demographic  information  and  visit histories  on all patients  using any of the  Sunset 
Park  Family  Health  Center  facilities,  including  the  School  Health  Program.  The 
school-based  health  centers  are  electronically  linked  to this system,  so that  visit 
information  is available  network-wide. 
While  this arrangement  has potential  benefits  for children  enrolled  in Health  Care 
Plus, Sunset  Park  still faces  many  obstacles  to treating  children  at  school-based  health 
centers.  For  example,  parents  may not  understand  that  they  can  choose  their  childs 
school-based  health  center  as the  primary  care  provider  in Health  Care  Plus.  If 
parents  do not  choose  the  school-based  health  centers  as a primary  care  provider  for 
13
 their  children,and thechildrenreceivecareat theschool-basedhealthcenter, 
reimbursementisnotprovidedandcoordinationof carebecomesmore difficult. 
Another  drawback  to this  arrangement  is that  it does  not  address  how or whether  the 
school-based  health  centers  treat  students  enrolled  in other  managed  care  plans. 
Because  Sunset  Park  runs  a managed  care  program,  other  managed  care  providers  see 
Sunset  Park  as a competitor  for patients.  This  impedes  coordination  with  other 
managed  care  providers  whose  enrolled  patients  receive  services  at the  school-based 
health  centers. 
14
 Hillsborowh  County.  Florida 
Managed careprovidersauthorizeschool-basedhealthcentersto providecareandbill 
Medicaid directlyfor seMce 
Several  States  told  us that  some  managed  care  providers  authorize  school-based  health 
centers  to provide  services  to children  enrolled  with  managed  care  providers.  One  site 
we visited,  the  Hillsborough  County  Public  Health  Unit  in Tampa,  Florida,  sponsors 
several  school-based  health  centers  that  serve  many  children  enrolled  with  managed 
care  providers.  The  Hillsborough  County  Public  Health  Unit  recently  began  to seek 
authorization  to perform  EPSDT  screening  and  limited  sexvices on managed  care 
enrolled  students  who  are  registered  at their  health  centers. 
The  State  of Floridas  Department  of Health  and  Rehabilitation  Semites  awards  over 
$9 million  in Supplemental  School  Health  Grants  to  192 schools  throughout  Florida. 
This  grant  program  provides  funds  for school  health  projects  at nine  Hillsborough 
county  schools  at  the  elementary,  middle,  and  high school  level.  Four  of these 
schools  deliver  services  through  on-site  school-based  health  centers.  This  program, 
called  the  Healthy  Student  and  Healthy  Young  Student  program  sexves two high 
schools,  one  middle  school,  and  one  alternative  school  for pregnant  teenagers.  The 
Hillsborough  County  Health  Department  manages  the  project  with  close  cooperation 
from  the  Hillsborough  County  School  System. 
The  schools  involved  in this program  share  three  mental  health  therapists,  a clinic 
nurse,  a nurse  practitioner,  a community  health  nurse,  a nutritionist,  health  aides,  a 
program  manager,  and  a physician.  These  professionals  deliver  a range  of services, 
including:  triage  for medical  injuries  and  illness, health  education  and  counseling, 
mental  health  assessment  and  counseling,  injury  prevention,  pregnancy  counseling 
semices,  and  baby  and  mother  semices.  The  alternative  school  for pregnant  teenagers 
provides  all pre-natal  and  post-partem  care  for its enrolled  students  and  their  newborn 
babies  up to 6 weeks  following  the  birth. 
The  project  is funded  primarily  through  the  Supplemental  School  Health  Grants,  but 
school-based  health  centers  also receive  in-kind  contributions  of staff from  the  County 
Health  department.  The  County  Public  Health  Unit  bills for Medicaid  services 
provided  at the  school-based  health  centers.  The  County  Public  Health  Unit  has set  a 
goal for school-based  health  centers  to provide  EPSDT  screenings  to all Medicaid 
eligible  students  in these  schools. 
To  ensure  that  all children  are  screened,  the  school-based  health  centers  are  trying  to 
obtain  authorization  to screen  those  children  enrolled  with Medicaid  managed  care 
providers.  Without  an authorization  number,  however,  any service  the  school-based 
health  centers  provide  to Medicaid  children  enrolled  in managed  care  plans  will not  be 
reimbursed  by Medicaid.  Due  to time  constraints  and  the  priority  of screening  eligible 
15
 students,  the  school-based  health  centers  are  focusing  authorization  efforts  on EPSDT 
services. 
Students  registering  for school-based  health  centers  must  indicate  if they  are  Medicaid 
eligible.  If eligible,  the  school-based  health  centers  ask students  to supply  their 
Medicaid  identification  number.  Using  the  Medicaid  identification  number,  or in some 
cases  the  childs name  and  supporting  information,  the  county  public  health  unit 
generates  printouts  of the  Medicaid  eligible  children  and  their  primary  care  providers. 
The  school-based  health  centers  then  separate  out  those  who  are  assigned  to a 
Medipass  provider  (Floridas  managed  care  Medicaid  plan  for individual  physicians  to 
become  primary  care  providers),  or to a managed  care  health  plan. 
When  a student  assigned  to a managed  care  provider  needs  an EPSDT  screening,  staff 
from  the  Hillsborough  county  school-based  health  centers  call the  primary  care 
provider  for that  student.  They  explain  that  the  health  center  will perform  the 
screening  and  request  an  authorization  number  so that  they  may bill Medicaid  for  the 
service.  If the  physician  agrees,  the  county  public  health  unit  receives  an  authorization 
number  for that  particular  service  and  performs  the  screening.  The  school-based 
health  centers  can  then  bill Medicaid  for the  service  through  the  county  public  health 
unit  and  be  reimbursed  at  the  regular  Medicaid  rate  for EPSDT. 
Sometimes,  the  county  public  health  unit  does  not  have  time  to receive  pre-
authorization  for screenings.  In these  cases,  they  perform  screenings  on children  who 
need  them  and  bill Medicaid  for the  sexvice.  These  Medicaid  bills will be  rejected  or 
accepted  based  on whether  the  managed  care  provider  authorizes  the  sexvice.1 
The  county  public  health  unit  also has billed  Medicaid  for pregnancy  related  semices 
provided  at the  alternative  school.  Using  the  same  process  as with the  EPSDT 
screening,  the  school-based  health  center  calls the  primary  care  provider  to authorize 
care.  Usually,  the  primary  care  provider  will authorize  the  school  to provide 
pregnancy  related  services  to this hard  to reach  population.  In this case,  the  school-
based  health  centers  are  reimbursed  at  the  regular  Medicaid  rate  for a pregnancy. 
The biggesbta rriertso thistypeofcoordinatihoanv ebeenovercomingt
he

competitivnea tureofmanagedcare,a ndtheschool-basehde althcentersla
ckoftime

toobtainauthorizatitoonp rovideserviceF.o rprovidertso
 make money,theymust

providesetices.By authorizisnogm eoneelsetodelivesre rvicteo theirp atienttsh,e
 y

potentiallloys esome income,andtheymay feelthatinthelongrun,theywilllo
se 
patients.  This  issue  makes  some  primary  care  providers  reluctant  to authorize  the 
school-based  health  centers  to provide  care.  The  other  barrier  is that  calling  for 
4 
I  Since Hilfaborough County started  requesting authorization  for EPSDT screening, obtaining authorization  haa 
beeome more difficult beeauae the State Medieaid agency no longer accepts authorization  for aeMcea after they have been 
provided.  This need to pre-authorize  aemieea will delay a childs screening or force the school-baaed health centers to perform 
screening without reimbursement  when there is no time to obtain authorization  numbers before delivering amvkes. 
16
 authorization  of care  is time-consuming,  particularly  in schools  where  only a few staff 
members  run  the  school-based  health  centers. 
Hillsborough  county  says they  have  been  able  to build  the  trust  of managed  care 
providers  in many  cases  because  the  physician  who works  at the  school-based  health 
centers  is well-known  and  respected  in the  community. 
The  issue  of time  constraints  continues  to be  a problem,  but  Hillsborough  county  tries 
to address  this by prioritizing  their  calls to managed  care  providers.  The  County 
Public  Health  Unit  calls physicians  they  have  worked  with before,  or physicians  who 
will be  more  likely to authorize  service  first.  They  still screen  all the  students  who 
need  it, regardless  of insurance  status.  But, by prioritizing  their  calls, school-based 
health  centers  maximize  the  reimbursement  they will receive  for performing  EPSDT. 
The  arrangement  is helpful  because  it allows the  schools  to serve  students  enrolled  in 
managed  care  conveniently,  and  the  school-based  health  centers  are  reimbursed  for 
services  that  have  gone  uncompensated  in the  past. 
17
 San Francisco.  California 
Managed caregivesexpeditedpatientcareon school-basedhealthcenter  referrals 
Balboa  Teen  Health  Center  was established  in  1986 in cooperation  with  the 
Department  of Public  Health  and  the  San Francisco  Unified  School  District.  Since 
opening,  Balboas  Teen  Health  Center  has provided  a full range  of primary  care, 
including  routine  examinations,  acute  care,  mental  health  programs,  health  education, 
and  other  semices.  All services  are  provided  confidentially  and  at no charge  to Balboa 
High  School  students,  regardless  of their  insurance  status.  The  only requirement  for 
treatment  is that  parents  sign a blanket  waiver  consenting  to services  when  enrolling 
children  at the  school-based  health  center. 
As part  of a baseline  budget  for childrens  programs  established  by proposition  J, 
Californias  Childrens  Budget  Initiative,  Balboa  Teen  Health  Center  receives  funding 
from  the  local  health  department.  This  funding  was intended  to cover  Balboa  Teen 
Health  Centers  financial  needs  for  10 years;  however,  recent  budget  difficulties  have 
threatened  the  stability  of this funding  source.  In addition  to these  funds,  the  State  of 
California  recently  authorized  Balboa  Teen  Health  Center  to bill for services  provided 
to students  enrolled  in Medi-Cal,  Californias  Medicaid  program.  However,  none  of 
the  San Francisco  area  managed  care  providers  authorize  Medi-Cal  to reimburse 
Balboa  Teen  Health  Center  for services  it provides  to their  patients. 
Many ofthestudentast BalboaHighSchoolareinsuredw
ithKaiserPermanence,

eitheprr ivateloyr throughtheMedi-Calprogram.Inaneffortto
 supplementits

healthcarecapabilitaineds toguaranteceo ntinuiotfyc are,B
alboaTeen Health

Centerhasestablishaend expediterde ferraplr ocessw
ithKaiserPermanenceforall

studentcso
 veredbythatprovider.

