Exhibit 10.1

 

UTAH DEPARTMENT OF HEALTH

Box 143104

288 North 1460 West, Salt Lake City, Utah  84114- 3104

CONTRACT

 

H0535503

 

 

Department Log Number

 

State Contract Number

 

1.                            CONTRACT NAME:

The name of this Contract is Health Plan - Molina.

 

2.                            CONTRACTING PARTIES:

This Contract is between the Utah Department of Health (DEPARTMENT), and Molina
Healthcare of Utah (CONTRACTOR).

 

3.                            CONTRACT PERIOD:

The service period of this Contract will be January 1, 2006 through June 30,
2006, unless terminated or extended by agreement in accordance with the terms
and conditions of this Contract.  This Contract may be extended annually 1
times, at the option of the DEPARTMENT, by means of an amendment to this
Contract.  Such extension must be in writing.

 

4.                            CONTRACT AMOUNT:

The CONTRACTOR will be paid up to a maximum amount of $90,000,000.00 in
accordance with the provisions in this Contract.  This Contract is funded with
70.76% Federal funds and with 29.24% State funds.  The CFDA # is 93.778 and
relates to the federal funds provided.

 

5.                            CONTRACT INQUIRIES:

Inquiries regarding this Contract shall be directed to the following
individuals:

 

CONTRACTOR

 

 

 

DEPARTMENT

 

 

Contact Person:

 

Brian Monsen

 

Program:

 

Managed Health Care

Business Address:

 

7050 Union Park Ctr #200

 

Contact Person:

 

Julie Olson

 

 

Salt Lake City, UT 84074

 

Phone Number:

 

(801) 538-6505

Phone Number:

 

(801) 587-6443

 

 

 

 

 

6.         REFERENCE TO ATTACHMENTS INCLUDED AS PART OF THIS CONTRACT:

 

Attachment A:

Utah Department of Health General Provisions

Attachment B:

Special Provisions

Attachment C:

Covered Services

Attachment D:

Utah’s Quality Assessment and Performance Improvement Plan

Attachment E:

Medicaid Enrollment (Table 1), Cost Date (Table 2), Utilization Data (Table 3),
Medicaid

 

Malpractice Information (Table 4)

Attachment F:

Payment Methodology

 

7.         PROVISIONS INCORPORATED INTO THIS CONTRACT BY REFERENCE, BUT NOT
ATTACHED HERETO:

 

A.                  All other governmental laws, rules, regulations, or actions
applicable to services provided herein.

 

B.                    If the CONTRACTOR has provided the DEPARTMENT with
Assurances, then the DEPARTMENT is entering into this agreement based upon the
Assurances provided by the CONTRACTOR and the Assurances are incorporated by
reference.

 

8.         If the CONTRACTOR is not a local public procurement unit as defined
by the Utah Procurement Code (UCA § 63-56-5), this Contract must be signed by a
representative of the State Division of Finance and the State Division of
Purchasing to bind the State and the DEPARTMENT to this Contract.

 

9.        This Contract, its attachments, and all documents incorporated by
reference constitute the entire agreement between the parties and supercede all
prior negotiations, representations, or agreements, either written or oral
between the parties relating to the subject matter of this Contract.

 

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IN WITNESS WHEREOF, the parties sign this Contract.

 

CONTRACTOR:

Molina Healthcare of Utah

 

 

UTAH DEPARTMENT OF HEALTH

 

 

 

 

 

 

By:

      /s/ G. Kirk Olsen

 

 

By:

     /s/ Shari A. Watkins

 

Signature of Authorized Individual

Date

 

Shari A. Watkins, C.P.A.

Date

 

 

Director

Print Name:

    G. Kirk Olsen

 

 

Office of Fiscal Operations 

 

 

 

Title:

Chief Executive Officer

 

 

 

 

 

 

 

State Finance:

Date 

 

 

 

 

     33-0617992

 

 

 

 

 

Federal Tax Identification Number

 

State Purchasing:

Date

 

1

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ATTACHMENT “A”

 

UTAH DEPARTMENT OF HEALTH

 

General Provisions

 

I. CONTRACT DEFINITIONS

1

 

 

II. AUTHORITY

1

 

 

III. MISCELLANEOUS PROVISIONS

2

 

 

IV. UTAH INDOOR CLEAN AIR ACT

3

 

 

V. RELATED PARTIES & CONFLICTS OF INTEREST

4

 

 

VI. OTHER CONTRACTS

4

 

 

VII. SUBCONTRACTS & ASSIGNMENTS

4

 

 

VIII. FURTHER WARRANTY

4

 

 

IX. INFORMATION OWNERSHIP

4

 

 

X. SOFTWARE OWNERSHIP

4

 

 

XI. INFORMATION PRACTICES

5

 

 

XII. INDEMNIFICATION

5

 

 

XIII. SUBMISSION OF REPORTS

6

 

 

XIV. PAYMENT

6

 

 

XV. RECORD KEEPING, AUDITS, & INSPECTIONS

6

 

 

XVI. CONTRACT ADMINISTRATION REQUIREMENTS

7

 

 

XVII. DEFAULT, TERMINATION, & PAYMENT ADJUSTMENT

9

 

 

XVIII. FEDERAL REQUIREMENTS

10

 

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ATTACHMENT “A”

 

UTAH DEPARTMENT OF HEALTH GENERAL PROVISIONS

 

I. CONTRACT DEFINITIONS

 

The following definitions apply in these general provisions:

 

“Assign” or “Assignment” means the transfer of all rights and delegation of all
duties in the contract to another person.

 

“Business” means any corporation, partnership, individual, sole proprietorship,
joint stock company, joint venture, or any other private legal entity.

 

“This Contract” means this agreement between the Department and the Contractor,
including both the General Provisions and the Special Provisions.

 

“The Contractor” means the person who delivers the services or goods described
in this Contract, other than the state or the Department.

 

“The Department” means the Utah Department of Health.

 

“Director” means the Executive Director of the Department or authorized
representative.

 

“Equipment” means capital equipment which costs at least $1,000 and has a useful
life of one year or more unless a different definition or amount is set forth in
the Special Provisions or specific Department Program policy as described in
writing to Contractor.

 

“Federal law” means the constitution, orders, case law, statutes, rules, and
regulations of the federal government.

 

“General provisions” means those provisions of this Contract which are set forth
under the heading “General Provisions.”

 

“Governmental entity” means a federal, state, local, or federally-recognized
Indian tribal government, or any subdivision thereof.

 

“Individual” means a living human being.

 

“Local health department” means a local health department as defined in §
26A-1-102, Utah Code Annotated, 1953 as amended (UCA.).

 

“Non-governmental entity” means privately held non-profit or for profit
organization not classified as a “Governmental entity.”

 

“Person” means any governmental entity, business, individual, union, committee,
club, other organization, or group of individuals.

 

“Recipient” means an individual who is eligible for services provided by the
Department or by an authorized Contractor of the Department under the terms of
this Contract.

 

“Services” means the furnishing of labor, time, or effort by a Contractor, not
involving the delivery of a specific end product other than reports which are
merely incidental to the required performance.

 

“Special provisions” means those provisions of this Contract which are in
addition to the General Provisions and which more fully describe the goods or
services covered by this Contract.

 

“State” means the State of Utah.

 

“State law” means the constitution, orders, case law, statutes, and rules, of
the state.

 

“Subcontract” means any signed agreement between the Contractor and a third
party to provide goods or services for which the Contractor is obligated, except
purchase orders for standard commercial equipment, products, or services.

 

“Subcontractor” means the person who performs the services or delivers the goods
described in a subcontract.

 

II. AUTHORITY

 

1. The Department’s authority to enter into this Contract is derived from
Chapter 56, Title 63, UCA; Titles 26 and 26A, UCA; and from related statutes.

 

2. The Contractor represents that it has the institutional, managerial, and
financial capability to ensure proper planning, management, and completion of
the project or services described in this Contract.

 

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III. MISCELLANEOUS PROVISIONS

 

1. For reference clarity, as used in these General Provisions: “ARTICLE” refers
to a major topic designated by capitalized roman numerals; “SECTION” refers to
the next lower numbered heading designated by arabic numerals, and “SUBSECTIONS”
refers to the next two lower headings designated by lower case letters and lower
case roman numerals.

 

2. If the General Provisions and the special provisions of this Contract
conflict, the special provisions govern.

 

3. These provisions distinguish between two Contractor types: Governmental and
Non-governmental. Unspecified text applies to both types. Type-specific
statements appear in bold print (e.g., Non-governmental entities only).

 

4. Once signed by the Director and the State Division of Finance, when
applicable, and the State Division of Purchasing, when applicable, this Contract
becomes effective on the date specified in this Contract. Changes made to the
unsigned Contract document shall be initialed by both persons signing this
Contract on page one. Changes made to this Contract after the signatures are
made on page one may only be made by a separate written amendment signed by
persons authorized to amend this Contract.

 

5. Neither party may enlarge, modify, or reduce the terms, scope of work, or
dollar amount in this Contract, except by written amendment as provided in
section 4.

 

6. This Contract and the contracts that incorporate its provisions contain the
entire agreement between the Department and the Contractor. Any statements,
promises, or inducements made by either party or the agent of either party which
are not contained in the written Contract or other contracts are not valid or
binding.

 

7. The Contractor shall comply with all applicable laws regarding federal and
state taxes, unemployment insurance, disability insurance, and workers’
compensation.

 

8. The Contractor is an independent Contractor, having no authorization, express
or implied, to bind the Department to any agreement, settlement, liability, or
understanding whatsoever, and agrees not to perform any acts as agent for the
Department unless expressly set forth herein. Compensation stated herein shall
be the total amount payable to the Contractor by the Department. The Contractor
shall be responsible for the payment of all income tax and social security
amounts due as a result of payments received from the Department for these
contract services.

 

9. The Contractor shall maintain all licenses, permits, and authority required
to accomplish its obligations under this Contract.

 

10. The Contractor shall obtain prior written Department approval before
purchasing any equipment with contract funds.

 

11. Notice shall be in writing, directed to the contact person on page one of
this Contract, and delivered by certified mail or by hand to the other party’s
most currently known address. The notice shall be effective when placed in the
U.S. mail or hand-delivered.

 

12. The Department and the Contractor shall attempt to resolve contract disputes
through available administrative remedies prior to initiating any court action.

 

13. This Contract shall be construed and governed by the laws of the State of
Utah. The Contractor submits to the jurisdiction of the courts of the State of
Utah for any dispute arising out of this Contract or the breach thereof. The
proper venue of any legal action arising under this contract shall be in Salt
Lake City, Utah.

 

14. Any court ruling or other binding legal declaration which declares that any
provision of this Contract is illegal or void, shall not affect the legality and
enforceability of any other provision of this Contract, unless the provisions
are mutually dependent.

 

15. The Contractor agrees to maintain the confidentiality of records that it
holds as agent for the Department as required by the Government Records Access
and Management Act, Title 63, Chapter 2, UCA and the confidentiality of records
requirements of Title 26, UCA.

 

16. The Contractor agrees to abide by the State of Utah’s executive order, dated
March 17,1993, which prohibits sexual harassment in the workplace.

 

17. The waiver by either party of any provision, term, covenant or condition of
this Contract shall not be deemed to be a waiver of any other provision,
covenant or condition of this Contract nor any subsequent breach of the same or
any other provision, term, covenant or condition of this Contract.