For  students  covered  by Kaiser  Permanence,  whether  Medi-Cal  recipients  or not,  the

Balboa  Teen  Health  Center  performs  a triage  function.  Balboa  provides  basic  primary

or acute  care  to students  who register  for the  health  center.  If follow-up  or treatment

beyond  the  capabilities  of the  Balboa  Teen  Health  Center  is necessaV,  the health

center  immediately  refers  the  student  to Kaiser  Perrnanente.  Balboa  Teen  Health

Center  telephones  the  physician  contact  at Kaiser  Perrnanente,  explains  the  problem,

and  schedules  an  appointment  for the  patient.  For  these  students,  continuity  of care  is

ensured.

Balboa  Teen  Health  Center  shares  patient  information  with Kaiser  only when

referring  students  for emergency  care,  follow-up  visits, or additional  services  not

available  at Balboa.  Although  information  is usually  shared  informally  by telephone  or

facsimile  machine,  all information  shared  outside  the  school-based  health  center  with

facilities  other  than  the  San Francisco  Department  of Public  Health  recluires  specific

patient  release  of information.

18
 There  is no formal  contract  between  the  two providers.  However,  Balboa  Teen

Health  Center  recently  drafted  a letter  to the  physician  contact  at Kaiser  Teen  Clinic

in San Francisco  to create  a more  formal  structure  for their  working  relationship.

Kaiser  has  agreed  to and  followed  the  terms  of this letter.  While  this agreement  helps

ensure  continuity  of care  for Kaiser  Permanence  patients,  it does  not  address  the

funding  issues  raised  when  school-based  health  centers  provide  uncompensated  care  to

students  enrolled  in managed  care  plans.

19
 APPENDIX  A 
OREGON  SENATE BILL  760 
A-1  -.. 
.. 
. . 
, 
ASSEMBLY-1R9e9g1ul3aers
 skn
66th OREGON LEGISLATIVE
Enrolled 
Senate  Bill  760 
Sponsored  by  SenatoKrENNEMER; Senators  BRENNEMAN,CEASE,  COHEN,  GOLD,  HAMBY, 
McCOY,  TROW,  Re  resentatiBvAeRsNES,BAUMAN,CARTER,CLARK,HAYDEN,MASON, 
McTEAGUE,MEE&, MILLER,SHIPRACK,SOWA,  STEIN  (at  the  requesotfClackamm 
County,  Coalition  of  Local  HealtOhflieiald

.. .  Z37 
CHAPTER.........-
...  .......-...
Relatitnogp overtlye vemle
dical  programs. 
Be  It Enacted  by  the  Peoploef theStateof
 Oregosx
SECIION  1.  h is  the  purpose  of this  Act  to take  advan~ge  of opportunities  tcx

(1)  Enhance  the  state   nd local  public  health  partnership

(2)  Improve  the  access  to  care   nd  health  status  of women  and  childrem   nd

(3) Strengthen  public  health  programs  and  semices  at  the  county  health  department  level.

SECIION  Z  The  Adult  and  Family  Services  Division,  the  Oflice  of  Mtilcal  Assistance  Pro-

grams  and  the  Health  Division  shall  endeavor  to develop   greements  with  local  governments  to  fa
cilitate  the  enrollment  of  poverty  level  me&cal  assistance  program  clients.  Subject  to  the 
availability  of funds  therefor,  the   greement  shall  be structured  to allow  flexibility  by the  state  and 
local  governments  and  may  allow   ny  of the  following  options  for enrolling  clients  in poverty  level 
medical  assistance  progrm. 
(1)  Initial  processing  shall  be done  at  the  county  health  department  by employees  of the  county, 
Divi
with  eligibility  determination  completed  at  the  local  orlce  of  the  Adult  and  Family  Services 
sion; 
(2)  Initial  processing  and  eligibility  determination  shall  be done   t the  county  health  department 
by employees  of the  Adult  and  Family  Services  Division:  or 
(3)  Application  forms  shaJl  be  made   vailable   t  the  county  health  department  with  initial 
processing  and  eligibility  determination  shall  be  done  at  the  local  off~ce  of  the  Adult  and  Family 
Services  Dlviaion. 
SECTION  S. To  capitalize  on  the  successful  public  health  programs  provided  by county  health 
department   nd the  sizable  investment  by state  and  local  governments  inthe  public  health  system. 
state  agencisehsa lelncourage  agreements  that  allow  county  health  departments  and other  publicly 
supported  programs  to  continue  to  be  the  providers  of  those  prevention  and  health  promotion  ser
vices  now   vailable,  plus  other  maternal   nd  child  health  services  such   s  prenatal  outreach  and 
care,  child  health  services   nd  family  planning  services  to women   nd children  who  become  eligible 
for poverty  level  medical  assistance  program  benefits  pursuant  to  section  4 of this  Act. 
SECIION  4.  [n  order  to  make  advantageous  use  of  the  system  of  public  health  services  avail
 ble  through  county  health  departments  and  other  publicly  supported  programs   nd to insure  access 
to  public  heaith  services  through  contract  under  ORS  chapter  414,  the  state  shall: 
(1)

Unless  cause  can  be  shown  why  such   n  agreement  is  not  feasible,  require  and  approve 
agreements  between  prepaid  health  plans  and publicly  funded  providers  for authorization  of payment 
for point  of contact  services  in  the  following  categories: 
A-2  . 
(8)  hnmuniz4tionq

(b) Sexually  transmitted  diseaseq   nd

(c) Other  communicable  diseases;