 

18. The Contractor agrees to warrant and assume responsibility for each
hardware, firmware, and/or software product (hereafter called the product) that
it licenses, or sells, to the Department under this Contract. The Contractor

 

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acknowledges that the Uniform Commercial Code applies to this Contract. In
general, the Contractor warrants that:

 

(a) the product will do what the salesperson said it would do, (b) the product
will live up to all specific claims that the manufacturer makes in their
advertisements, (c) the product will be suitable for the ordinary purposes for
which such product is used, (d) the product will be suitable for any special
purposes that the Department has relied on the Contractor’s skill or judgement
to consider when it advised the Department about the product, (e) the product
has been properly designed and manufactured, and (f) the product is free of
significant defects or unusual problems about which the Department has not been
warned.

 

19. The State of Utah’s sales and use tax exemption number is E33399. The
tangible personal property or services being purchased are being paid for from
State funds and used in the exercise of that entity’s essential functions. If
the items purchased are construction materials, they will be converted into real
property by employees of this government entity, unless otherwise stated in the
contract.

 

20. The Contractor agrees that the Contract will be a public document, and may
be available for distribution. Contractor gives the Department express
permission to make copies of the Contract and/or of the response to the
solicitation in accordance with State of Utah Government Records Access and
Management Act. The permission to make copies as noted will take precedence over
any statements of confidentiality, proprietary information, copyright
information, or similar notation.

 

21. This Contract may be amended, modified, or supplemented only by written
amendment to the Contract, executed by the parties hereto, and attached to the
original, signed copy of the Contract..

 

22. Unless otherwise specified in this Contract, all deliveries will be F.O.B.
destination with all transportation and handling charges paid by the Contractor.
Responsibility and liability for loss or damage will remain with Contractor
until final inspection and acceptance, when responsibility will pass to the
Department, except as to latent defects, fraud and Contractor’s warranty
obligations.

 

23. All orders will be shipped promptly in accordance with the delivery
schedule. The Contractor will promptly submit invoices (within 30 days of
shipment or delivery of services) to the Department. The State contract number
and/or the agency purchase order number shall be listed on all invoices, freight
tickets, and correspondence relating to the Contract order. The prices paid by
the Department will be those prices listed in the Contract. The Department has
the right to adjust or return any invoice reflecting incorrect pricing.

 

24. The Contractor will release, indemnify, and hold the State, its officers,
agents, and employees harmless from liability of any kind or nature, including
the Contractor’s use of any copyrighted or un-copyrighted composition, secret
process, patented or un-patented invention, article, or appliance furnished or
used in the performance of this Contract.

 

25. Neither party to this Contract will be held responsible for delay or default
caused by fire, riot, acts of God, and/or war which is beyond that party’s
reasonable control. The Department may terminate this Contract after determining
that such delay or default will reasonably prevent successful performance of the
Contract.

 

26. The Contractor understands that a person who is interested in any way in the
sale of any supplies, services, construction, or insurance to the State of Utah
is violating the law if the person gives or offers to give any compensation,
gratuity, contribution, loan, or reward, or any promise thereof to any person
acting as a procurement officer on behalf of the State, or who in any official
capacity participates in the procurement of such supplies, services,
construction, or insurance, whether it is given for their own use or for the use
or benefit of any other person or organization (63-56-73, Utah Code Annotated,
1953 as amended).

 

27. Contractor Terms and Conditions that apply must be in writing and attached
to the Contract. No other Terms and Conditions will apply to this Contract,
including terms listed or referenced on a Contractor’s website, terms listed in
a Contractor quotation/sales order, etc. In the event of any conflict in the
contract terms and conditions, the order of precedence shall be: a. Department
General Provisions; b. Department Special Provisions; c. Contractor Terms and
Conditions.

 

IV. UTAH INDOOR CLEAN AIR ACT

 

The Contractor, for all personnel operating within the State of Utah, shall
comply with the Utah Indoor Clean Air Act, Title 26, Chapter 38, UCA, which
prohibits smoking in public places.

 

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V. RELATED PARTIES & CONFLICTS OF INTEREST

 

1. The Contractor may not pay related parties for goods, services, facilities,
leases, salaries, wages, professional fees, or the like for contract expenses
without the prior written consent of the Department. The Department may consider
the payments to the related parties as disallowed expenditures and accordingly
adjust the Department’s payment to the Contractor for all related party payments
made without the Department’s consent. As used in this section, “related
parties” means any person related to the Contractor by blood, marriage,
partnership, common directors or officers, or 10% or greater direct or indirect
ownership in a common entity.

 

2. The Contractor shall comply with the Public Officers’ and Employees’ Ethics
Act, § 67-16-10, UCA, which prohibits actions that may create or that are actual
or potential conflicts of interest. It also provides that “no person shall
induce or seek to induce any public officer or public employee to violate any of
the provisions of this act.” The Contractor represents that none of its officers
or employees are officers or employees of the State of Utah, unless disclosure
has been made in accordance with § 67-16-8, UCA.

 

VI. OTHER CONTRACTS

 

1. The Department may perform additional work related to this Contract or award
other contracts for such work. The Contractor shall cooperate fully with other
contractors, public officers, and public employees in scheduling and
coordinating contract work. The Contractor shall give other contractors
reasonable opportunity to execute their work and shall not interfere with the
scheduled work of other contractors, public officers, and public employees.

 

2. The Department shall not unreasonably interfere with the Contractor’s
performance of its obligations under this Contract.

 

VII. SUBCONTRACTS & ASSIGNMENTS

 

The Contractor shall not assign, sell, transfer, subcontract, or sublet rights
or delegate responsibilities under this Agreement, in whole or part, without the
prior written consent of the Department. The Department agrees that the
Contractor may partially subcontract services, provided that the Contractor
retains ultimate responsibility for performance of all terms, conditions and
provisions of this Agreement. When subcontracting, the Contractor agrees to use
written subcontracts that conform with Federal and State laws. The Contractor
shall request Department approval for any assignment at least 20 days prior to
its effective date.

 

VIII. FURTHER WARRANTY

 

The Contractor warrants that (a) all services shall be performed in conformity
with the requirements of this Contract by qualified personnel in accordance with
generally recognized standards; and (b) all goods or products furnished pursuant
to this Contract shall be free from defects and shall conform to contract
requirements. For any item that the Department determines does not conform with
the warranty, the Department may arrange to have the item repaired or replaced,
either by the Contractor or by a third party at the Department’s option, at the
Contractor’s expense.

 

IX. INFORMATION OWNERSHIP

 

Except for confidential medical records held by direct care providers, the
Department shall own exclusive title to all information gathered, reports
developed, and conclusions reached in performance of this Contract. The
Contractor may not use, except in meeting its obligations under this Contract,
information gathered, reports developed, or conclusions reached in performance
of this Contract without the express written consent of the Department.

 

X. SOFTWARE OWNERSHIP

 

1. If the Contractor develops or pays to have developed computer software
exclusively with funds or proceeds from this Contract to perform its obligations
under this Contract, or to perform computerized tasks that it was not previously
performing to meet its obligations under this Contract, the computer software
shall be exclusively owned by or licensed to the Department. In the case of
software owned by the Department, the Department grants to the Contractor a
nontransferable, nonexclusive license to use the software in the performance of
this Contract. In the case of software licensed to the Department, the
Department grants to the Contractor permission to use the software in the
performance of this Contract. This license or permission, as the case may be,
terminates when the Contractor

 

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has completed its work under this Contract.

 

2. If the Contractor develops or pays to have developed computer software which
is an addition to existing software owned by or licensed exclusively with funds
or proceeds from this Contract, or to modify software to perform computerized
tasks in a manner different than previously performed, to meet its obligations
under this Contract, the addition shall be exclusively owned by or licensed to
the Department. In the case of software owned by the Department, the Department
grants to the Contractor a nontransferable, nonexclusive license to use the
software in the performance of this Contract. In the case of software licensed
to the Department, the Department grants to the Contractor permission to use the
software in the performance of this Contract. This license or permission, as the
case may be, terminates when the Contractor has completed its work under this
Contract.

 

3. If the Contractor uses computer software licensed to it which it does not
modify or program to handle the specific tasks required by this Contract, then
to the extent allowed by the license agreement between the Contractor and the
owner of the software, the Contractor grants to the Department a continuing
nonexclusive license to use the software, either by the Department or by a
different Contractor, to perform work substantially identical to the work
performed by the Contractor under this Contract. If the Contractor cannot grant
the license as required by this section, then the Contractor shall reveal the
input screens, report formats, data structures, linkages, and relations used in
performing its obligations under this Contract in such a manner to allow the
Department or another Contractor to continue the work performed by the
Contractor under this Contract.

 

4. The Contractor shall deliver to the Department a copy of the software or
information required by this Article within 90 days after the commencement of
this Contract and thereafter immediately upon making a modification to any of
the software which is the subject of this Contract.

 

XI. INFORMATION PRACTICES

 

1. (Governmental entities only) The Contractor shall establish, maintain, and
practice information procedures and controls that comply with Federal and State
law. The Contractor assures that any information about an individual that it
receives or requests from the Department pursuant to this Contract is necessary
to the performance of its duties and functions and that the information will be
used only for the purposes set forth in this Contract. The Department shall
inform the Contractor of any non-public designation of any information it
provides to the Contractor.

 

2. (Non-governmental entities only) The Contractor shall establish, maintain,
and practice information procedures and controls that comply with Federal and
State law. The Contractor may not release any information regarding any person
from any information provided by the Department, unless the Department first
consents in writing to the release.

 

XII. INDEMNIFICATION

 

1. (Governmental entities only) It is mutually agreed that each party assumes
liability for the negligent or wrongful acts committed by its own agents,
officials, or employees, regardless of the source of funding for this Contract.
Neither party waives any rights or defenses otherwise available under the
Governmental Immunity Act.

 

2. (Non-governmental entities only) To the extent authorized by law, the
Contractor shall indemnify and hold harmless the Department and any of its
agents, officers, and employees, from any claims, demands, suits, actions,
proceedings, loss, injury, death, and damages of every kind and description,
including any attorney’s fees and litigation expenses, which may be brought,
made against, or incurred by that party on account of loss or damage to any
property, or for injuries to or death of any person, caused by, arising directly
or indirectly out of, or contributed to in whole or in part, by reason of any
alleged act, omission, professional error, fault, mistake, or negligence of the
Contractor or its employees, agents, or representatives, or subcontractors or
their employees, agents, or representatives, in connection with, incident to, or
arising directly or indirectly out of this Contract, or arising out of workers’
compensation claims, unemployment, or claims under similar such laws or
obligations.

 

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XIII. SUBMISSION OF REPORTS

 

If the Contractor is a Local Health Department, it shall submit monthly
expenditure reports to the Department in a format approved by the Department.
All other Contractors shall submit monthly summarized billing statements to the
Department. Expenditure reports and billing statements must be submitted to the
Department within 30 days following the last day of the month in which the
expenditures were incurred or the services provided.

 

XIV. PAYMENT

 

1. If a recipient, a recipient’s insurance, or any third-party is responsible to
pay for services rendered pursuant to this Contract, the Contractor shall bill
and collect for the goods or services provided to the recipient. The Department
shall reimburse total actual expenditures, less amounts collected as required by
this section.

 

2. Under no circumstances shall the Department authorize payment to the
Contractor that exceeds the amount specified in this Contract without an
amendment to the Contract.

 

3. The Department agrees to make every effort to pay for completed services, and
payments are conditioned upon receipt of applicable, accurate, and completed
reports prepared by the Contractor and delivered to the Department. The
Department may delay or deny payment for final expenditure reports received more
than 20 days after the Contractor has satisfied all Contract requirements.

 

4. In the case that funds are not appropriated or are reduced, the Department
will reimburse Contractor for products delivered or services performed through
the date of cancellation or reduction, and the Department will not be liable for
any future commitments, penalties, or liquidated damages.