(2) Continuteo 811oewnrollees  in prepaid  health  plans  to  receive  family  planning  aervicea  from 
fee-for-service  providem, 
(3)  Encoura~e   d  am..m  ove   greements  between  prepaid  health  plans  nd publicly  funded pro
videm  for  uthoridon  of  nd payment  for services  in the  following  categories: 
(a)  Maternity  case  management; 
(b) Well-child  care;   nd   
(c)  Prenatal  care;   nd 
(4)R
ecognize  the  social  value  of  partnerships  between  county  health  departments   nd other 
publicly  supported  programs   nd other  health  providers,   nd  take   ppropriate  measures  to  involve 
publicly  supported  health  care   nd  service  programs  in  the  development   nd  implementation  of 
managed  health  care  programs  in their   reaa  of responsibility. 
Passed  by Senate  May s  19Dl  Ree8ived  by tkvo~ 
4d%z9a%?&
..............
..  . .  ..  ... ..  ..  ..  .  .. ...  . ........ 
.................................................... 
-----p~%: 
Passed  by House  %e  4, lWl 
Pii  by OKI  of Secmtmy  of StatQ: 
c ..J2i.. 2..d .5._-. 
3
../.f:&i.&.M  . . ,*1 
..._?&
Speaker of Housa .......... .............../..L........4........................
.
? 
Secretary0[ St 
Enrolled  Senate  Bill  760  Page  2 
A-3
 APPENDIX  B 
CONTRACT  BETWEEN  MULTNOMAH  COUNTY  AND GOOD  HEALTH  PLAN 
B-1  Letter  of  Agreement 
1.	 Sewices  will be provided  by the Multnomah  County  Department  of Health,  hereinafter 
referred  to  as  Provider,  to  Good  Health  Plan  of  Oregon  Medicaid-sponsored 
members,  who  are Office of Medical  Assistance  Programs  (OMAF)  eligible  recipients 
who  have enrolled  with the Good  Health Plan, hereinafter  referred to as Members, or 
Membet.  Sewices  will be provided  for immunizations,  sexually  transmitted  diseases, 
and  other  communicable  diseases  of public  health  concern.  Good  Health  Plan  of 
Oregon  will hereinafter  be referred to as Health Plan. 
2.	 Health  Plan will furnish Provider each month with a current roster of enrolled  Members, 
which  will indicate  all existing  Primary Care  Physician  designations. 
3.	 Services  will be provided  within the scope  and guidelines  of S6  760 with the intent to 
involve  publicly  supported  health  care and service programs  in the development  and 
implementation  of managed  health  care programs  in their areas  of responsibility. 
4.	 Provider  agrees  to bill services  to Health  Plan, not to  Members.  Provider  will make 
every  effort to bill in a timely  manner.  Bills will be submitted  beginning  14 days  after 
date  of service,  but they  may be submitted  up to one  year  from date  of sewice.  Any 
bill submitted  more than one year after the date of seMce  will not be payable  by either 
Health  Plan or Member.  Provider will submit bills on standard  HCFA  1500 forms, using 
CPT codes  and [CD-9 codes.  Services for individual Members  will be billed separately, 
and Provider will bill for all services provided to Member  regardless  of whether  services 
are covered  by this Agreement.  Health  Plan will pay only for those  sewices  covered 
by this Agreement.  Clean  claims will be paid within 30 working  days.  Provider  must 
appeal  any claims adjudications  or other matters within 90 days of the date of payment 
and  if Provider  fails to  do  so,  Provider will be deemed  to  have  waived  any appeals 
rights. 
5.	 Provider  agrees  to  accept  Health  Plans  payment  as  payment  in  full for  covered 
services.  Health  Plans  payment  will  be  as  listed  in  Attachment  A.  Appropriate 
services  covered  by this Agreement  that are not listed specifically  in Attachment  A will 
be  reimbursed  at  the  Health  Plan  allowable  for  the  service.  Payments  will  be 
considered  payment  in full for applicable  charges.  Provider  agrees  that no copay ;,lent 
will be charged  at time of service. 
6.	 Provider  agrees  to provide  Members  with the same  quality  and  timeliness  of care  as 
other  patients.  Quality of care will be commensurate  with the  professional  standards 
of the community. 
7.	 Provider  through  the state of Oregon,  is self-insured  under  provisions  of ORS 30.260 
through  30.300  (as now or hereafter  amended)  for its tort liabilities.  Pursuant  to ORS 
30.260  through  30.300,  Provider  and  its  employees  are  insured  against  any claim or 
claims for damages  arising by reason of personal  injuries or death  occasioned  directly 
or indirectly  in connection  with the performance  of, or failure  to perform,  any Provider 
service provided  hereunder,  the use of any property and facilities provided  by Provider, 
and  activities  performed  by  Provider  in connection  with  this  Agreement.  A  letter 
certifying  Providers  insurance  shall be provided  to Health  Plan  upon  request. 
B-2  8.  The patiies  hereto mutually agree to indemnify, defend, and hold each other  (including 
their officers, agents,  and employees)  harmless against  any and all claims,  demands, 
damages,  liabilities,  and  costs  incurred  by  the  other  party,  including  reasonable 
attorneys  fees,  arising  out  of or in connection  with, either  directly  or  indirectly,  the 
performance  of any setice,  or any other actor  omission  by or under the direction  of 
the indemnifying  patty,  its officers,  agents,  or employees. 
9.  Provider hereby  agrees  that  in no event,  including  but not limited to non-payment  by 
Health  Plan,  insolvency  of Health  Plan,  or breach  of this  Letter of Agreement,  shall 
Provider  bill, charge,  collect  a deposit  from,  seek  compensation,  remuneration,  or 
reimbursement  from, or have  any recourse  against  Member,  or other  persons  acting 
on their behalf,  other than  Health  Plan, for covered  services provided  pursuant  to this 
Letter  of  Agreement.  ~is is  further  dictated  by  the  Federal  Medicaid  Act  and 
applicable  Oregon  Statutes  and Oregon Administrative Rules concerning  the provision 
of Medical  Services  under  prepaid  capitated  health plans. 
Provider  further  agrees  that  this  provision  shall survive termination  of this  Letter  of 
Agreement  regardless  of the cause  giving  rise to termination  and  shall be construed 
to be for the benefit  of Health  Plans Member;  and that this provision  supersedes  any 
oral  or written  contra~  agreement  now  existing  or hereafter  entered  into  between 
Provider  and  Member,  or persons  acting  on their behalf.  This  provision  applies  to 
services  provided  during  a time period  for which Member  premiums  have  been  paid. 
10.
 Provider agrees  to maintain  all required  licenses,  certificates,  and/or  registrations  as 
issued by the appropriate  State,  Federal,  and local governmental  agencies  to provide 
the health  care services which  Provider undertakes  to provide to Members  under  this 
Letter of Agreement. 
11.  Provider  agrees,  except  in  accordance  with  provisions,  spirit  and  intent  of  this 
Agreement  not to differentiate  or discriminate  in its provision  of services  to Members 
because  of race,  color,  national  origin,  ancestry,  religion,  sex, marital  status,  sexual 
orientation,  or age. 
12.  Attachment  B lists current service locations.  Provider will notify Health  Plan of service 
location  changes  as theyoccur. 
13.  Provider will make  every reasonable  effort to direct the Member  to Members  primary 
care physician  for services  not included  in this contract.  Members  may be billed only 
for those  services  not covered  by Medicaid. 
14.  Provider and Health  Plan may agree to contract for certain services not included  in this 
Agreement  on  an  as-needed  basis.  Provider  and  Health  Plan will agree  at time  of 
service on rates and charges  associated  with such services.  Services will include  but 
are not limited to obstetrical  case  management  and specialized  programs  sponsored 
by Provider. 
15.  In the event of any dispute  arising out of or relating to this Agreement,  the parties shall 
attempt  in good  faith  to  mutually  resolve  the  dispute.  Any  appeals  on  decisions 
related to treatment  or services  will be mediated  between  Health  Plan and  Provider. 
B-3
 16.	 - This Letter of Agreement  may be terminated  at any time without  cause  by either party 
upon  sixty (60)  days  advance  written notice to the other  party. 
17.  The  term of this  Letter of Agreement  shall commence  on Janua~  1, 1993  and  shall 
1993  and  thereafter  until  December  31  of
continue  in effect  through  December  31, 
each  following  year  unless  terminated  by either  party  pursuant  to  the  terms  stated 
herein.	 The  fee  schedule  as listed  in Attachment  A may  be  revised  concurrent  with 
renewal. 
AGREED  AND ACCEPTED: 
Multnomah  CounWf  0re90n
Sisters of Providence 
Department  of Health 
Health  Plans in Oregon 
Provider
Good  Health  Plan of Oregon  HMO 
Health  Plan 
.-
----
.-
47 
/..  ; 
By:=- ?:~~  A  - ~~  ~ 
Ted  von  Glahn 
Chief  Operating  Officer 
?3  -086307) 
>: 
Employer  I.D. Number 
By: 
BilllOdegaard,  Direct8r,  Health  Dept. 
By-:
Progra  Manager,  Health  Department
Date: 
REVIEWED: 
IJ+URENCE B. KRESSEL, County Counsel 
-
0.,. 
B-4  Addendum  A 
This Addendum to the Letter of Agreement  seines to establish operational  protocol and procedures  to 
help ensure coordinated  delive~  of the health services specified in the Letter of Agreement,  which 
Medicaid-s~nsored,  Managed  Care  Program  enrollees may receive from both County health department 
personnel and their Good  Health  Plan of Oregon  (Plan) providers. 
(1)	 Primary Care Physician (PCP)  Coordination:  Plan PCPS are to be informed of Plan
reimbursad,  optional health care services received by their members  at County health clinics. 
	 The respective  County  wifl b~l the Plan for each service encounter  in a format that 
mme,
identifies the date,  member  diagnostic  code(s),  and procedure  code(s)  enabling 
the Plan to generate  a report for entry by the PCP in the members  medical  record. 
(2)  Protocol  to Support  Compliance  with  Recommended  Immunization  Schedules  -
The involved PCP and County  clinic wUI adhere to the fallowing  procedures: 
	 During the initial offiie  v&it, the PCP is expected  to discuss the immunizations  deliv~ 
option and help the member  determine  where they wifl most readily compfy with 
schedules,
immunization  at their PCPS office or at a County  clinic. 
	 If a member  selfdirects  to the County for immunization  services, she wifl be encouraged 
to remain with the County  provider to completion  of the immediate  immunization 
schedule. 
  The Plan will assist PCPS with a tracking and recall system. 
(3)	 Protocol Related to Sexually Transmitted  Diseases:  Routine screening, treatment, and 
monitoring for recurrence  of STDS will be providd  exclusively by the PCP in the course  of 
providing the members  primaty  care. 
	 Both the invofved County  and the PCP will screen and treat sexually transmitted 
diseases when a member  presents  episodically. 
	 The Plan expects  the County  to proceed with treatment  and all immediate 
foflowup to assure that this episodic treatment  was effective. 
	 Members  will be directed  to their PCPS for annual  gynecological  examinations, 
which include routine  STD screening,  and ongoing  monitoring of conditions 
previously treated  by the County. 
mayarise
  The point-of-sewice  contact  directly from STO concerns  or from the delivery 
of family pfanning services,  which  routinely involve a PAP test and, secondarily,  may 
detect the presence  of a STD. 
Continued 
B-5  Addendum  A - page 2 
(4)	 Protocol  Related  to Other  Communicable  Diseases:  The County will provide  necessqf 
diagnostic  testing and counseling  when a member  contact  presents the opportunity  to screen 
for a communicable  disease  of public health concern  (i.e., TB, HIV/AIDS, and viral hepatitis). 
The County  will refer the member  to the PCP for treatment  and concurrently  notify the members 
PCP of the referral, to facilitate PCP follow up, as soon as the member  is informed of an 
HIV/AIDS  diagnosis  or TB diagnosis  (services typically invdve  skin test/chest  x-ray/lNH). 
  The PCP, in providing  primary c-are, routinely will screen for communicable  diseases 
	 When the PCP makes a TB diagnosis,  she/he  may refer the member  to the County  for 
treatment  if justified by the Countys  capabii~  to treat more effectively; otherwise, 
treatment  will be provided  routinely by the PCP or referred to a Plan specialist. 
	 The County  will be asked to furnish the Plan with informational  material about  its 
communicable  disease  prevention  and treatment  sewices,  which  may be used to inform 
PCPS more fully about this treatment  option. 
(5)	 Referral  to Plan  Pharmacies:  To ensure efficient dispensing,  prescriptions  for members  should 
be called  in or taken to a Plan pharmacy  (see listing provided  as Addendum  B). 
  The Plan will supply all County  clinics with updated  Plan Pharmacies  listings as issued. 
	 The rationale for this restriction is the likelihood that a non-Plan  pharmacy  will deny 
service to a Medical  Card  holder designated  as an enrollee  of the Good  Health  Plan. 
(6)	 Access  to Family Planning Sewices:  Members may obtain OMAP-coverecffamify pfanning 
services from the County or any other licensed, enrolled OMAP provider. Counseling on 
methods of family planning  is the only service covered  by the Good  Health  Plan.  However,  the 
members  PCP, as an individually-enrdled OMAP provider, can provide OMAP-covered family 
planningmedicalservicesand prescriptionsona fee-for-servicereimbursementbasis. 
	 When the County  provides covered  family planning services to a GHPO-Medicaid 
member,  the County  will bill OMAP  for these sewices  on a fee-for-service  basis. 
Therefore,  neither the Plan nor the members  PCP will be notified of County-provided 
family planning  services. 
	 To ensure access  to provider  options for family planning  services,  member  materials will 
promote the publicly-funded  1-800 -SAFEN=  telephone  information  and referral service, 
which  can direct the member  to her County  heaith department  and community  providers 
of all-options  family planning.  Plan Providers will be furnished  SafeNet  promotional 
materials for additional  distribution to members. 
B-6  APPENDIX  C 
CONTRACT  BETWEEN  HEALTH  START AND RAMSEYCARE 
c-1  PREPAID MEDICAL ASSISTANCE PROGRAM

PRIMARY CARE PROVIDER AGREEMENT

This Agreement,  made  and entered  into this irst  day of cc* 
t 199<,  by  and  between  the  party  executing this Agreement  on  t 
Signature  and Declaration  Page  attached  hereto  (ProviderZ)  and NW 
HEALTH  NETWORK,  INC.  (Health Plan) 
SECTION  1  PARTIES  AND PURPOSE

Section 1.1  Parties.  The  Health  Plan  is  a  Minneso 
nonprofit  corporation  licensed  and organized  as a health  maintenan 
organization  to arrange to provide health care services to residen 
of  Minnesota  on a  prepaid  basis.  The  Health  Plan  has  been  du 
approved  and  designated by  the  State  of Minnesota  as  a  vendor 
health  care  services  for  the  Prepaid  Medical  Assistance  Progr 
(PMAP) for eligible Medical  Assistance  (MA) recipients  whc]enro 
in the Health Plan.  Provider  is a community  health  care  clinic  a 
is duly licensed by the State of Minnesota. 
Section 1.2  PurDose.  The  Health  Plan  wishes  to  contract  wi 
Provider  to provide Primary  Health  Care  Services  under  PMAP to 
recipients enrolled in the Health Plan.  Provider agrees to work wi 
the  Health  Plan  in  the  delivery  of  health  care  services  to  M 
eligible persons participating in PMAP who are enrolled in the Heal 
Plan.  Provider  is  willing  to  provide  such  persons  with  Prima 
Health  Care  Services  as  provided  under  federal  and Minnesota law a 
regulations  governing PMAP  and  the  Health  Plan,  and  to  receive 
payment in full the payment specified  h  this Agreement. 
c-2  SECTION II:  DEFINITIONS

.  The following definitions shall apply to this Agreement and t

all exhibits and addenda attached hereto:

Section  ~Care  Coordination-.  The  initial and  periodi 
2.1 
assessment  of  each  Enrollee~s health  and  social situation and  th 
development,  implementation and monitoring  of  care plans  for  ea 
Enrollee. 
Section 2.2  Care Coordinator.  The nurse,  social worker

other appropriate professional person who is designated by Provider

selected Primary Care Site medical staff to perform Care Coordinati

for assigned Enrollees.

Section 2.3  Clinic Professional-.  All medical doctors  a

other duly qualified licensed or registered health care professiona

who are members, partners, shareholders, owners, agents, or employe

of Provider or are otherwise  affiliated  with  Provider.

Section  2.4  Covered Services.  Those health care produc

and  services included in the PMAP benefit package and described

the Health Plans Description of Benefits.

Section  2.5  Emeraencv  Care-.  The  provision  of  medically 
necessary Covered Services  which  are  required  to  treat  an  immediat 
medical emergency. 
Section 2.6  Enrollee.  An  MA-eligible  individual  who 
enrollment  in the Health  Plan  under  PMAP  has  been  entered  into  t 
State  Client Information File. 
Section 2.7  ~E.n rolle  A contract, certifica

or  other evidence of coverage issued to  an  Enrollee that describ 
c-3  the Covered  Services  available  to  the  Enrollee  under  PMAP  and  th 
Health  PlanJs  Description  of  Benefits. 
Section  2.8  Health  P1an  Quali.tv  ASsurance  Protocol_  #   Th 
standards  and  operating  procedures  adopted  from  time  to  thue  by  th 
Health  Plan  as  necessary  to  maintain  the  Health  Plans  quality 
assurance  program  i.n  accordance  with  Minnesota  law  and  acceptable 
the  United  States  Departxtent  of  Health  and  Human Services  (DHHS). 
Section  2.9  am  Care  Protocol.  The  utilization  and  quali 
assurance standards and procedures identified and developed from ti

T

to time by the Health Plan to be used in the care of Enrollees. 
MA Care Protocol includes specific penalties for non-compliance wi

established  standards  and  provides  an  appeals  process  for  a

participating  providers  affected  by  the  Protocol.  The  MA  Ca

Protocol is subject to the Quality Assurance Plan and is contained

the MA Care Manual maintained by the Health Plan and is incorporat

herein by reference.

Section 2.10  ~.
   A physician appointed

the Health Plan to oversee the quality of Covered Services deliver

to Enrollees and to review cases of excessive utilization of Cover

Services.  The MA Medical Director shall have the authority to ma

determinations  in accordance  with  the MA Care Protocol.

Section  2.11  ~W
  a  Prov*der&.  A  provider

{Uovered  Services  under  PMAP  who  is  a  Primary  care  Providerr

Referral  Provider  or  other  provider  under  contract  with  the  Heal

Plan  to provide  such health  services.

Section  2.12  Medical  Emeraencv  Servicesm.  Covered  Servic

provided  as Emergency  Care.  For purposes  of this contract,  Medic

c-4  Emergency~  shall mean  a  condition  that  if not treated  immediately

could  cause  a  person  serious  physical  or  mental  disability  the

continuation of severe pain or death. Labor and delivery is a medical

emergency if it meets this definition.

Section 2.13  Out-of-Plan Care.  Health care provided to an

Enrollee by providers who are not under contract with the Health Plan

to provide health services under PMAP.

Section 2.14  ~  Screeni  aive  roclram.

The  State  program mandated  by  Minnesota  Statutes, Section 256B=69

(1990), section 256B.0915  (Supp. 1991), and Minnesota Rules, parts

9505.2390 to 9505.2500.

Section 2.15  ~Pre~aid Medical Assistance PrOCfram(PMAP)#*  The

program authorized under Minnesota Statutes, Section 256B.091 (1990),

Section  256B.0915  (1992) and  Minnesota  Rules,  parts  9500.1450  to

9500.1464.

Section 2.16  Primarv  CareU.  A  type  of  medical  care 
emphasizing  first  contact  care  and  the  assumption  of  ongoing 
responsibility  for  the  patient  in both health maintenance  and therapy 
for  illness  or injury.  It is comprehensive  in scope and involves the

overall  coordination  of care of the patient~s health problems whether

biological, behavioral or social.

Section 2.17  Primarv  Care  Providerm.  A  piimary  care

physician  or other provider  of health care who  has entered into a

contract  with and who  is authorized by the Health Plan to provide

Primary Care Covered Services to Enrollees and to authorize Covered

Services to be performed by Referral Providers.

Section 2.18  Primarv Care Site.  A medical clinic location

c-5
 whose medical  staff  agrees  to  serve  as  the  primary  control  point  for 
an.Enrollees medical care needs. 
Section  2.19  Provider  Manual#.  The  official  Minnesota

Department  of  Human  Services  publication,  entitled  ~Medical

Assistance  and  General  Assistance  Medical  Care  Provider  Manual,

which  is  issued  to  providers  by  the  State  to  clarify  policy,

procedures, or definitions of Covered Services under PMAP.

Section 2.20  ~eferral  Provider.  A provider of health care 
who  delivers  Covered Services to  Enrollees  as requested by a duly 
authorized Primary Care Provider and who has entered into a  Referral 
Provider  contract  with  the  Health  Plan  to  deliver  such  Covered 
Services. 
Section 2.21  ~  @.  Covered  Services  provided 
to  Enrollees  by  Referral  Providers  as  requested  by  a Primary  Care 
Provider. 
Section 2.22  ~r.e
   Covered  medical  services  which
are medically necessary in order to prevent a serious deterioration

of the health of an Enrollee who is temporarily outside the service

area,  Ramsey  County  of  the  State  of  Minnesota,  when  the  need  for  care 
arises. 
SECTION  111$  PROVISION  OF SERVICES  . 
Section 3.1  Ob lIU  atIo  n  to Provide Covered Services.  Provider
is  a  Primary  Care Provider and  shall  provide, or  arrange  for  the 
provision by MA Participating Providers designated by the Health Plan 
pursuant  to the MA Care Protocol, to Enrollees who choose to obtain 
services  from  Provider,  all  medically  necessary  and  appropriate 
C-6  Covered  Services including  those  services  in  Appendix  I  to  this 
Agreement, attached and incorporated herein.  Provider shall, to the 
maximum extent possible, provide Care Coordination for each Enrollee 
who chooses to obtain services from Provider, including all Covered 
Services rendered to such Enrollee by providers not affiliated with 
Provider.  The Health Plan may make deletions from or additions to 
the Covered Services as nay be required from time to time by  federal 
or  state  law  subject  to  approval  by  the  Minnesota  Department of 
Health.  The  Health  Plan  shall  give  written  notice  of  any  such 
deletions or additions to Provider within seven (7) days of being so 
notified by appropriate persons responsible for the PMAP. 
Section 3.2  C.L.I.A.  Requirements.  All  laboratory testing

sites providing services for PMAP pursuant to arrangements under this

Agreement  shall  have  either  a  Clinical  Laboratory  Improvement

Amendments  (CLIA)  certificate  of  waiver  or  a  certificate  of

registration  along  with  a  CLIA  identification  number.  Those

laboratories with certificates of waiver will provide only the eight

types  of  tests  permitted  under  the  terms  of  their  waiver.

Laboratories  with  certificates  of  registration may  perform a  full

range of laboratory tests.

Section 3.2  s~  ervic .  Provider is responsible for 
and  agrees  to  provide  Covered  Services to  Enrollees  in accordance 
with  the  professional  standards  of  the  community  and  h  accordance 
with  the  Health  Plan  Quality  Assurance  Protocol  and  the MA  Care

Protocol.  All  Covered  Services provided  in  accordance  with  this

Agreement  shall  be  at  least  equal  in  quality,  completeness  and

promptness  to  services  provided  by  Provider  to  other  persons not

c-7
 covered by this Agreement.

.  Section 3.4  Jnformation Reaardina  Services*  Provider shall

furnish to the Health Plan without charge reports and data concerning

Covered  Services provided by Provider to Enrollees in such form and

at such times as may be reasonably required by the Health Plan, the

State  of Minnesota, or the United  States Department of Health  and

Human Services (@DHHS~).

Section 3.5  Control  of  Operations.  The  operation  and

maintenance  of  the  offices,  facilities  and  equipment  of  Provider

shall be solely and exclusively under the control and supervision of

Provider.  The Health Plan shall have no right, authority or control

over  the  selection  of  staff  or  the  supervision  of  personnel  of

Provider.  Each  Clinic  Professional  sha11  maintain  the  same

doctor/patient  relationship as would  arise  in the absence of  this

Agreement,  and no provision of this Agreement shall have the effect

of infringing upon a Clinic Professional/s professional relationship

with each Enrollee.

Section 3.6  Enrollee  Identification.  Based  on  information

made  available  to the Health  Plan  by  the  State of Minnesota,  the

Health Plan shall maintain such lists as are needed for the purpose

of  enabling  Provider to  establish procedures  for identification of

eligible  Enrollees.  The  Health  Plan  shall  also  issue  an

identification  card  to  each  Enrollee,  promptly  after  his  or  h=

enrollment,  bearing the name of the Enrollee, Enrollee numb=,  and

effective  date  of  coverage.  Provider  agrees  to  use  reasonable

efforts to verify the current status of an Enrolleets eligibility for

Covered Services.