 

XV. RECORD KEEPING, AUDITS, & INSPECTIONS

 

1. The Contractor shall use an accrual or a modified accrual basis for reporting
annual fiscal data, as required by Generally Accepted Accounting Principles
(GAAP). Required monthly or quarterly reports may be reported using a cash
basis.

 

2. The Contractor and any subcontractors shall maintain financial and operation
records relating to contract services, requirements, collections, and
expenditures in sufficient detail to document all contract fund transactions.
The Contractor and any subcontractors shall maintain and make all records
necessary and reasonable for a full and complete audit, inspection, and
monitoring of services by state and federal auditors, and Department staff
during normal business hours or by appointment, until all audits and reviews
initiated by federal and state auditors are completed, or for a period of four
years from the date of termination of this Contract, whichever is longer, or for
any period required elsewhere in this Contract.

 

3. The Contractor shall retain all records which relate to disputes,
litigations, claim settlements arising from contract performance, or
cost/expense exceptions initiated by the Director, until all disputes,
litigations, claims, or exceptions are resolved.

 

4. The Contractor shall comply with federal and state regulations concerning
cost principles, audit requirements, and grant administration requirements,
cited in Table 1. Unless specifically exempted in this Contract’s special
provisions, the Contractor must comply with applicable federal cost principles
and grant administration requirements if state funds are received. The
Contractor shall also provide the Department with a copy of all reports required
by the State Legal Compliance Audit Guide (SLCAG) as defined in Chapter 2, Title
51, UCA. All federal and state principles and requirements cited in Table 1 are
available for inspection at the Utah Department of Health during normal business
hours. A Contractor who receives $100,000 or more in a year from all federal or
from all state sources may be subject to federal and state audit requirements. A
Contractor who receives $500,000 for fiscal years ending after December 31, 2003
or more per year from federal sources may be subject to the federal single audit
requirement. Counties, cities, towns, school districts, and all non-profit
corporations that receive 50 percent or more of its funds from federal, state or
local governmental entities are subject to the State of Utah Legal Compliance
Audit Guide. Copies of required audit reports shall be sent to the Utah
Department of Health, Bureau of Financial Audit, Box 144002, Salt Lake City,
Utah 84114-4002.

 

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Federal and State Principles and Requirements

 

 

 

Cost

 

Federal Audit

 

State Audit

 

Grant Admin.

Contractor

 

Principles

 

Requirements

 

Requirements

 

Requirements

State or Local Govt. & Indian Tribal Govts.

 

OMB Circular A-87

 

OMB Circular A-133

 

SLCAG

 

OMB Common Rule

 

 

 

 

 

 

 

 

 

Hospitals

 

45 CFR 74, App. E

 

OMB Circular A-133

 

SLCAG

 

OMB Common Rule

 

 

 

 

 

 

 

 

or Circular A-110

 

 

 

 

 

 

 

 

 

College or University

 

OMB Circular A-21

 

OMB Circular A-133

 

SLCAG

 

OMB Circular A-110

 

 

 

 

 

 

 

 

 

Non-Profit Organization

 

OMB Circular A-122

 

OMB Circular A-133

 

SLCAG

 

OMB Circular A-110

 

 

 

 

 

 

 

 

 

For-Profit Organization

 

48 CFR 31

 

n/a

 

n/a

 

OMB Circular A-110

 

Documents

 

Web Address

OMB Circulars

 

http://www.whitehouse.gov/omb/circulars/index.html

 

 

 

OMB Common Rule

 

http://www.whitehouse.gov/omb/grants/attach.html

 

 

 

CFRs

 

http://www.access.gpo.gov/nara/cfr/cfr-table-search.html

 

 

 

SLCAG

 

http://www.sao.state.ut.us/resources/resources-lg.htm

 

Table 1

 

XVI. CONTRACT ADMINISTRATION REQUIREMENTS

 

The Contractor agrees to administer this Contract in compliance with either OMB
Common Rule or OMB Circular A-110 depending upon the legal status of the of the
Contractor as shown in Table 1. Financial management, procurement, and
affirmative step requirements specify that:

 

1. the Contractor must have fiscal control and accounting procedures sufficient
to:

 

a. permit preparation of reports required by this Contract, and

 

b. permit the tracing of funds to a level of expenditures adequate to establish
that such funds have not been used in violation of the restrictions and
prohibitions of applicable statutes.

 

2. the Contractor’s financial management systems must meet the following
standards:

 

a. financial reporting. Accurate, current, and complete disclosure of the
financial results of financially assisted activities must be made in accordance
with the financial reporting requirements of this Contract.

 

b. accounting records. The Contractor must maintain records which adequately
identify the source and application of funds provided for federally
financially-assisted activities. These records must contain information
pertaining to the Contract’s awards and authorizations, obligations, unobligated
balances, assets, liabilities, outlays or expenditures, and income.

 

c. internal control. Effective control and accountability must be maintained for
all Contract cash, real and personal property, and other assets. The Contractor
must adequately safeguard all such property and must assure that it is used
solely for authorized purposes.

 

d. budget control. Actual expenditures or outlays must be compared with budgeted
amounts for the Contract Financial information must be related to performance or
productivity data, including the development of unit cost information whenever
appropriate or specifically required in this Contract. If unit cost data are
required, estimates based on available documentation will be accepted whenever
possible.

 

3. Federal OMB cost principles, federal agency program regulations, and the
terms of grant and subgrant, and contract agreements will be followed in
determining the reasonableness, allowability, and allocability of costs.

 

a. source documentation. Accounting records must be supported by such source
documentation as canceled checks, paid bills, payrolls, time and attendance
records, contract and subcontract award documents, etc.

 

b. cash management. Procedures for minimizing the time elapsing between the
transfer of funds from the U.S. Treasury and disbursement by the Department and
the Contractor must be followed whenever advance payment procedures are used.

 

7

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4. the Contractor shall use its own procurement procedures which reflect
applicable State and local laws, rules, and regulations, provided that the
procurements conform to applicable Federal law and the standards identified in
this Contract.

 

a. The Contractor will maintain a contract administration system which ensures
that subcontractors perform in accordance with the terms, conditions, and
specifications of its contracts or purchase orders.

 

b. The Contractor will maintain a written code of standards of conduct governing
the performance of its employees engaged in the award and administration of
contracts. No employee, officer or agent of the Department or the Contractor
shall participate in selection, or in the award or administration of a contract
supported by federal funds if a conflict of interest, real or apparent, would be
involved. Such a conflict would arise when:

 

i. the employee, officer or agent,

ii. any member of his immediate family,

iii. his or her partner; or

iv. an organization which employs, or is about to employ, any of the above, has
a financial or other interest in the firm selected for award. The Department’s
or the Contractor’s officer, employees or agents will neither solicit nor accept
gratuities, favors or anything of monetary value from contractors, potential
contractors, or parties to subagreements. The Department and the Contractor may
set minimum rules where the financial interest is not substantial or the gift is
an unsolicited item of nominal intrinsic value. To the extent permitted by State
or local law or regulations, such standards or conduct will provide for
penalties, sanctions, or other disciplinary actions for violations of such
standards by the Department’s or the Contractor’s officers, employees, or
agents, or by subcontractors or their agents.

 

c. The Contractor’s procedures will provide for a review of proposed
procurements to avoid purchase of unnecessary or duplicative items.
Consideration should be given to consolidating or breaking out procurements to
obtain a more economical purchase. Where appropriate, an analysis will be made
of lease versus purchase alternatives, and any other appropriate analysis to
determine the most economical approach.

 

d. To foster greater economy and efficiency, the Contractor, if a governmental
entity, is encouraged to enter into State and local intergovernmental agreements
for procurement or use of common goods and services.

 

e. If allowed by law, the Contractor is encouraged to use Federal excess and
surplus property in lieu of purchasing new equipment and property whenever such
use is feasible and reduces project costs.

 

f. The Contractor may contract only with responsible contractors possessing the
ability to perform successfully under the terms and conditions of a proposed
procurement.

 

g. The Contractor shall maintain records sufficient to detail the significant
history of a procurement. These records shall include, but are not necessarily
limited to the following:

 

i. the rationale for the method of procurement,

ii. selection of contract type,

iii. contractor selection or rejection, and

iv. the basis for the contract price.

 

h. The Contractor may use time and material type contracts only:

i. after a determination that no other contract is suitable, and

ii. if the Contract includes a ceiling price that the Contractor exceeds at its
own risk.

 

i. The Contractor alone will be responsible, in accordance with good
administrative practice and sound business judgment, for the settlement of all
contractual and administrative issues arising out of procurements. These issues
include, but are not limited to source evaluation, protests, disputes, and
claims. These standards do not relieve the Contractor of any contractual
responsibilities under its contracts.

 

j. The Contractor shall have protest procedures to handle and resolve disputes
relating to its procurements and shall in all instances disclose information
regarding the protest to the federal funding agency. A protestor must exhaust
all administrative remedies with the Department and the Contractor before
pursuing a protest with the federal funding agency.

 

5. the Contractor shall take all necessary affirmative steps to assure that
minority firms, women’s business enterprises, and labor surplus area firms are
used when possible. Affirmative steps shall include:

 

a. placing qualified small and minority businesses and women’s business
enterprises on solicitation lists;

 

b. assuring that small and minority businesses, and women’s business enterprises
are solicited whenever they

 

8

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are potential sources;

 

c. dividing total requirements, when economically feasible, into smaller tasks
or quantities to permit maximum participation by small and minority business,
and women’s business enterprises;

 

d. establishing delivery schedules, where the requirement permits, which
encourage participation by small and minority business, and women’s business
enterprises;

 

e. using the services and assistance of the Small Business Administration, and
the Minority Business Development Agency of the Department of Commerce; and

 

f. requiring the prime contractor, if subcontracts are to be let, to take the
affirmative steps listed in Article XVI, section 5, subsections a - e.

 

XVII. DEFAULT, TERMINATION, & PAYMENT ADJUSTMENT

 

1. Each party may terminate this Contract with cause. If the cause for
termination is due to the default of a party, the non-defaulting party shall
send a notice, which meets the notice requirements of this Contract, citing the
default and giving notice to the defaulting party of its intent to terminate.
The defaulting party may cure the default within fifteen days of the notice. If
the default is not cured within the fifteen days, the party giving notice may
terminate this Contract 45 days from the date of the initial notice of default
or at a later date specified in the notice.

 

2. The Department may terminate this Contract without cause, in advance of the
specified termination date, upon 30 days written notice.

 

3. The Department agrees to use its best efforts to obtain funding for
multi-year contracts. If continued funding for this Contract is not appropriated
or budgeted at any time throughout the multi-year contract period, the
Department may terminate this Contract upon 30 days notice.

 

4. If funding to the Department is reduced due to an order by the Legislature or
the Governor, or is required by federal or state law, the Department may
terminate this Contract or proportionately reduce the services and goods due and
the amount due from the Department upon 30 days written notice. If the specific
funding source for the subject matter of this Contract is reduced, the
Department may terminate this Contract or proportionately reduce the services
and goods due and the amount due from the Department upon 30 written notice
being given to the Contractor.

 

5. If the Department terminates this Contract, the Department may procure
replacement goods or services upon terms and conditions necessary to replace the
Contractor’s obligations. If the termination is due to the Contractor’s failure
to perform, and the Department procures replacement goods or services, the
Contractor agrees to pay the excess costs associated with obtaining the
replacement goods or services.

 

6. If the Contractor terminates this Contract without cause, the Department may
treat the Contractor’s action as a default under this Contract.

 

7. The Department may terminate this Contract if the Contractor becomes
debarred, insolvent, files bankruptcy or reorganization proceedings, sells 30%
or more of the company’s assets or corporate stock, or gives notice of its
inability to perform its obligations under this Contract.

 

8. If the Contractor defaults in any manner in the performance of any obligation
under this Contract, or if audit exceptions are identified, the Department may,
at its option, either adjust the amount of payment or withhold payment until
satisfactory resolution of the default or exception. Default and audit
exceptions for which payment may be adjusted or withheld include disallowed
expenditures of federal or state funds as a result of the Contractor’s failure
to comply with federal regulations or state rules. In addition, the Department
may withhold amounts due the Contractor under this Contract, any other current
contract between the Department and the Contractor, or any future payments due
the Contractor to recover the funds. The Department shall notify the Contractor
of the Department’s action in adjusting the amount of payment or withholding
payment. This Contract is executory until such repayment is made.

 

9. The rights and remedies of the Department enumerated in this article are in
addition to any other rights or remedies provided in this Contract or available
in law or equity.

 

10. Upon termination of the Contract, all accounts and payments for services
rendered to the date of termination will be processed according to the financial
arrangements set forth herein for approved services rendered to date of
termination. If the Department terminates this Contract, the Contractor shall
stop all work as specified in the notice of termination. The Department shall
not be liable for work or services performed beyond the termination date as
specified in the notice of termination.

 

9

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11. Any of the following events will constitute cause for the Department to
declare Contractor in default of the Contract: a. Nonperformance of contractual
requirements; b. A material breach of any term or condition of this contract.
The Department will issue a written notice of default providing a ten (10) day
period in which Contractor will have an opportunity to cure. Time allowed for
cure will not diminish or eliminate Contractor’s liability for damages. If the
default remains, after Contractor has been provided the opportunity to cure, the
Department may do one or more of the following: c. Exercise any remedy provided
by law; d. Terminate this Contract and any related Contracts or portions
thereof; e. Impose liquidated damages, if liquidated damages are listed in the
Contract; f. Suspend Contractor from receiving future solicitations.

 

XVIII. FEDERAL REQUIREMENTS

 

The Contractor shall comply with all applicable federal requirements. To the
extent that the Department is able, the Department shall give further
clarification of federal requirements upon the Contractor’s request. If the
Contractor is receiving federal funds under this Contract, certain federal
requirements apply. The Contractor agrees to comply with the federal
requirements to the extent that they are applicable to the subject matter of
this Contract and are required by the amount of federal funds involved in this
Contract.

 

1. Civil Rights Requirements:

 

a. The Civil Rights Act of 1964, Title VI, provides that no person in the United
States shall, on the grounds of race, color, or national origin, be excluded
from participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity receiving federal financial
assistance. The Health and Human Services regulation implementing this
requirement is 45 CFR Part 80.

 

b. The Civil Rights Act of 1964, Title VII, (P.L. 88-352 & 42 U.S.C. § 2000e)
prohibits employers from discriminating against employees on the basis of race,
color, religion, national origin, and sex. Title VII applies to employers of
fifteen or more employees, and prohibits all discriminatory employment
practices.

 

c. The Rehabilitation Act of 1973, as amended, section 504, provides that no
otherwise qualified handicapped individual in the United States shall, solely by
reason of the handicap, be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under any program or activity
receiving federal financial assistance. The Health and Human Services regulation
45 CFR Part 84 implements this requirement.

 

d. The Age Discrimination Act of 1975, as amended (42 U.S.C. §§ 6101-6107),
prohibits unreasonable discrimination on the basis of age in any program or
activity receiving federal financial assistance. The Health and Human Services
regulation implementing the provisions of the Age Discrimination Act is 45 CFR
Part 91.

 

e. The Education Amendments of 1972, Title IX, (20 U.S.C. §§ 1681-1683 and
1685-1686), section 901, provides that no person in the United States shall, on
the basis of sex, be excluded from participation in, be denied the benefits of,
or be subjected to discrimination under any educational program or activity
receiving federal financial assistance. Health and Human Services regulation 45
CFR Part 86 implements this requirement.

 

f. Executive Order No. 11246, as amended by Executive Order 11375 relates to
“Equal Employment Opportunity,” (all construction contracts and subcontracts in
excess of $10,000)

 

g. Americans with Disabilities Act of 1990, (P.L.101-336), section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C. § 794), prohibits
discrimination on the basis of disability.

 

h. The Public Health Service Act, as amended, Title VII, section 704 and TITLE
VIII, section 855, forbids the extension of federal support for health manpower
and nurse training programs authorized under those titles to any entity that
discriminates on the basis of sex in the admission of individuals to its
training programs. Health and Human Services regulation implementing this
requirement is 45 CFR Part 83.

 

i. The Public Health Service Act, as amended, section 526, provides that drug
abusers who are suffering from medical conditions shall not be discriminated
against in admission or treatment because of their drug abuse or drug
dependence, by any private or public general hospital that receives support in
any form from any federally funded program. This prohibition is extended to all
outpatient facilities receiving or benefitting from federal financial assistance
by 45 CFR Part 84.

 

j. The Public Health Service Act, as amended, section 522, provides that alcohol
abusers and alcoholics who are suffering from medical conditions shall not be
discriminated against in admission or treatment, solely because of their alcohol
abuse or alcoholism, by any private or public general hospital that receives
support in

 

10

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any form from any federally funded program. This prohibition is extended to all
outpatient facilities receiving or benefitting from federal financial assistance
by 45 CFR Part 84.

 

2. Confidentiality: The Public Health Service Act, as amended, sections 301(d)
and 543, require that certain records be kept confidential except under certain
specified circumstances and for specified purposes. Confidential records include
records of the identity, diagnosis, prognosis, or treatment of any patient that
are maintained in connection with the performance of any activity or program
relating to drug abuse prevention, i.e., drug abuse education, training,
treatment, or research, or alcoholism or alcohol abuse education, training,
treatment, rehabilitation, or research that is directly or indirectly assisted
by the federal government. Public Health Service regulations 42 CFR Parts 2 and
2a implement these requirements.

 

3. Lobbying Restrictions: Lobbying restrictions as required by 31 U.S.C. § 1352,
requires the Contractor to abide by this section and to place it’s language in
all of it’s contracts:

 

a. No federal funds have been paid or will be paid, by or on behalf of the
Contractor, to any person for influencing or attempting to influence an officer
or employee of any federal 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, or the
extension, continuation, renewal, amendment, or modification of any federal
contract, grant, loan, or cooperative agreement.

 

b. 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 federal agency, a member of Congress, an officer or employee of
Congress, or an employee of a member of Congress in connection with the federal
contract, grant, loan, or cooperative agreement, the Contractor shall complete
and submit Federal Standard Form LLL, “Disclosure Form to report Lobbying,” in
accordance with its instructions.

 

c. The Contractor shall require that the language of this article be included in
the award documents for all subcontracts and that subcontractors shall certify
and disclose accordingly.

 

4. Debarment, suspension or other ineligibility: The Contractor certifies that
neither it nor its principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or excluded from participation in this Contract
by any governmental department or agency. The Contractor must notify the
Department within 30 days in accordance with the notification requirements
specified in Article III, section 11 of this Contract if the Contractor has been
debarred by any governmental entity within the contract period. Debarment
regulations are stated in Health and Human Services regulation 45 CFR Part 76.

 

5. Environmental Impact: The National Environmental Policy Act of 1969 (NEPA)
(Public Law 91-190) establishes national policy goals and procedures to protect
and enhance the environment. NEPA applies to all federal agencies and requires
them to consider the probable environmental consequences of any major federal
activity, including activities of other organizations operating with the
concurrence or support of a federal agency.  This includes grant-supported
activities under this Contract if federal funds are involved. Additional
environmental requirements include:

 

a. the institution of environmental quality control measures under the National
Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order 11514;

 

b. the notification of violating facilities pursuant to Executive Order 11738
(all contracts, subcontracts, and subgrants in excess of $100,000);

 

c. the protection of wetlands pursuant to Executive Order 11990;

 

d. the evaluation of flood hazards in floodplains in accordance with Executive
Order 11988;

 

e. the assurance of project consistency with the approved State management
program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. §§
1451 et seq.);

 

f. the conformity of Federal actions to State (Clear Air) Implementation Plans
under Section 176 (c) of the Clear Air Act of 1955, as amended (42 U.S.C. §§
7401 et seq.);

 

g. the protection of underground sources of drinking water under the Safe
Drinking Water Act of 1974, as amended, (P.L. 93-523),

 

h. the protection of endangered species under the Endangered Species Act of
1973, as amended, (P.L. 93- 205) and;

 

i. the protection of the national wild and scenic rivers system under the Wild
and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.).

 

11

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6. Human Subjects: The Public Health Service Act, section 474(a), implemented by
45 CFR Part 46, requires basic protection for human subjects involved in Public
Health Service grant supported research activities. Human subject is defined in
the regulation as “a living individual about whom an investigator (whether
professional or student) conducting research obtains data through intervention
or interaction with the individual or identifiable private information.” The
regulation extends to the use of human organs, tissues, and body fluids from
individually identifiable human subjects as well as to graphic, written, or
recorded information derived from individually identifiable human subjects. The
regulation also specifies additional protection for certain classes of human
research involving fetuses, pregnant women, human in vitro fertilization, and
prisoners. However, the regulation exempts certain categories of research
involving human subjects which normally involve little or no risk. The
exemptions are listed in 45 CFR Part 46.101(b). The protection of human subjects
involved in research, development, and related activities is found in P.L.
93-348.

 

7. Sterilization: Health and Human Services and Public Health Service have
established certain limitations on the performance of nonemergency
sterilizations by Public Health Service grant-supported programs or projects
that are otherwise authorized to perform such sterilizations. Public Health
Service has issued regulations that establish safeguards to ensure that such
sterilizations are performed on the basis of informed consent and that the
solicitation of consent is not based on the withholding of benefits. These
regulations, published at 42 CFR Part 50, Subpart B, apply to the performance of
nonemergency sterilizations on persons legally capable of consenting to the
sterilization. Federal financial participation is not available for any
sterilization procedure performed on an individual who is under the age of 21,
legally incapable of consenting to the sterilization, declared mentally
incompetent, or is institutionalized.

 

8. Abortions and Related Medical Services: Federal financial participation is
generally not available for the performance of an abortion in a grant-supported
health services project. For further information on this subject, consult the
regulation at 42 CFR Part 50, Subpart C.

 

9. Recombinant DNA and Institutional Biosafety Committees: Each institution
where research involving recombinant DNA technology is being or will be
conducted must establish a standing Biosafety Committee. Requirements for the
composition of such a committee are given in Section IV of Guidelines for
Research Involving Recombinant DNA Molecules, (49 FR 46266 or latest revision),
which also discusses the roles and responsibilities of principal investigators
and contractor institutions. Guidelines for Research Involving Recombinant DNA
Molecules and Administrative Practices Supplement should be consulted for
complete requirements for the conduct of projects involving recombinant DNA
technology.

 

10. Animal Welfare: The Public Health Service Policy on Humane Care and Use of
Laboratory Animals By Awardee Institutions requires that applicant organizations
establish and maintain appropriate policies and procedures to ensure the humane
care and use of live vertebrate animals involved in research activities
supported by Public Health Service. This policy implements and supplements the
U.S. Government Principles for the Utilization and Care of Vertebrate Animals
Used in Testing, Research, and Training and requires that institutions use the
Guide for the Care and Use of Laboratory Animals as a basis for developing and
implementing an institutional animal care and use program. This policy does not
affect applicable State or local laws or regulations which impose more stringent
standards for the care and use of laboratory animals. All institutions are
required to comply, as applicable, with the Animal Welfare Act as amended (7
U.S.C. 2131 et seq.) and other federal statutes and regulations relating to
animals. These documents are available from the Office for Protection from
Research Risks (OPRR), National Institutes of Health, Bethesda, MD 20892, (301)
496-7005.