C-8
 Section 3.7  primarv Care Sites.  At the time of enrollment,

Enrollees  shall  be  notified  of  the  names  of  MA  Participating

Providers who  have  been designated by the Health Plan to serve as

Primary Care Sites. Enrollees shall be notified that they are to seek

Covered  Services  exclusively  from  those  Primary  Care  Sites  or  from

Referral  Providers  to  whom  Enrollees  are  referred  in writing  by  a

Primary  Care  Provider.  Provider  agrees  to make  the Primary  Care Site

as designated  by Provider  available  t.oeach  Enrollee.  Provider  will

furnish  the  Health  Plan  with  a  current  list  of  all  Clinic

Professionals  who  will  be  providing  Covered  Services  and  shall

provide  the Health  Plan with an amended  list within  ten  (10) working

days of any changes.

Section  3.8  site Designation Enrollees.  Enrollees  will  also 
be notified  that  the Health Plan retains the right to designate a 
specific Primary Care Site for each Enrollee and will do so when it 
is judged appropriate by the Health Plan.  If an Enrollee is informed 
that he or she has been assigned to receive Covered Services from a 
specific Primary Care Site, then all subsequent Covered Services for 
that  Enrollee must  be provided or arranged  for by such Site. Only 
Covered  Services  authorized  by  Enrollees  designated  Primary  Care 
Site will be covered by the Health Plan, except for Medical Emergency 
Services  and  out-of-plan~ Urgent Care  servicesf as de-finedherein 
and in the Enrollee Certificate. 
Section 3.9  Other  Providers.  Except  in  cases  of  Medical 
Emergency or as provided otherwise in PMAP or as expressly specified 
by  the  Health  Plan  in writing  from  time  to  time,  if Provider  is 
unable  for  any  reason to render a necessary Covered Service to an

c-9
 Enrollee,  Provider  shall  arrange  to  have  such  Covered  Services

rendered  to  Enrollee  by  another  HA  Participating  Provider  if

possible.  The Health Plan will make available to Provider a list of

all  XA  Participating  Providers,  as  modified  from  time  to  time=

Providers  shall obtain prior authorization from the Health Plan for

any  such arrangement to have Covered Services rendered by a provider

that  is not a Primary Care Provider under contract with the Health

Plan to provide services under PMAP.

SECTION IV  PAYMENT FOR SERVICES

Section 4.1  Pavment  Procedure.  The  Health  Plan  shall  pay

Provider  for the provision of Covered Services to Enrollees and the

other  responsibilities assumed by Provider under this Agreement, as

provided  in  Exhibit  A  attached  hereto  and  incorporated  herein.

Provider  shall send all  invoices for Covered Services provided to

Enrollees to the Health Plans Claim Department as specified by the

Health Plan.  Information required to be submitted in such invoices

by  Provider  includes,  but  is  not  necessarily  limited  to  the

following:

a)  primary and secondary diagnosis codes using ICD-9 coding;

b)  procedure codes including modifiers;

c)  unit of service and date of service;

d)	 place  of  service  (e.g.  inpatient  hospital;  outpatient

hospital, outpatient clinic, physician office, etc.); and,

e)  MA identification number.

Provider must file all such invoices within sixty (60) days following

the close of the calendar quarter in which the services invoiced were

provided.

c-lo
 Section 4.2  EXcJusive  Pavment.  Provider  agrees  that  the

payment for  Covered  Services specified  in this Section constitutes

the  entire  payment  for  the  Covered  Services  provided  and

responsibilities  assumed  by Provider  under  this  Agreement,  and  that

Provider  shall  not  charge  Enrollees  for additional  amounts  for  said

Covered  Services.  If payment for any Covered Service is denied due

to  non-compliance  with  the  MA  Care  Protocol  or  the  Health  Plan

Quality  Assurance  Protocol,  Provider  agrees  not  to  bill  the  Health

Plan or the Enrollee for such Covered Services.

Provider  shall accept as payment  in full for Covered Services

rendered  to  Enrollees  such  amounts  as  are  paid  pursuant  to  this

Agreement.  PROVIDER  AGREES  NOT  TO  BILL,  CHARGE,  COLLECT  A  DEPOSIT

FROM ,  SEEK  REMUNERATION  FROM,  OR  HAVE  ANY  RECOURSE  AGAINST  AN

ENROLLEE  OR  PERSONS  ACTING  ON  THEIR  BEHALF  FOR  SERVICES  PROVIDED

UNDER  THIS  AGREEMENT.  THIS PROVISION  APPLIES  TO  BUT  IS NOT LIMITED

TO  THE  FOLLOWING  EVENTS:  (1) NONPAYMENT  BY THE  HEALTH MAINTENANCE

ORGANIZATION  OR  (2) BREACH OF THIS AGREEMENT.  THIS PROVISION DOES

NOT  PROHIBIT  THE  PROVIDER  FROM COLLECTING  COPAYMENTS OR  FEES  FOR

UNCOVERED SERVICES.

THIS  PROVISION  SURVIVES THE TERMINATION OF  THIS  AGREEMENT  FOR

AUTHORIZED  SERVICES  PROVIDED  BEFORE  THIS  AGREEMENT  TERMINATES,

REGARDLESS OF THE REASON FOR TERMINATION.  THIS PROVISION IS FOR THE

BENEFIT OF THE HEALTH MAINTENANCE ENROLLEES. THIS PROVISION DOES NOT

APPLY TO SERVICES PROVIDED AFTER THIS AGREEMENT TERMINATES.

C-11
 THIS  PROVISION  SUPERSEDES  ANY CONTRARY OIU.LOR WRITTEN  AGREEMENT

EXISTING  NOW  OR  ENTERED  INTO  IN THE  FUTURE BETWEEN  THE  PROVIDER  AND

THE  ENROLLEE  OR  PERSONS  ACTING  ON  THEIR  BEHALF  REGARDING  LIABILITY

FOR PAYMENT  FOR SERVICES  PROVIDED  UNDER THIS AGREEMENT.

SECTION  v:  -CASE MANAGEMENT AND UTILIZATION PROTOCOLS 
Provider  agrees  to  cooperate  and  comply  with  all  protocols 
established  from  time  to  time  by  the  Health  Plan  with  respect  to  the 
provision  by  Provider  of  Covered  services  to  Enrollees  under  this 
Agreement,  including,  without  limitation,  protocols  related  to 
hospital  admissions,  length  of  stays,  referrals,  and  medical  Case 
management.  Provider  understands  that  failure  to  obtain  necessary 
prior  authorization  from  the  Health  Plan  may  result  in  a  financial 
penalty  to  Provider. 
SECTION  VI  QUALITY REVIEW AND EVALUATION 
Section 6.1  Performance of Duties.  Provider agrees to comply

with any and all quality evaluation, quality assurance, and quality

control  responsibilities,  including  the  Clinic  Professional

credentialing  and recredentialing process, which may  be established

by the Health Plan from time to time or to  which the Health Plan may 
be subject under  local, state or federal law with respect to PMAP. 
Provider agrees to abide by the decisions of the MA Medical Director 
and the Health Plan during the term of this Agreement. 
All Clinic Professionals retain their right to make independent

decisions affecting individual patient care and to advocate the needs

of  patients.  Clinic Professionals primary consideration  shall be

the quality of services rendered to Enrollee.

C-12
 Section 6.2  Evaluatiorl.  Provider  shall  participate  as

reasonably requested in the Health Plans ongoing evaluation of the 
delivery of Covered Services  and shall provide such information at no 
Plan to 
charge  as  may  be  reasonably  requested  to  enable  the  Health 
impleInent  the  Health  Plan  Quality  Assurance  Protocol  and MA  Care 
Protocol. 
Section  6.3  Audit. Inspection.  Provider shall make  available 
during  normal  business  hours  all records  pertaining  to MA  Enrollees 
that  are  relevant  to this  Agreement  to authorized  representatives  of 
the  State  and DHHS  and at such times, places, and in such manner as 
such a-uthorizedrepresentatives may reasonably request for purpose of 
audit,  inspection, and examination of the quality, appropriateness~ 
and  timeliness  of  services  performed by  Provider pursuant to  this 
Agreement. 
SECTION VII  CONSUMER COMPLAINT PROCEDURES

Section 7.1  ~do~tion of Procedure.  Provider shall adopt and 
implement the Health Plants consumer complaint system and procedures 
with respect to PMAP as modified from time to time.  Such procedures 
shall comply with all  applicable  statutes,  rules  and  regulations. 
Section 7.2  J?oleof the Health Plan.  The Health Plan shall

make available written procedures for the handling and resolving of

complaints, inquiries and opinions with respect to PMAP in a fair and

reasonable manner.

Section 7.3  Designation  of  Representative.  Provider  shall

designate  a  person  with  appropriate  authority  who  shall  be

responsible  for the handling  and resolving of all such complaints,

inquiries and opinions.

C-13  Section 7.4  Coo~eratio~.  Provider  shall  inform the  Health

plan  of  all written  complaints,  inquiries and opinions  filed with

Provider by Enrollees and shall cooperate and assist the Health Plan

in resolving such matters.  Pursuant to the requirements of Minnesota

Statutes  Chapter  256,  Provider  shall  inform  the  State  Ombudsman

within three  (3) working days of its receipt of a formal complaint,

provide the Health Plan with copies of correspondence with the State

Ombudsman,  and  provide  the Enrollee complaining with  the name  and

number  of the State Ombudsman.

Section  7.5  Arbitration.  My  complaint  which  the Enrollee, 
Provider  or  the Health Plan determines has not been satisfactorily 
resolved shall be settled by arbitration in accordance with Minnesota 
Statutes,  Chapter  572, provided  that the arbitration  is not required 
when  an  Enrollee  elects  to  litigate  his  or  her  complaint  prior  to 
submission  to  arbitration  or  a  medical  malpractice  damage  claim  is 
involved. 
SECTION VIII  BOOKS AND RECORDS

Section  8.1  Access  by  Plan.  The  Health  Plan  shall  have

access  to  Providers  books,  Enrollee  patient  records,  records  of

accounts  and  any  other  relevant  documents  at  reasonable  hours  and

upon  reasonable  notice  for  examination  and  inspection  as  may  be

necessary  for the administration  of this Agreement  or to meet  federal

or state  requirements  under PMAP.

Section  8.2  Release  of Information.  The Health  Plan shall be

authorized  publicly  to release  aggregate  cost,  utilization  and other

information  concerning  PMAP.  Specific  information  that  identifies

C-14
 Provider  shall  not  be  released  without  Providers  written

authorization except as a part of reports required by the State of

Minnesota  or  I)HHS.  The  Health  Plan  is  authorized  to  release

information  in  its  possession  or  obtained  under  this  Agreement

pertaining  to  providers  or  Enrollees,  necessary  to  comply  with

federal and state statutes applicable to the Health Plan.

Section 8.3  Data Privacy.  Provider agrees to comply with all

the requirements of the Minnesota  Government Data Practices Act  in

providing services under this Agreement.  In accordance with Minn.

Stat.,  Section  13.46,  subd.  10  (1990),  Provider  accepts

responsibility for providing adequate supervision and training to its

agents and employees to ensure compliance with the Act.  No private

or confidential data collected, maintained, or used in the course of

performance  of  this  Agreement  shall  be  disseminated  except  as

authorized by statute, either during the period of this contract or

thereafter.  Provider  agrees  to  indemnify and  save  and  hold  the

Health  Plan,  its  agents  and  employees,  harmless  from  all  claims

arising out of, resulting from, or in any manner attributable to any

violation by Provider of any provision of the Minnesota  Government

Data Practices Act,  including  legal fees and disbursements  paid or

incurred  to enforce  the provisions  of this Agreement.

Section  8.4  &fedi.calRecords.  Provider  shall  provide  for the

development  of  a  medical  record-keeping  system  through  which  all

pertinent  information  relating  to rnedi,calservices  and management  of

Enrollees  provided  by  Provider  is  accumulated  and  readily  available

to appropriate  health  professionals.

Section  8.5  Encounter  Data.  Provider  must  maintain

C-15
 sufficient  patient  encounter  data  to  identify  the  PhYs~Cian  who

delivers  services  to  Enrollees,  as  required  by  section

1902 (In)(2)(A)(xi)  Of  the  Social  Security  Act  (42  U.s.c.  s

1396b(m) (2)(A)(xi)).

Section  8.6  Other  Reau i.red Records%  Provider  agrees  to

furnish  information  from  its  records  to  the  HEALTH ~JJ~  to  be 
provided  to the STATE or  its  agents which the STATE may reasonably 
require to administer PMAP including, but not necessarily limited  to, 
the  information  in  the  Provider  Manual,  as  defined  in  Section  2.20  of 
this  Agreement. 
Section  8.7  B~ ecord  rer3aratio  All
records  collected,  used,  dissexainated  and  stored  by  the  Provider 
pertaining  to  MA  Enrollees  shall  be  maintained  in  accordance  with 
Minn.  Stat.  Ch.  13  (1990)  and  Minn.  Stat.  ~  144.335  (1990), 
safeguarded in accordance  with  the requirements  of 42 CFR 431 Subpart 
F and retained in accordance with the record retention requirements 
of  45  CFR Part 74.  Provider  agrees  to  maintain  such records and 
prepare such reports and statistical data as may be deemed necessary 
by  the Health Plan.  Provider  agrees to  furnish or  make  available 
without  cost all records to authorized representatives of the Health 
Plan,  the  State and DHHS  during  normal business hours  and in such

form as shall  redesignated.  Provider agrees to maintain and make

available to the HEALTH PLAH, the STATE, and DHHS all records related

to  Enrollees and required  under this Agreement for a period of six

(6) years after the termination date of this Agreement.  Records to

be  retained  include but  are  not  limited to  medical,  claims,  case

management, and prior-authorization records.

C-16
 Upon termination of the contract, or at such time as individual

MA .Enrollees terminate enrollment, Provider  shall~ ~Pon request bY

the HEALTH PLAN and at Providers expense provide to the HEALTH PLAN

copies  of  all  records  pertaining  to  medical  services  provided  MA

Enrollee(s).

SECTION IX  ADVERTISING AND PROMOTION

Section 9.1  Use  of  Names.  Each  party  to  this  Agreement

reserves the right to, and control of the use of, its names and all

symbols, trademarks and service marks presently existing or hereafter

established  with  respect  to  it,  except  that  Provider  hereby

authorizes  the Health Plan to use  the  names, addresses, and phone

numbers,  for  purposes  of  promotion  and  advertising by  the  Health

Plan.  Such authorization is limited to listing the name of Provider,

including  clinic or  institution names,  individual physician  names,

addresses  and phone  numbers,  in an ethical  and reasonable  manner for

purposes  of promotion  and advertising.

Section  9.2  Prohibition  Acrai.nstUnauthorized  Use.  Except as

authorized  above,  each  party  agrees  that  it will  not use  the names,

symbols,  trademarks,  or  service  marks  of  any  other  party  in

advertising  or  promotion  or  otherwise  without  the  prior  written

consent  of  such  other  party  and  will  cease  any  and  all  use

immediately  upon termi.nati.on.

Section  9.3  RamseyCare  The  Health  Plan  shall  have  sole

responsibility  for all advertising  and promotion  and for solicitation

of Enrollees  under the MA RamseyCare  program.

C-17
 SECTION X  DURATION AND TERMINATION

Section 10.1  XEX3!* The term of this Agreement  shall commence

on the date  first above written and continue through June 30, 1994,

unless otherwise terminated as provided under this Agreement.

Section 10.2  ~erminatio~

a.  This Agreement  may be terminated  by Provider  or Plan at any 
time  upon  at  least  one hundred  twenty-five  (125) days  prior  written 
notice  to  the  other  party  provided  that  the  effective  date  of 
termination  under  this Section  10.2.a.  shall not occur  prior  to June 
30, 1994. 
b:  If  Provider  violates  the  Health  Plan  Quality  Assurance

Protocol  or  the  MA  Care  Protocol,  as  amended  from  time  to  time,

including  the  failure  of  the  any  Clinic  Professional  to  satisfy  the

credentialing  or  recredentialing  requirements, the  Health  Plan may

terminate this Agreement immediately upon notice to Provider.  In any

event, any Clinic Professional who does not satisfy the credentialing

or recredentialing process or laboratory testing site that does not

meet federal and state requirements will not be permitted to provide

Covered Services  to Enrollees.

c.  This  Agreement  further  may  be terminated  at  the  option  of 
any  non-breaching  party,  upon  a  material  breach  of  any  party  in 
substantial  performance  of  any  term  or  covenant  in  this Agreement, 
after  thirty  (30) days  prior  written  notice  of such  breach  is given 
to the  breaching  party;  provided  however  that  such  termination  will 
not  limit  or  otherwise  affect  any  rights or  remedies  of  any  non-
breaching  party  otherwise  available  at  law  or  in  equity  for  such 
breach. 
c-18
 d.  In the event that the Health Plans arrangement with the

State of Minnesota regarding  PMAP  terminates,  this Agr@ement  maY  be

terminated  by  the  Health  Plan  upon  at  least  thirty  (30) days  prior

written  notice to Provider.

Section  10.3  Termination  of  Obligations.  The  rights  and

obligations  of  each  party  to  this  Agreement  shall  continue  until

termination  of  this  Agreement.  Upon  termination,  the  rights  and

obligations  of  each  party  shall  cease;  provided,  however,  that

termination  shall  not  relieve  the  Health  Plan  or  provider  of

obligations  with  respect  to  Covered  Services  furnished  prior  to

*

termination.

Section  10.4  CooDeratioq.  Upon  notice  of termination  of this 
Agreement,  the Health  Plan  and  Provider  shall cooperate with  each 
other  in giving notice of termination to all  Enrollees  and  Provider 
shall  cooperate  with  the  Health  Plan  in  transferring  to  other  ~ 
Primary  Care  Providers  all  Enrollees  then  under  Providers  Care. 
SECTION  XI  MISCELLANEOUS 
Section  11.1  Independent  Parties.  Each  party  to  this 
Agreement  is  and  shall  continue  to  be  an  independent  entity,  and  no 
party  is  an  agent  or  representative  of  any  other. 
Section  11.2  Insurance  and  Licensing.  Provider  shall  provide 
<and maintain  policies  of  malpractice  insurance  as  shall  be necessary 
to  insure Provider and its employees or agents against any claim or 
claims  for damages arising by reason of personal injuries or  death 
incurred directly or indirectly in connection with the performance of

any service provided by Provider, and shall provide the Health Plan

with  evidence that such coverage is in effect. Unless such policies

C-19
 are  occurrence policies,U Provider will maintain such coverage for 
at L least  thirty-six  (36)  months  following  te~ination  of  this 
Agreement.  Provider and each Clinical Professional providing Covered 
Services  hereunder  shall  maintain  all  federal,  state,  and  local 
licenses,  permits,  and association  memberships  required  to operate  a 
medical  or--dental.clinic :in the tState.-of--Mhnesota8  as  applicable, 
and shall comply with all applicable state and federal statutes and 
regulations.  Provider  shall  notify  the  Health  Plan  as  soon  as 
reasonably  possible of any actions brought against Provider or any 
Clinic  Professionals  by  any  federal  or  state  agency  restricting, 
suspending,  or  terminating  Providers  authority  to operate  a  clinic 
or the Clinic  Professional/s  license  to practice. 
Section  11.3  J401d Harmless  bv  Provider.  Provider  shall  hold

the  Health  Plan  harmless  from  any  claims,  demands,  and  expenses  of

any  kind  by reason  of any act or omission  caused or alleged  to have

been  caused  by  Provider,  or  any  agent  or  employee  thereof,  or  any

person  or group  to whom referral is made by Provider.

Section 11.4  Hold Harmless  bv  the  Health Plan.  The  Health 
Plan  shall  hold  Provider  harmless  from  any  claims,  demands,  and 
expenses  of  any  kind  by  reason  of  any  act  or  omission  caused  or 
alleged  to  have  been caused  by  the  Health  Plan, or  any  agent  or

employee  thereof,  in the  discharge  of  its responsibil~itiesto  an

Enrollee under this Agreement.