 

11. Contract Provisions: The Contractor must include the following provisions in
its contracts, as limited by the statements enclosed within the parentheses
following each provision:

 

a. administrative, contractual, or legal remedies in instances where contractors
violate or breach contract terms, and provides for such sanctions and penalties
as may be appropriate. (Contracts other than small purchases. Small purchase
involve relatively simple and informal procurement methods that do not cost more
than $100,000 in aggregate.)

 

b. termination for cause and for convenience by the contractor or subgrantee
including the manner by which it will be effected and the basis for settlement.
(All contracts in excess of $10,000)

 

c. compliance with Executive Order 11246 of September 24, 1965 entitled “Equal
Employment Opportunity,” as amended by Executive Order 11375 of October 13, 1967
and as supplemented in Department of Labor regulations (41 CFR Chapter 60). (All
construction contracts awarded in excess of

 

12

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$10,000 by the Contractor and its contractors or subgrantees)

 

d. compliance with the Copeland “Anti-Kickback” Act (18 U.S.C. 874) as
supplemented in Department of Labor regulations (29 CFR Part 3). (All contracts
and subgrants for construction or repair)

 

e. compliance with the Davis-Bacon Act (40 U.S.C. 276a to a-7) as supplemented
by Department of Labor regulations (29 CFR Part 5). (Construction contracts in
excess of $2,000 awarded when required by Federal grant program legislation)

 

f. compliance with the Contract Work Hours and Safety Standards Act, sections
103 and 107, (40 U.S.C. 327-330) as supplemented by Department of Labor
regulations (29 CFR Part 5). (Construction contracts awarded in excess of
$2,000, and in excess of $2,500 for other contracts which involve the employment
of mechanics or laborers)

 

g. notice of the federal awarding agency requirements and regulations pertaining
to reporting.

 

h. notice of federal awarding agency requirements and regulations pertaining to
patent rights with respect to any discovery or invention which arises or is
developed in the course of or under such contract.

 

i. federal awarding agency requirements and regulations pertaining to copyrights
and rights in data.

 

j. access by the Department, the Contractor, the Federal funding agency, the
Comptroller General of the United States, or any of their duly authorized
representatives to any books, documents, papers, and records of the Contractor
which are directly pertinent to that specific contract for the purpose of making
audit, examination, excerpts, and transcriptions.

 

k. compliance with all applicable standards, orders, or requirements of the
Clear Air Act, section 306, (42 U.S.C. 1857(h)), the Clean Water Act, section
508, (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection
Agency regulations (40 CFR Part 15). (Contracts, subcontracts, and subgrants of
amounts in excess of $100,000)

 

l. mandatory standards and policies relating to energy efficiency which are
contained in the state energy conservation plan issued in compliance with the
Energy Policy and Conservation Act (Pub. L. 94-163).

 

12. (Governmental entities only) Merit System Standards: The Intergovernmental
Personnel Act of 1970 (42 U.S.C. §§ 4728-4763), requires adherence to prescribed
standards for merit systems funded with federal funds.

 

13. Misconduct in Science: The United States Public Health Service requires
certain levels of ethical standards for all PHS grant-supported projects and
requires recipient institutions to inquire into, investigate and resolve all
instances of alleged or apparent misconduct in science. Issues involving
potential criminal violations must be promptly reported to the HHS Office of
Inspector General. (See regulations in 42 CFR Part 50, Subpart A)

 

END OF GENERAL PROVISIONS

 

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ATTACHMENT B

SPECIAL PROVISIONS

 

TABLE OF CONTENTS

 

 

 

Page

 

 

 

Article I

Definitions

1

 

 

 

Article II

Service Area

5

 

 

 

Article III

Marketing, Enrollment, Orientation, Education, and Disenrollment

5

 

 

 

A.

Marketing Activities

5

B.

Enrollment Process

6

C.

Member Orientation

9

D.

Member Education

11

E.

Disenrollment by Enrollee

15

F.

Disenrollment by CONTRACTOR

17

G.

Enrollee Transition Between Health Plans

19

H.

Enrollee Transition from FFS to Health Plan or from Health Plan to FFS

19

 

 

 

Article IV

Benefits

20

 

 

 

A.

In General

20

B.

Scope of Services

20

C.

Clarification of Covered Services

21

 

1.

Emergency Services

21

 

2.

Care Provided in Skilled Nursery Facilities

24

 

3.

Hospice

25

 

4.

Inpatient Hospital Services for Scheduled Admissions

26

 

5.

Children in Custody of the Department of Human Services

26

 

6.

Organ Transplantations

28

 

7.

Mental Health Services

29

 

8.

Developmental and Organic Disorders

29

 

9.

Out-of-State Accessory Services

30

 

10.

Non-Contractor Prior Authorizations

30

D.

Additional Services for Enrollees with Special Health Care Needs

31

 

1.

In General

31

 

2.

Identification

31

 

3.

Choosing a Primary Care Provider

31

 

4.

Referrals and Access to Specialty Providers

32

 

5.

Survey of Enrollees with Special Health Care Needs

32

 

6.

Collaboration with Other Programs

33

 

7.

Case Management and Coordination of Care Program

33

 

8.

Specific Requirements for Children with Special Health Care Needs

34

 

i

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Article V

Delivery Network

35

 

 

 

A.

Availability of Services

35

B.

Subcontracts and Assurances

36

C.

Contractor’s Selection of Providers

39

 

 

 

Article VI

Authorization of Services and Notices of Action

41

 

 

 

A.

Service of Authorization and Notice of Action

41

B.

Other Actions Requiring Notice of Action

46

C.

Content of Notice of Action

47

D.

Attachment to Notice of Actions - Written Appeal Request Form

49

E.

Compensation for Utilization Management Activities

50

F.

Medical Necessity Denials

50

 

 

 

Article VII

Grievance Systems

50

 

 

 

A.

Overall Grievance System

50

B.

Special Requirements for Appeals

50

C.

Standard Appeals Process

51

D.

Process for Expedited Resolution of Appeals

54

E.

Continuation of Benefits During Appeal or State Fair Hearing Processes

57

F.

Duration of Continued or Reinstated Benefits

57

G.

Reversed Appeal Resolutions

57

H.

State Fair Hearings

58

I.

Grievances

59

J.

Documentation

61

 

 

 

Article VIII

Enrollee Rights and Protections

62

 

 

 

A.

Written Information on Enrollee Rights and Protections-General Requirements

62

B.

Specific Enrollee Rights and Protections

62

C.

Provider - Enrollee Communications

63

 

 

 

Article IX

Contractor Assurances

64

 

 

 

A.

Nondiscrimination

64

B.

Member Services Function

64

C.

Provider Services Function

65

D.

Enrollee Liability

65

E.

Access

65

F.

Coordination and Continuity of Care

68

G.

Billing Enrollees

71

 

ii

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H.

Survey Requirements

72

 

iii

--------------------------------------------------------------------------------

 

Article X

Measurement and Improvement Standards

73

 

 

 

A.

Practice Guidelines

73

B.

Quality Assessment and Performance Improvement Program

73

 

 

 

Article XI

Other Requirements

75

 

 

 

A.

Compliance with Public Health Service Act

75

B.

Advance Directives

75

C.

Fraud and Abuse Requirements

75

D.

Disclosure of Ownership and Control Information

76

E.

Safeguarding Confidential Information on Enrollees

76

F.

Disclosure of Provider Incentive Plans

77

 

 

 

Article XII

Payments

78

 

 

 

A.

Non-Risk Contract

78

B.

Payment Methodology

78

C.

Contract Maximum

78

D.

Medicare

78

E.

Third Party Liability (Coordination of Benefits)

80

F.

Third Party Responsibility (Including Worker’s Compensation)

82

G.

Changes in Covered Services

83

H.

Clarification of Payment Responsibilities

83

 

 

 

Article XIII

Records and Reporting Requirements

87

 

 

 

A.

Health Information Systems

87

B.

Federally Required Reports

88

C.

Periodic Reports

89

D.

Data Certification

94

 

 

 

Article XIV

Compliance/Monitoring

95

 

 

 

A.

Audits

95

B.

Quality Monitoring by the DEPARTMENT

95

C.

External Quality Review

96

D.

Corrective Action

98

 

 

 

Article XV

Termination of the Contract

101

 

 

 

A.

Automatic Termination

101

B.

90-Day Termination Option

101

 

iv

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C.

Effect of Termination

101

D.

Assignment

103

 

 

 

Article XVI

Miscellaneous

103

 

 

 

A.

Integration

103

B.

Enrollees May Not Enforce Contract

103

C.

Interpretation of Laws and Regulations

103

D.

Adoption of Rules

103

 

v

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Attachment B

Molina Healthcare of Utah

Effective January 1, 2006

 

For the purpose of the Contract all article, section, and subsection headings in
these Attachments B and C are for convenience in referencing the provisions of
the Contract. They are not enforceable as part of the text of the Contract and
may not be used to interpret the meaning of the provisions that lie beneath
them.

 

Special Provisions

 

Article I - Definitions

 

For the purpose of the Contract:

 

A.                                   “Action” means:

(1)                                  the denial or limited authorization of a
requested service, including the type or level of service;

(2)                                  the reduction, suspension, or termination
of a previously authorized service;

(3)                                  the denial in whole or in part, of payment
for a service and the denial could result in the Enrollee liable for payment;

(4)                                  the failure to provide services in a timely
manner, as defined as failure to meet performance standards for appointment
waiting times (see Article IX - Contractor Assurances, Section E - Access,
Subsection 4.e. - Waiting Time Benchmarks); or

(5)                                  the failure of the CONTRACTOR to act within
the time frames established for resolution and notification of grievances and
appeals.

 

B.                                     “Advance Directives” means a written
instruction such as a living will or durable power of attorney for health care,
recognized under State law (whether statutory or as recognized by the courts of
the State), relating to the provision of health care when the individual is
incapacitated.

 

C.                                     “Appeal” means a request for review of an
Action.

 

D.                                    “Balance Bill” means the practice of
billing patients for charges that exceed the amount that the CONTRACTOR will
pay.

 

E.                                      “CHEC Eligible” means any Medicaid
recipient under the age of 21 who is eligible to receive Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) services in accordance with 42 CFR
Part 441, Subpart B.

 

F.                                      “CHEC Program” or Child Health
Evaluation and Care program is Utah’s version of the federally mandated Early
Periodic Screening, Diagnosis and Treatment (EPSDT) program as defined in 42 CFR
Part 441, Subpart B. Medicaid recipients who are eligible for the
Non-Traditional Medicaid Plan are not eligible to receive EPSDT services. (See
Attachment C, Covered Services, U.)

 

G.                                     “Child with Special Health Care Needs”
means a child under 21 years of age who has or is at increased risk for chronic
physical, developmental, behavioral, or emotional conditions and requires health
and related services of a type or amount beyond that required by children
generally, including a child who, consistent with 1932(a)(2)(A) of the Social
Security Act, 42 U.S.C., Section 1396u-2(a)(2)(A):

 

1

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(1)                                  is blind or disabled or in a related
population (eligible for SSI under title XVI of the Social Security Act);

(2)                                  is in foster care or other out-of-home
placement;

(3)                                  is receiving foster care or adoption
assistance; or

(4)                                  is receiving services through a
family-centered, community-based coordinated care system that receives grant
funds described in section 501(a)(1)(D) of title V.

 

H.                                   “CMS” means the Centers for Medicare and
Medicaid Services, the federal Medicaid agency, within the Department of Health
and Human Services.

 

I.                                         “Covered Services” means services
identified in Attachment C of this Contract which the CONTRACTOR has agreed to
provide and pay for under the terms of this Contract.

 

J.                                      “Division of Health Care Financing” or
“DHCF” means the division within the Department of Health responsible for the
administration of the Utah Medicaid program.

 

K.                                    “Emergency Medical Condition” means a
medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in:

(1)                                  Placing the health of the individual (or,
with respect to a pregnant woman, the health of a woman or her unborn child) in
serious jeopardy;

(2)                                  Serious impairment to bodily functions; or

(3)                                                                                                                                                                                                                                                                                                                                 
Serious dysfunction of any bodily organ or part.

 

L.                                     “Emergency Services” means covered
inpatient and outpatient services that are furnished by a provider that is
qualified to furnish these services and that are needed to evaluate or stabilize
an emergency medical condition.

 

M.                                  “Enrollee” means any Medicaid recipient who
is currently enrolled with this Health Plan and:

(1)                                  who, at the time of enrollment resides
within the geographical limits of the CONTRACTOR’s Service Area;

(2)                                  whose name appears on the DEPARTMENT’s
Eligibility Transmission as a new, reinstated, or retroactive Enrollee; and

(3)                                  who is accepted for enrollment by the
CONTRACTOR according to the conditions set forth in this Contract excluding
residents of the Utah State Hospital, Utah State Developmental Center, and
long-term care facilities except as defined in Attachment C.

 

N.                                    “Enrollees with Special Health Care Needs”
means enrollees who have or are at increased risk for chronic physical,
developmental, behavioral, or emotional conditions and who also require health
and related services of a type or amount beyond that required by adults and
children generally.

 

O.                                    “Enrollment Area” or “Service Area” means
the counties enumerated in Article II.

 

P.                                     “External Quality Review” means the
analysis and evaluation by an EQRO, of

 

2

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aggregated information on quality, timeliness, and access to the health care
services that a Health Plan, or its contractors, furnish to Medicaid recipients.

 

Q.                                   “External Quality Review Organization
(EQRO)” means an entity under contract with the DEPARTMENT to conduct an
external quality review of the CONTRACTOR in accordance with Federal regulations
governing external quality reviews.

 

R.                                     “Family Member” means all Medicaid
eligibles who are members of the same family living at home.

 

S.                                      “Grievance” means an expression of
dissatisfaction about any matter other than an action (as defined in this
section). Possible subjects for grievances include, but are not limited to, the
quality of care or services provided, aspects of interpersonal relationships
such as rudeness of a provider or employee, or failure to respect the Enrollee’s
rights.

 

T.                                     “Grievance Process” means the
CONTRACTOR’s process for handling grievances that complies with the requirements
including, but not limited to, the procedural steps for an Enrollee to file a
grievance, the process for disposition of a grievance, and the timing and manner
of required notifications.

 

U.                                    “Grievance System” means an overall system
that includes a grievance process, an appeal process, and access to the State’s
fair hearing system.

 

V.                                     “Health Plan” means a federally defined
Prepaid Inpatient Health Plan, a federally defined Primary Care Case Management
system, or a federally defined Managed Care Organization under contract with the
DEPARTMENT to provide specified physical health care services to a specific
group of Medicaid clients.

 

W.                                 “Home and Community-Based Services” means
services, not otherwise furnished under the State’s Medicaid plan, that are
furnished under a waiver of statutory requirements granted under the provisions
of CFR Part 441, subpart G. These services cover an array of Home and
Community-Based Services that are cost-effective and necessary for an individual
to avoid institutionalization.

 

X.                                    “Medically Necessary” means any medical
service that is (1) reasonably calculated to prevent, diagnose, or cure
conditions in the Enrollee that endanger life, cause suffering or pain, cause
deformity or malfunction, or threaten to cause a handicap; and (2) there is no
equally effective course of treatment available or suitable for the Enrollee
requesting the service which is more conservative or substantially less costly.
Medical services will be of a quality that meets professionally recognized
standards of health care, and will be substantiated by records including
evidence of such medical necessity and quality. Those records will be made
available to the DEPARTMENT upon request. For CHEC Enrollees, “Medically
Necessary” means preventive screening services and other medical care,
diagnostic services, treatment, and other measures necessary to correct or
ameliorate defects and physical and mental illnesses and conditions, even if the
services are not included in the Utah State Medicaid Plan.

 

Y.                                     “Member Services” means a method of
assisting Enrollees in understanding CONTRACTOR policies and procedures,
facilitating referrals to participating specialists, and assisting in the
resolution of problems and member complaints. The purpose of Member Services is
to

3

--------------------------------------------------------------------------------

 

improve access to services and promote Enrollee satisfaction.

 

Z.                                     “Non-risk Contract” means a contract
under which the CONTRACTOR is not at financial risk for changes in utilization
or for costs incurred under the Contract that do not exceed the DEPARTMENT’s
Payment Limit. The Payment Limit is the total amount Medicaid would have paid,
in aggregate, for the same services on a fee-for-service basis net of third
party payments.

 

AA.                           “Non-Traditional Medicaid Plan” means the reduced
benefit plan provided to Medicaid eligibles age 19 through 64 who are in certain
TANF, Medically Needy, and Transitional Medicaid aid categories. Services
covered under the reduced benefit plan are similar to the Traditional Medicaid
Plan with some limitations and exclusions.

 

BB.                           “Notice of Action” means written notification to
an Enrollee and written or verbal notification of a provider when applicable, of
an Action that will be taken by the CONTRACTOR.

 

CC.                           “Notice of Appeal Resolution” means written
notification of an Enrollee, and a provider when applicable, of the CONTRACTOR’s
resolution of an Appeal.

 

DD.                           “Physician Incentive Plan” means any compensation
between a contracting organization and a physician group that may directly or
indirectly have the effect of reducing or limiting services provided with
respect to Enrollees in the organization.

 

EE.                           “Post-stabilization Services” means Covered
Services related to an Emergency Medical Condition that are provided after an
Enrollee is stabilized in order to maintain the stabilized condition, or to
improve or resolve the Enrollee’s condition.

 

FF.                           “Potential Enrollee” means a Medicaid recipient
who is subject to mandatory enrollment or may voluntarily elect to enroll in a
given managed care program, but is not yet an enrollee of a specific Health
Plan.

 

GG.                           “Prepaid Inpatient Health Plan” means an entity
that provides medical services to Enrollees under contract with the DEPARTMENT,
and on the basis of prepaid capitation payments, or other payment arrangements
that do not use State plan payment rates; provides, arranges for, or otherwise
has responsibility for the provision of inpatient hospital or institutional
services for its Enrollees; and does not have a comprehensive risk contract.

 

HH.                           “Prepaid Mental Health Plan” means the mental
health centers that contract with the DEPARTMENT to provide inpatient and
outpatient mental health services to Medicaid clients living within each mental
health center’s jurisdiction.

 

II.                                     “Primary Care” means all health care
services and laboratory services customarily furnished by or through a general
practitioner, family physician, internal medicine physician,
obstetrician/gynecologist, or pediatrician, to the extent the furnishing of
those services is legally authorized in the State in which the practitioner
furnishes them.

 

JJ.                               “Primary Care Case Management” or “PCCM” means
a system under which a PCCM contracts with the DEPARTMENT to furnish case
management services (which include the location, coordination and monitoring of
primary health care services) to Medicaid

 

4

--------------------------------------------------------------------------------

 

recipients.

 

KK.                           “Primary Care Provider” or “PCP” means a health
care provider the majority of whose practice is devoted to internal medicine,
family/general practice or pediatrics. The CONTRACTOR may allow other
specialists to be PCPs, when appropriate. PCPs are responsible for delivering
primary care services, coordinating and managing Enrollees’ overall health, and
authorizing referrals for other necessary care.

 

LL.                             “Restriction Program” means the Federally
mandated program (42 CFR 431.54(e)) for Medicaid clients who over-utilize
Medicaid services. If the DEPARTMENT in conjunction with the CONTRACTOR finds
that an Enrollee has utilized Medicaid services at a frequency or amount that is
not Medically Necessary, as determined in accordance with utilization guidelines
adopted by the DEPARTMENT, the DEPARTMENT may place the Enrollee under the
Restriction Program for a reasonable period of time to obtain Medicaid services
from designated providers only.

 

MM.                       “State Plan” means the State Plan for organization and
operation of the Medicaid program as defined pursuant to Section 1902 of the
Social Security Act (42 U.S.C. 1396a).

 

NN.                           “Subcontract” means any written agreement between
the CONTRACTOR and another party to fulfill the requirements of this Contract.
However, such term does not include insurance purchased by the CONTRACTOR to
limit its loss with respect to an individual Enrollee.

 

OO.                         “Traditional Medicaid Plan” means the scope of
services contained in the State Plan provided to Medicaid eligibles who fall
under one of the following eligibility groups:

(1)                                  Section 1931 children and related poverty
level populations (TANF/AFDC);

(2)                                  Section 1931 pregnant women (TANF/AFDC);

(3)                                  Blind/disabled children and related
populations (SSI);

(4)                                  Blind/disabled adults and related
populations (SSI);

(5)                                  Aged and related populations (SSI, QMB and
Medicaid, Medicare and Medicaid);

(6)                                  Foster care children;

(7)                                  Individuals who qualify for Medicaid by
paying a spenddown and are under age 19 or are also aged or disabled;

(8)                                  Pregnant women (non-TANF/AFDC)

 

Article II - Service Area

 

The Service Area is limited to the counties of Beaver, Box Elder, Cache, Davis,
Garfield, Iron, Juan, Kane, Millard, Morgan, Piute, Rich, Salt Lake, Sanpete,
Sevier, Summit, Tooele, Utah, Washington, Wayne, and Weber.

 

Article III - Marketing, Enrollment, Orientation, and Disenrollment

 

A.                                   Marketing Activities

 

1.                                       The DEPARTMENT does not permit the
CONTRACTOR to conduct direct or indirect marketing as defined in this section.
In this Article III, Section A - Marketing

 

5

--------------------------------------------------------------------------------

 

Activities, “CONTRACTOR” includes any of the CONTRACTOR’s employees, affiliated
providers, agents, or contractors.

 

2.                                       “Marketing” means any communication,
from the CONTRACTOR to a Potential Enrollee, that can reasonably be interpreted
as intended to influence the Potential Enrollee to enroll in the CONTRACTOR’s
Medicaid product, or either to not enroll in, or to disenroll from, another
Health Plan’s Medicaid product.

 

3.                                       “Marketing materials” means materials
that are produced in any medium, by or on behalf of the CONTRACTOR and can
reasonably be interpreted as intended to market to Potential Enrollees. The
CONTRACTOR cannot, either directly or indirectly, conduct door-to-door,
telephonic or other “cold call” marketing activities.

 

a.                                       These three marketing practices are
prohibited whether conducted by the CONTRACTOR itself (“directly”) or by an
agent or independent contractor (“indirectly”).

 

b.                                      Cold call marketing means any
unsolicited personal contact with a potential Enrollee for the purpose of
marketing.

 

c.                                       All other non-requested marketing
approaches to Medicaid clients by the CONTRACTOR are also prohibited unless
specifically approved in advance by the DEPARTMENT.

 

4.                                       The CONTRACTOR may not influence
enrollment in conjunction with the sale or offering of any private insurance.