Section 11.5  Confidential  Information.  Provider  shall  keep

all  quality  assurance  and  utilization  review  information  of  the

Health  Plan  (including but  not  limited  to  all  statistical  data,

reports  and  standards), and  all  financial  information relating  to

C-20
 this  Agreement  confidential,  and  shall  use  its  best  efforts  to

prevent and protect such information from unauthorized disclosure by 
its agents or employees.  Provider shall not use or allow  its  agents 
or  employees  to  use  any  such  information  to  the  competitive 
disadvantage or detriment of the Health Plan.  Provider shall comply 
with all applicable confidentiality laws and regulations. 
Section 11.6  Amendment and InterDretatioq.  This Agreement may

be amended by mutual written agreement of the parties hereto at any

time.  In addition, the Health Plan may inform Provider in writing of

reasonable  interpretations, clarifications and  guidelines  which do

not materially alter the terms of this Agreement.

Section 11.7  No Assignment.  This Agreement and the rights and

obligations  of  the  parties  hereto  shall  not  be  assigned  or

transferred without the written consent of all parties hereto, except

that  the  Health  plan  may  assign  any  or  all  of  its  rights  and

responsibilities to any corporation that is a subsidiary or affiliate

of the Health Plan as allowed by federal or state law.

Section 11.8  Severability.  The provisions of this Agreement

are  intended to be severable.  In the event any provision of this

Agreement  shall  be  held  invalid or  unenforceable  by  any  court of

competent  jurisdiction,  such holding  shall  not  validate  or  render

unenforceable any other provision hereof.

Section 11.9  No Waiver  The failure of either party to insist

upon the strict observation or performance of any provision of this

Agreement  or  to  exercise  any  right or remedy  shall  not  impair or

~aiveany such right or remedy.

Section 11.10  P~n  Aqainst  Discrimination.  In  the

C-21
 performance of obligations under  this contract, Provider
 agrees  to 
comply with provisions of:  the Constitution of the United
 States and

the  State of Minnesota;  the  Civil  Rights  Acts  of  1964;
 Executive

Order 11246, Equal Employment Opportunity, dated September 24, 1965,

42  CFR  434.25; Minn.  Stat.  363.073  (1990); and  any  other  laws,

regulations, or orders which  prohibit  discrimination on grounds  of

race, sex, color, age, religion, health status, disability  national

origin or public assistance  status.

Section 11.11  Comnliance  with  Environmental  Laws.  In  the

performance of obligations under this contract, Provider shall comply

with  all applicable standards,  orders or requirements issued under

section 306 of the Clean Air Act, 42 U.S.C. 1857 (h), Section  5.08 of

the  Clean Water  Act,  33  U.S.C.  1368,  Executive  Order  11738,  and

Environmental Protection Agency regulations (40 C.F.R. Part 15) which

prohibit  the use of
 facilities included on the EPA List of Violating

Facilities.

Section  11.12
 Conmliance  with  Enerm  Policv  and  Conservation

Laws.  In  the  performance  of  obligations  under  this  contract, 
Provider  agrees  to  comply  with  Public  Law  94-165  and  the  provisions 
of the State Energy Conservation Plan.

Section 11.13  ~.  Provider

shall comply with state and federal law in their perfofiance of its

obligations under this contract,  including but not limited to Minn.

Stat., section 256B.69, Minn.  Rules,  parts 9500.1450 to 9500.1464,

Title XIX of the Social Security Act (42 U.S.C. s 1396 et. sea.), and

the  applicable  provisions  of  42  C.F.R.  section  431.200  et.  sea.

Minn.  Rules, parts 9500.1450 to  9500.1464 are  attached as Appendix

c-22
 III  and  incorporated herein.  If any  terms  of  this  agreement  are 
determined to be inconsistent with  rule  or  law,  the  applicable  rule 
or law provision shall govern. 
Section  11.14  Affirmative  Action.  Provider  certifies  that  it

has  received  a  certificate  of  compliance  from  the  Co)~ission@r  of

Human Rights pursuant to Minn. Stat., section 363.073 (1990).

Section  Voter Registration.  Provider certifies that  it 
11.15 
will  comply with Minnesota Statutes, section  201.162  (Iggo)  . 
Section  11.16  Lobbvinu  Disclosure.  Provider  certifies  that, to 
the best
 of its knowledge,  understanding,  and belief~  that:

(i)  No  Federal  appropriated  funds  have  been paid  or will  be

paid  in what  the  Provider  believes  to  be  a  violation  of

section  1352,  title  31,  U.S.  Code,  by  or  on  behalf  of

Provider  to  any  person  for  influencing  or  att@mPtin9  to

influence  an officer  or employee  of an agency,  a Member  of

Congress,  an  officer  or  employee  of  Congress,  or  an

employee of  a Member  of  Congress  in connection with  the

awarding of any Federal contract, the making of any Federal

grant, the making of any Federal loan, the entering into of

any cooperative agreement, and the extension, continuation~

renewal,  amendment,  or  modification  of  any  Federal

contract, grant, loan, or cooperative agreement.

(2)	 If  any  funds  other  than  Federal  appropriated funds have

been paid or will be paid to any person for influencing or

attempting  to  influence  an  officer  or  employee  of  any

agency,  a Member  of  Congress,  an  officer or  employee of

Congress,  or  an  employee  of  a  Member  of  Congress  in

C-23
 connection  with  any  Federal  contract,  grant,  loan,  or

cooperative  agreement,  provider  shall  complete  and  submit

Standard  Form-LLL,  Disclosure  Form to Report Lobbying~m  in

accordance  with  its instructions.

(3)  Provider  will  require  that  the  language  of  this

certification be  included in the award documents for all

subawards at all tiers  (including subcontracts, subgrantsl

and  contracts  under  grants,  loans,  and  cooperative

agreements) and will require that all subrecipients certify

and disclose accordingly.

This  certification  is a material representation of facts upon

which  reliance  was  placed  when  this  transaction  was  made  or entered

into.  Submission  of this certification  is a prerequisite  for making

or entering  this  transaction  imposed  by section  1352, title 31, V.S.

Code.  Any  person  who  fails to file the required  certification  shall

be subject  to a civil  penalty  of not  less than  $10,000  and not more

than  $100,000  for  each  such  failure.

Section  11.17  Mediation.  If  either  party  requests  that  the

Commissioner  of  Health  order  that  a  dispute  pertaining  to the  terms

of renewal  or maintenance  of this Agreement  be submitted  to mediation

in accordance  with  Minnesota  law, then  the  Health  Plan and Provider

agree  that  the  party  requesting  the mediation  will bear the cost of

the mediation.

Section 11.18  Entire Aqreement.  This Agreement, including the

exhibits and any addenda attached hereto, and any separate agreement

made a part hereof, constitute the entire understanding between the

c-2d
 parties  hereto  concerning  the  subject  matter  hereof.  This  Agreement 
supersedes  all  prior  agreements  and  any  amendments  thereto  concerning 
such  subject  matter  with  respect  to  all  obligations  and  rights 
hereunder arising as of the effective date of this Agreement.

IN  WITNESS  WHEREOF,  the  parties  hereto  have  caused  this 
Agreement  to be executed  on the day and year first written above. 
See Sianature and Declaration Paue

C-25
 Exhibit  A 
. 
Fee for  Service  pavme  nt forServices 
I.  General  Terms  for Payment 
1.	 MA Provider  shall submit directly to NWNL  Health Network, 
on forms  approved  by the Plan,  all statements  for Covered 
Sendces  rendered  by MA Provider  to Enrollees,  and shall 
contain  complete statistical and  descriptive  medical and 
patient data. 
2.	 For  all  Covered  Services  eligible  for  payment,  NWNL  Health 
Network  shall  pay  GAMC  Provider  an  amount  equal  to  the 
lesser  of 
~ne hundred  fifteen Dercen~  (l 150/0o~f the Maximum
;ee  for Health Services, as set forth in the NWNL  Health 
Network  RamseyCare  MA Fee Schedule,  or 
b.  GAMC  Provider billed charges. 
3.	 The NWNL  Health Network RamseyCare  MA Fee Schedule  will 
be based  on the State of Minnesotas  Medical  Assistance  Rates, 
as maybe  modified horn time to time by NWNL  Health Network. 
Changes  to the NWNL  Health Network  RamseyCare  MA Fee 
Schedule  will be communicated  in writing  to the MA Provider 
thirty (30) days prior to the effective date of such  changes. 
C-26
 SERVICE  DELIVERY  REQUIREMENTS

The  Provider  shall  provide  to Enrollees  all  Covered  Services  set

forth  in  section  3.o1  of  the  contract,  and  as  clarified  in  this

appendix.

A.  Service  Requirements

prenatal Care Services

1. 
As  a  means of reducing the number of  low birth weight and 
preterm births occurring in the population eligible for MA, 
the  Minnesota  Department  of  Human  Services  (DHSHI  has 
instituted a special prenatal care initiative.  This prenatal 
care initiative is designed to identify women who are at risk 
of  having  a  low birth  weight/preterm  baby,  assure  increased 
access  to  prenatal  care  and  provide  additional  services 
tailored  to  the  special prenatal  care  needs  of  high  risk 
pregnant  women.  Consistent  with  the  fee-for-service

requirements,  Provider  must perform  the following  tasks:

a.	 All pregnant women must be screened during their initial

prenatal care office visit to determine  their risk of

poor  pregnancy  outcome.  A  referral  to  the  Women,

Infants,  Children  Supplemental  Food  and  Nutrition

Program (WIC) should be made at this time.

b.	 The DHS Prenatal Risk Assessment Form  DHS-3060, or an

alternative form approved by DHS, must be completed at

this initial visit and forwarded to  DHS within thirty 
(30) days of the assessment,  unless  directed  other~ise 
by  the  Health  Plan,  and  maintained  in  Providers  medical 
records  for  the  Enrollee. 
c.  Those women who are identified at high risk (a  of 
score 
10 or more points on the DHS Risk Assessment Form) must

be  offered  enhanced  perinatal  services.  Enhanced

perinatal  services  include:  high  risk  antepartum

management,  prenatal  health  education,  prenatal

nutrition education, childbirth education,  and  a  high

risk follow-up home visit.