 

5.                                       The CONTRACTOR will not distribute any
materials that include statements that will be considered inaccurate, false, or
misleading including, but not limited to, any assertion or statement (whether
written or oral) that the Potential Enrollee must enroll in Healthy U in order
to obtain benefits or in order to not lose benefits; or that Healthy U is
endorsed by CMS, the Federal or State government, or similar entity.

 

B.                                    Enrollment Process

 

1.                                      Enrollee Choice

 

a.                                       The DEPARTMENT will offer Potential
Enrollees a choice among all Health Plans available in the Enrollment Area.

 

b.                                      The DEPARTMENT will inform Potential
Enrollees of Medicaid benefits.

 

c.                                       The Medicaid client’s intent to enroll
is established when the applicant selects the CONTRACTOR, either verbally or by
signing a choice of health care delivery form or equivalent. This initiates the
action to send an advance notification to the CONTRACTOR.

 

d.                                      Medicaid Enrollees made eligible for a
retroactive period prior to the current month are not eligible for CONTRACTOR
enrollment during the retroactive period.

 

6

--------------------------------------------------------------------------------

 

2.                                      Period of Enrollment

 

a.                                       Each Enrollee will be enrolled for the
period of the Contract or the period of Medicaid eligibility or until such
person disenrolls or is disenrolled, whichever is earlier.

 

b.                                      Until the DEPARTMENT notifies the
CONTRACTOR that an Enrollee is no longer Medicaid eligible, the CONTRACTOR may
assume that the Enrollee continues to be eligible.

 

c.                                       Each Enrollee will be automatically
re-enrolled at the end of each month unless that Enrollee notifies the
DEPARTMENT’s Health Program Representative of an intent not to re-enroll in the
Health Plan prior to the benefit issuance date.

 

3.                                      Open Enrollment

 

The CONTRACTOR will have a continuous open enrollment period that meets the
requirements of Section 1301(d) of the Public Health Service Act. The DEPARTMENT
will certify, and the CONTRACTOR agrees to accept individuals who are eligible
to be enrolled in the Health Plan under the provisions of this Contract:

 

a.                                       in the order in which they apply; and

 

b.                                      without restrictions unless authorized
by the DEPARTMENT.

 

4.                                      No Health Screening

 

The DEPARTMENT and the CONTRACTOR agree that no Potential Enrollee will be
pre-screened or selected by either party for enrollment on the basis of
pre-existing health problems or on the basis of race, color, national origin,
disability or age.

 

5.                                      Independent Enrollment

 

Each Medicaid eligible can be enrolled with or disenrolled from the Health Plan,
independent of any other Family Member’s enrollment or disenrollment.

 

6.                                      Representative Population

 

The CONTRACTOR will service a population representative of the categories of
eligibility within the area it serves.

 

7.                                      Eligibility Transmission

 

a.                                      In general

 

(1)                                  Before the close of business each day, the
DEPARTMENT will provide to the CONTRACTOR an Eligibility Transmission which is
an electronic file that includes individuals which the DEPARTMENT certifies as
Medicaid eligible and who enrolled in the Health Plan. Eligibility transmissions
include new Enrollees,

 

7

--------------------------------------------------------------------------------

 

reinstated Enrollees, retroactive Enrollees, terminated Enrollees and Enrollees
whose eligibility information results in a change to a critical field.

 

(2)                                  The Eligibility Transmission will be in
accordance with the Utah Health Information Network (UHIN) standard.

 

(3)                                  The DEPARTMENT represents and warrants to
the CONTRACTOR that the appearance of an individual’s name on the Eligibility
Transmission, other than a deleted Enrollee, will be conclusive evidence for
purposes of this Contract, that such person is enrolled in the program and
qualifies for medical assistance under Medicaid Title XIX.

 

b.                                      New Enrollees

 

(1)                                  New Enrollees are enrolled in this Health
Plan until otherwise specified; these Enrollees will not appear on future
transmissions unless there is a change in a critical field.

 

(2)                                  Critical fields are coverage dates,
recipient name, date of birth, date of death, sex, social security number, case
information, address, telephone number, payment code, coordination of benefits,
and the Enrollee’s provider under the Restriction Program.

 

(3)                                  Enrollees with a spenddown requirement will
appear on the eligibility transmission on a month by month basis after the
spenddown is met.

 

c.                                       Retroactive Enrollees

 

Retroactive Enrollees are those who were Enrollees previous to the current
month. Retroactive Enrollees include newborn Enrollees or Enrollees who have
been reported in one payment category in a previous month, but have been

 

8

--------------------------------------------------------------------------------

 

changed to a new payment category for that previous month when they are made
eligible for the current month.

 

d.                                      Reinstated Enrollees

 

Reinstated Enrollees are those who were enrolled for the previous month and also
closed at the end of the previous month. These Enrollees are eligible
retroactively to the beginning of the current month.

 

e.                                       Terminated Enrollees

 

Terminated Enrollees are those who are no longer eligible for Medicaid, were
disenrolled from the Health Plan, or had their premium retracted.

 

8.                                      Change of Enrollment Procedures

 

a.                                       The CONTRACTOR will be advised of
anticipated changes in DEPARTMENT policies and procedures as they relate to the
enrollment process and their comments will be solicited.

 

b.                                      The CONTRACTOR agrees to be bound by
such changes in DEPARTMENT policies and procedures that are mutually agreed upon
by the CONTRACTOR and the DEPARTMENT.

 

C.                                    Member Orientation

 

 

1.                                      Initial Contact - General Orientation

 

a.                                       The CONTRACTOR will make a good faith
effort to ensure that each Enrollee or Enrollee’s family or guardian receives
the CONTRACTOR’s member handbook.

 

b.                                      The CONTRACTOR’s representative will
make a good faith effort, as evidenced in written or electronic records, to make
an initial contact with the Enrollee within 10 working days after the CONTRACTOR
has been notified through the Eligibility Transmission of the Enrollee’s
enrollment with this Health Plan.

 

(1)                                  If the CONTRACTOR’s representative cannot
contact the Enrollee within 10 working days or at all, the CONTRACTOR’s
representative will document its efforts to contact the Enrollee.

 

(2)                                  The initial contact will be in person or by
telephone (or in writing, but only if reasonable attempts have been made to make
the contact in person by telephone) and will inform the Enrollee of the
CONTRACTOR’s rules and policies.

 

c.                                       The CONTRACTOR will ensure that
Enrollees are provided interpreters, Telecommunication Device for the Deaf
(TDD), and other auxiliary aids to ensure that Enrollees understand their rights
and responsibilities.

 

9

--------------------------------------------------------------------------------

 

d.                                      During the initial contact the
CONTRACTOR’s Representative will provide, at a minimum, the following
information to the Enrollee or Potential Enrollee appropriate to the Enrollee’s
eligibility (Traditional versus Non-Traditional Medicaid):

 

(1)                                  specific written and oral instructions on
the use of the CONTRACTOR’s Covered Services and procedures;

 

(2)                                  availability and accessibility of all
Covered Services, including the availability of family planning services and
that the Enrollee may obtain family planning services from Medicaid providers
other than providers affiliated with the CONTRACTOR;

 

(3)                                  the client’s rights and responsibilities as
an Enrollee of this Health Plan, including the right to file a grievance and how
to file a grievance;

 

(4)                                  the right to terminate enrollment with the
Health Plan; and

 

(5)                                  encouragement to make a medical appointment
with a provider.

 

2.                                      Identification of Enrollees with Special
Health Care Needs

 

a.                                       During the initial contact with each
Enrollee, the CONTRACTOR’s representative will use a process that will identify
children and adults with special health care needs.

 

b.                                      The CONTRACTOR’s representative will
clearly describe to each Enrollee during the initial contact the process for
requesting specialist care.

 

c.                                       When an Enrollee is identified as
having special health care needs, the CONTRACTOR’s Representative will forward
this information to a CONTRACTOR’s  individual with knowledge of coordination of
care and services necessary for such Enrollees. The CONTRACTOR’s individual with
knowledge of coordination of care for Enrollees with special health care needs
will make a good faith effort to contact Enrollees within ten working days after
identification to begin coordination of health care needs, if necessary.

 

d.                                      The CONTRACTOR will not discriminate on
the basis of health status or the need for health care services.

 

e.                                       The DEPARTMENT’s Health Program
Representatives are responsible to forward information, including risk
assessments, that identify Enrollees with special health care needs and limited
language proficiency needs to the CONTRACTOR in a timely manner, coinciding with
the daily Eligibility Transmission as much as possible.

 

10

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3.                                      Enrollees Receiving Out-of-Plan Care
Prior to Orientation

 

If the Enrollee receives Covered Services by an out-of-plan provider after the
first day of the month in which the client’s enrollment became effective, and if
a CONTRACTOR  orientation, either in-person or by telephone (or in writing, but
only if reasonable attempts have been made to make the contact in person or by
telephone), has not taken place prior to receiving such services, the CONTRACTOR
is responsible for payment of the services rendered provided the DEPARTMENT
informs the CONTRACTOR by the 20th of any month prior to the month that
enrollment with the Health Plan begins.

 

D.                                    Member Education

 

1.                                       Enrollee Information Requirements

 

a.                                       In General

 

(1)                                  The CONTRACTOR will write all Enrollee and
Potential Enrollee informational, instructional, and educational materials,
including the CONTRACTOR’s member handbook, in a manner and format that may be
easily understood; e.g. at no greater than a sixth grade reading level.

 

(2)                                  Once per year, the CONTRACTOR will notify
all Enrollees of their right ro request and obtain the CONTRACTOR’s member
handbook.

 

b.                                      Prevalent Language

 

(1)                                  The CONTRACTOR will use the Eligibility
Transmission to determine  prevalent non-English languages. A language is
prevalent when it is spoken by five percent or more of the CONTRACTOR’s enrolled
population.

 

(2)                                  The CONTRACTOR will make available all
written Enrollee informational and instructional materials, including the member
handbook, in the prevalent non-English languages. Written materials include
vital documents such as applications, consent forms, release of information
forms, letters containing important information, etc.

 

c.                                       Alternative formats

 

The CONTRACTOR will make Enrollee informational and instructional materials,
including the member handbook, available in alternative formats that take into
consideration the special needs of those who, for example, are visually limited
or have limited reading proficiency (e.g., audio tapes).

 

2.                                      Member Handbook

 

a.                                       The CONTRACTOR will produce a member
handbook that will be submitted

 

11

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to the DEPARTMENT for review and approval before distribution. The DEPARTMENT
will notify the CONTRACTOR in writing of its approval or disapproval within ten
working days after receiving the member handbook unless the DEPARTMENT and
CONTRACTOR agree to another time frame. If the DEPARTMENT does not respond
within the agreed upon time frame, the CONTRACTOR may deem such materials are
approved.

 

b.                                      If there are changes to the content of
the material in the handbook, the CONTRACTOR will update the member handbook and
submit a draft to the DEPARTMENT for review and approval before distribution to
its Enrollees.

 

c.                                       At a minimum, the member handbook will
explain in clear terms the following information:

 

(1)                                  The amount, duration, and scope of benefits
provided by the CONTRACTOR delineating Traditional versus Non-Traditional
Medicaid scopes of service in sufficient detail to ensure that enrollees
understand the benefits to which they are entitled;

 

(2)                                  Instructions on where and how to obtain
Covered Services, including any service authorization requirements; how and
under what circumstances out-of-area services are covered; policy on referrals
to speciality care and for other benefits not furnished by the Enrollee’s
primary care provider; and procedures for resolving Enrollee issues related to
authorization of coverage or payment for services;

 

(3)                                  The extent to which, and how, after-hours
and emergency coverage are provided, including:

 

(a)                                  What constitutes an emergency medical
condition, emergency services, and post-stabilization services, with reference
to definitions in 42 CFR 438.114(a);

 

(b)                                 The fact that prior authorization is not
required for emergency services;

 

(c)                                  The process and procedures for obtaining
emergency services, including use of the 911-telephone system or its local
equivalent;

 

(d)                                 The location of any emergency settings and
other locations at which providers and hospitals furnish emergency services and
poststabilization services covered under the Contract; and

 

(e)                                  The fact that the Enrollee has the right to
use any hospital or other setting for emergency care.