2.	 Earlv and Periodic Screenin~, Diaanosis and Treatment  (EPSDTL 
Services/Child  and Teen Checkups 
EPSDT  is  a  comprehensive  screening  program  provided  to  a 
recipient  under  the  age  of  21  to  identify  a  potentially 
handicapping  condition  and  to  provide  for  diagnosis  and 
treatment of specific medical conditions.  The intent of the 
EPSDT Program is to provide the standards by which children 
receive  preventive  health  care  and  early  interventive 
C-27
 services.  DHS  recommends  that  the  provision  of  EPS

services become  a  regular  part  of  ongoing  well  child  car

physical  exams.  The  following  EPSDT  services  are  currentl

covered  by MA when performed  in accordance  with EPSDT progra

standards:

Q  Health  history 
Assessment  of physical growth 
 
Physical  examination 
 
Oral examination 
 
Vision  evaluation 
 
.  Hearing  evaluation 
Developmental  screening 
 
.  Sexual development 
.  Nutritional  assessment 
Immunizations 
 
.  Laboratory  tests 
.  Health  education 
The  obligations  of  the  Provider  with  regard  to  EPSDT  services  a 
described  below. 
a.	 The Provider must notify Enrollees under the age of 21 of t

availability of EPSDT services.

b.	 The  Provider  must  provide  all  of  the  required  scre~~n

components according to the EPSDT standards and perlod~cl

schedule as directed by the Health Plan.  The Provider m

offer  additional  preventive  services  beyond  these  minim

standards.

c.	 The  Provider  must  record the  results  of  the  EPSDT  heal

screening  on  the  EPSDT  Child  Screening  Form  (DHS-1973)  a

forward  the  top  copy  of the  form  to  DHS within thirty  (3

days of the assessment.

3.  Mental Health and Chemical De~endencv  (MH/CD) Services

The Provider  i.sresponsible  for referring  MH/CD  services as need

by Enrollees  to MA Participating  Providers  who are MH/CD provide

as determined  by the Health Plan.

4.  Servinq Minority and S~ecial Needs Populations  

The  Provider  must  provide  or  arrange  to  provide  appropria

services for the following special needs groups when required

requested.  If the Provider already provides specialized servic

to the following populations as described  in this section, th

the Provider agrees to make these services available to Enroll

served  pursuant  to  this  Agreement.  If  the  Provider does  n

provide  such  specialized  services,  the  Provider  will  ma

arrangements  with  the  Health  plan  to  assure  that  appropri

services  are delivered.

c-2a
 a.  Seriouslv  and  Persistently  Mentallv  ill  fSPMI)L  ong

medications review  and monitoring  day treatment  and o

milieu  alternatives  to  conventional  therapy,

coordination with  the  individual~s  case manager  to  as

appropriate utilization of all needed psychosocial servic

b.
 Elderlv. ~hvsicallv handicam ed and chronically ill:  in

services, neurological assessments.

c.
 Abused  children  and  adults,  abusive  individu

comprehensive  assessment  and  diagnostic  services

specialized  treatment  techniques  for victims  and perpetra

of maltreatment  (physical, sexual,  emotional).

d.
 Southeast  Asians  and  other  ~rou?m  with  langua~e  barri

interpreter  services, bilingual  staff, culturally appropr

assessment and treatment.  Whenever an individual reques

interpreter  in  order  to  obtain  health  care  services,

individual must be provided with access to an interprete

e.
 Cultural  and  racial  minorities:  culturally  approp

services  rendered  by  Clinic  Professionals  with  sp

expertise  in  the delivery  of  health  care  services  to

various cultural and racial minority groups.

f.
 Dual  Disabled  (DD1.  or  /CD  clie 
MH/WVelODEIent?!llV 
comprehensive  assessment,  diagnostic  and  treatment  serv 
provided  by staff who  are trained  to work with  clients

multiple  disabilities  and complex  needs.

9
 Lesbians  and  aav  men:  sensitivity  to critical social

family issues unique to these clients.

h.
 Hearinq  im~aired:  access  to  TDD  and  hearing  imp 
interpreter  services. 
i.
 ~  eed  o  end  snecific  c  treatm 
Enrollees  must  be  provided  with  an  opportunity  to  re 
MH/CD  services  from the same  sex therapist  and the optio 
participating  in  an  all  male/all  female  group  th 
program. 
Children and adolescents.  i.ncludinu severelv  and  emotion

j. 
disturbed  (SED) children  and  children  involved  in the

protection  svstem:  services  specific  to the  needs  of

groups,  including  day  treatment,  home-based  mental  h

services,  and  inpatient  services.  The  services  which

Provider  delivers  must  be  provided  in the  least  restri

clinical  setting,  individualized  to meet  the  specific

of each child, and designed  to  insure early identific

and  treatment  of  mental  illness.  Services  mus

coordinated with the childs county case manager.

C-29
 k.  Pevelornn entallv  Dlsabled  (DD]   ti  specialized  mental  health  and 
habilitative  services  and  other  appropriate  services  covered 
by  MA.  Such  services  may  include:  family planning services 
adapted to the special needs of the developmentally disabled

population,  behavior  management,  rehabilitative  and

therapeutic services, pain management, or genetic counseling.

After an initial assessment, a written treatment plan must be

developed for the Enrollee when  appropriate.  As required,

the treatment plans  should provide access  to  a coordinated

outpatient  rehabilitation  team,  independent  living  skills

training,  ongoing  medical  skill  rechecks,  and  services

designed to maintain or increase function and prevent.further

deterioration or dependency.  The treatment  plan should be

coordinated with  available community  resources  and support

systems, including the individuals county DD  case manager.

The treatment  plan  must  identify  the persons  responsible  for

providing  services  and  a case manager.  For  those  Enrollees

with  multiple  handicaps,  a  multidisciplinary  provider

consultation  should  be arranged.  Although  continuity  of care

should  be  a  major  consideration  in  the  treatment  planning

process,  referrals  to specialists  and  subspecialists  must be

made when medically indicated.

B.  ~E
nrollee

The Provider must insure proper MA Enrollee access to services and must

comply with all of the requirements listed below:

1.	 Provider must agree to accept all eligible MA Enrollees who

select or who are assigned to the Health Plan without regard

to current or previous medical condition.

2.	 Provider  agrees  to  not  set  any  enrollment  limits on  the 
number  of  MA  recipients  which  it will  serve  unless  other 
arrangements are made with the Health Plan. 
3.	 MA  Enrollees  in  the  Health  Plan  may  not  be  charged  any

deductible  costs  or  be  asked  to  make  any  copayments for

covered services under PMAP.

4.	 Provider may not discriminate against any MA Enrollee on the

of:  race,  sex,  color, religion,  health ,status, a9e,

basis 
handicap,  national  origin,  public  assistance  status,  or

sexual orientation.

5.	 Provider  must  insure  that  its  services  are  accessible to

handicapped MA  Enrollees.  A  barrier-free  service delivery

access  point  must  be  available  for  Enrollees  who  use

wheelchairs.

C-30
 6. Provider  services  must  be  available  to  MA  Enrollees  to  the 
same  extent  that  such  services  are  available  to  the  general 
population.  Some walk-in  or  unscheduled clinic hours must be 
available each week to accommodate MA Enrollees who are ill. 
The  Provider  must  have  available a  24 hour/day number  for

7.
Enrollees to call in case of an emergency.

a.	 Upon request, Provider must arrange with the Health Plan for

any  Enrollee  to  obtain  a  second  medical  opinion  by  a  MA

Participating  Provider,  and  an  out  of  plan  second  medical 
opinion  for  MH/CD  services,  when  the  Provider  determines 
through  the  initial  assessment  process  that  no  structured

treatment is required.

Provider must insure Enrollee confidentiality, as required by

9. 
Minnesota	 Statutes  Chapter  13  (1986),  the  Minnesota

Government Data Practices Act.

10.  Provider  must  safeguard  the  confidentiality  of  certain

services  (i.e.  family  planning,  diagnosis  of  pregnancy,

diagnosis and treatment of sexually transmittable diseases,

and  MH/CD  services)  provided  to  Enrollees  who  are  minors

(under-age 21), to the-extent allowable by law.

c.  Case Management

Providerts  case  management  system  must  be designed to coordinate the

provision  of  services- to  Enrollees  and  must  promote  and  assure  service 
accessibility,  attention  to  individual  needs,  continuity  of  care, 
comprehensive  -and  coordinated  service  delivery,  the  provision  of 
culturally  appropriate  care  and  fiscal  and  professional  accountability. 
At  a  minimum,  the.  Providerts  case  management  system  must  incorporate 
the  following  elements: 
a.	 Procedures  for  the  provision  of  an  individual  needs

assessment, the development of an individual treatment plan,

the establishment of treatment objectives, the monitoring of

outcomes,  and  a  process  to  insure  that  treatment  plans  are

revised  as  necessary.  These  procedures  must  be designed  to

accommodate  the specific  cultural  and linguistic  needs of the

Enrollees.

b.	 A  strategy  to  ensure  that  all  Enrollees  and/or  authorized

family  members  or  guardians  are  involved  in  treatment

planning and consent to the medical treatment.

c.	 A  method  for  coordinating  the  medical  needs  of  an  Enrollee 
with his/her  social  service  needs.  This  may  involve working 
with  county  social  service  staff  or  with  the  various 
community  resources  in  the  county.  Coordination  with  the 
county  social  service  staff  will  be  required  when  the 
Enrollee  is  in  need  of  the  following  services:  case 
C-31  . -. 
management  for  serious  and  persistent  mental  illness  or

seriously  emotionally  disturbed  children,  prepetition

screening, preadmission screening or elderly waiver  servicesl 
extended  care  or  halfway  house  services  through  the 
Consolidated  Chemical  Dependency  Treatment  Fund,  child 
protection,  court  ordered  treatment,  or  a  state  medical

review team or social security disability determination.

d.
 Procedures and criteria for making referrals to specialists

and subspecialists.

e.  Capacity  to  implement;  when  indicated,  case  management

functions  such  as:  individual  needs  assessment,  including

screening  for  special  needs  (e.g.  mental  health/chemical

dependency  problems,  mental  reta~dation~  high  risk  health 
problems,  difficulty  living  independently,  functional 
problems,  language  or  comprehension  barriers);  individual 
treatment  plan  development;  establishment  of  treatment 
objectives;  treatment  follow-up;  monitoring  of  outcones; 
revision  of  treatment plan. 
f.
 Procedures for insuring that appropriate Clinic Professionals

interact  with  the  school  districts  and  participate  in

developing  individualized  education  plans  (IEPs)  or

individualized family  service  plans  (IFSP) for  school  age

Enrollees, and providing for transportation, if services in

the IEP or IFSP are provided outside of the childs school.

C-32  -