 

(4)                                  The post-stabilization care services rules
set forth at 42 CFR 422.113(c);

 

12

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(5)                                  The extent to which, and how, Enrollees may
obtain benefits, including family planning services, from out-of-plan network
providers;

 

(6)                                  The importance of establishing a primary
care relationship with an affiliated provider, and processes for selecting or
changing primary care providers;

 

(7)                                  Description of Enrollee cost-sharing
requirements (if applicable);

 

(8)                                  How and where to access any benefits that
are available under the State Plan but are not covered under the Contract,
including any cost sharing, and how transportation is provided;

 

(9)                                  A statement that the CONTRACTOR does not
discriminate against any Enrollee on the basis of race, color, national origin,
disability, sex, religion, or age in admission, treatment, or participation in
its programs, services and activities;

 

(10)                            The phone number of the nondiscrimination
coordinator for Enrollees to call if they have questions about the
nondiscrimination policy or desire to file a complaint or grievance alleging
violations of the nondiscrimination policy;

 

(11)                            Information on the availability of oral
interpretation, including the fact that it is available for any language and
that written information is available in prevalent languages, and includes a
statement on how to access these services;

 

(12)                            Information on the availability of written
materials in alternative formats and in an appropriate manner that takes into
consideration the special needs of those who, for example, are visually limited
or have limited reading proficiency, and a statement on how to access these
formats;

 

(13)                            Names, locations, telephone numbers of, and
non-English languages spoken by, current contracted providers in the Enrollee’s
service area, including identification of providers that are not accepting new
patients. This includes, at a minimum, information on primary care physicians,
specialists, and hospitals;

 

(14)                            Any restrictions on the Enrollee’s freedom of
choice among network providers;

 

(15)                            Enrollee rights and protections, as specified in
Article VIII of this Contract;

 

(16)                            Information on Grievance, Appeal, and State fair
hearing procedures and timeframes as provided in 438.400 through 438.424, in a
DEPARTMENT-approved description that will include the following:

 

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(a)                                  the right to file Grievances and Appeals;

 

(b)                                 the requirements and timeframes for filing a
Grievance or Appeal;

 

(c)                                  the availability of assistance in the
filing process;

 

(d)                                 the toll-free numbers that the Enrollee can
use to file a Grievance or an Appeal by phone;

 

(e)                                  the fact that, when requested by the
Enrollee, benefits will continue if the Enrollee files an Appeal or a request
for a State fair hearing within the timeframes specified for filing, and the
Enrollee may be required to pay the cost of services furnished while the Appeal
is pending, if the final decision is adverse to the Enrollee;

 

(17)                            Information to adult Enrollees on Advance
Directives policies, including a description of applicable State law as set
forth in 42 CFR 422.128;

 

(18)                            A statement that additional information is
available upon an Enrollee’s request regarding structure and operation of the
center, including information on:

 

(a)                                  the CONTRACTOR’s policy for selection of
providers (staff and subcontractors) and what is required of them,

 

(b)                                 the CONTRACTOR’s grievance system,

 

(c)                                  the CONTRACTOR’s confidentiality policy,

 

(d)                                 that information is available on request
regarding the CONTRACTOR’s Physician Incentive Plan (if the CONTRACTOR has an
incentive plan), and

 

(e)                                  that a copy of the CONTRACTOR’s preferred
practice guidelines is also available to Enrollees on request;

 

(19)                            Circumstances in which the Enrollee may be
responsible for payment of services may include:

 

(a)                                  obtaining a service that is not a benefit
of the plan or

 

(b)                                 obtaining services not authorized by the
CONTRACTOR (in either situation, the Enrollee should be liable only if the
Enrollee gave advance written consent to the provider);

 

(c)                                  Appeal or State fair hearing decisions
adverse to the Enrollee when benefits (services) were continued during the
Appeal or State fair hearing process at the Enrollee’s request; or

 

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(d)                                 ineligibility for Medicaid for any portion
of the time period during which services were provided;

 

(20)                            Description of Member Services function; and

 

(21)                            Reasons the CONTRACTOR may initiate
disenrollment of an Enrollee.

 

3.                                      Notification to Enrollees of Policies
and Procedures

 

a.                                      Changes to Policies and Procedures

 

The CONTRACTOR will give each Enrollee written notice at least 30 days before
the intended effective date of change to significant information in the
CONTRACTOR’s member handbook.

 

b.                                      Annual Education on Emergency Care and
Grievance Procedures

 

The CONTRACTOR will annually reinforce, in writing, to Enrollees how to access
emergency and urgent services and how to register an Appeal or Grievance.

 

4.                                      Notification  of Changes in Provider
Network

 

The CONTRACTOR will make a good faith effort to give written notice of
termination of a contracted provider, within 15 days after receipt or issuance
of the termination notice, to each Enrollee who received his or her primary care
from, or was seen on a regular basis by, the terminated provider.

 

E.                                    Disenrollment by Enrollee

 

1.                                      Limited Disenrollment Requirements

 

The DEPARTMENT has a requirement that requires Health Plan Enrollees to stay
with the same Health Plan for up to twelve (12) months.

 

2.                                      Without Cause Exception to 12 Month
Enrollment with Same Health Plan Restriction

 

Enrollees are permitted to transfer from one Health Plan to another without
cause as follows:

 

a.                                       within the first three months of each
enrollment period with each Health Plan, or

 

b.                                      if no more than three months have passed
since the month the client’s Medicaid card has a Health Plan printed on it, or

 

c.                                       during the open enrollment period as
defined by the DEPARTMENT.

 

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3.                                      With Cause Exceptions to 12 Month
Enrollment with Same Health Plan

 

Enrollees may request to transfer from one Health Plan to another at any time
during their twelve (12) month restriction period for the following good cause
reasons:

 

a.                                       Enrollee moves out of the Health Plan’s
service area;

 

b.                                      Current Health Plan is no longer
available;

 

c.                                       Change in third party liability
insurance status;

 

d.                                      Health Plan choice not available when
Enrollee first made selection;

 

e.                                       Enrollee needs related services, some
of which are not available in the Health Plan’s network, and Enrollee’s provider
determines that receiving services separately would subject the enrollee to
unnecessary risk;

 

f.                                         Poor quality of care;

 

g.                                      Lack of access to Covered Services;

 

h.                                      Lack of access to providers experienced
in dealing with Enrollee’s health care needs;

 

i.                                          Enrollee becomes emancipated or is
added to a different Medicaid case;

 

j.                                          Difficulty getting continuity of
care with provider of choice (i.e., foster care Enrollee’s doctor switches
Health Plans); or

 

k.                                       Health Plan does not, because of moral
or religious objections, cover the service the Enrollee seeks.

 

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4.                                      Process for Requesting Health Plan
Change

 

a.                                       The Enrollee may request to switch
Health Plans by submitting an oral or written request to the State. The Enrollee
must declare the Health Plan in which he or she wishes to enroll should the
disenrollment be approved.

 

b.                                      The DEPARTMENT will review each request
to determine if the request meets the criteria for cause and if so, will allow
the Enrollee to switch to another Health Plan. If the request does not meet the
criteria for cause, or if the concern is with a provider and not the Health
Plan, the DEPARTMENT will deny the disenrollment request and inform the Enrollee
of his or her rights to request a State fair hearing.

 

c.                                       If the DEPARTMENT fails to make a
determination within ten (10) calendar days after receiving the disenrollment
request, the disenrollment is considered approved. The effective date of an
approved disenrollment request will be no later than the first day of the second
month following the month in which the enrollee filed the request.

 

d.                                      The disenrollment will be effective once
the DEPARTMENT has been notified by the Enrollee, the DEPARTMENT issues a new
Medicaid card and the disenrollment is indicated on the Eligibility
Transmission.

 

5.                                      Enrollees in an Inpatient Hospital
Setting

 

The DEPARTMENT agrees that if a new Enrollee is a patient in an inpatient
hospital setting on the date the new Enrollee’s name appears on the CONTRACTOR
Eligibility Transmission, the obligation of the CONTRACTOR to provide Covered
Services to such person will commence following discharge. If an Enrollee is a
patient in an inpatient hospital setting on the date that his or her name
appears as a deleted Enrollee on the CONTRACTOR Eligibility Transmission or he
or she is otherwise disenrolled under this Contract, the CONTRACTOR will remain
financially responsible for such care until discharge.

 

6.                                      Annual Study of Enrollees who
Disenrolled

 

Annually, the DEPARTMENT and CONTRACTOR will work cooperatively to conduct an
analysis of Enrollees who have voluntarily disenrolled from this Health Plan.
The results of the analysis will include explanations of patterns of
disenrollments and strategies or a corrective action plan to address unusual
rates or patterns of disenrollment. The DEPARTMENT will inform the CONTRACTOR of
such disenrollments.

 

F.                                    Disenrollment Initiated by CONTRACTOR

 

1.                                      Cannot Disenroll for Adverse Change in
Enrollee’s Health

 

The CONTRACTOR may not terminate enrollment because of an adverse change in the
Enrollee’s health status, or because of the Enrollee’s utilization of medical
services, diminished mental capacity, or uncooperative or disruptive behavior
resulting from his or her special needs (except when his or her continued
enrollment

 

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in the health plan seriously impairs the CONTRACTOR’s ability to furnish
services to either this particular Enrollee or other Enrollees).

 

2.                                      Valid Reasons for Disenrollment

 

The CONTRACTOR may initiate disenrollment of any Enrollee’s participation in the
Health Plan upon one or more of the following grounds:

 

a.                                       For reasons specifically identified in
the CONTRACTOR’s member handbook.

 

b.                                      When the Enrollee ceases to be eligible
for medical assistance under the State Plan, in accordance with Title 42 USCA,
1396, et. seq., and as finally determined by the DEPARTMENT.

 

c.                                       Upon termination or expiration of the
Contract.

 

d.                                      Death of the Enrollee.

 

e.                                       Confinement of the Enrollee in an
institution when confinement is not a Covered Service under this Contract.

 

f.                                         Violation of enrollment requirements
developed by the CONTRACTOR and approved by the DEPARTMENT but only after the
CONTRACTOR and/or the Enrollee has exhausted the CONTRACTOR’s applicable
internal grievance procedure.

 

3.                                      Approval by DEPARTMENT Required

 

To initiate disenrollment of an Enrollee’s participation with this Health Plan,
the CONTRACTOR will provide the DEPARTMENT with documentation justifying the
proposed disenrollment. The DEPARTMENT will approve or deny the disenrollment
request in writing within thirty (30) days of receipt of the request. Failure by
the DEPARTMENT to deny a disenrollment request within such thirty (30) day
period will constitute approval of such disenrollment requests.

 

4.                                      Enrollee’s Right to File a Grievance

 

If the DEPARTMENT approves the CONTRACTOR’s disenrollment request, the
CONTRACTOR will give the Enrollee thirty (30) days written notice of the
proposed disenrollment, and will notify the Enrollee of his or her opportunity
to invoke the CONTRACTOR’s Grievance Process. The CONTRACTOR will give a copy of
the written notice to the DEPARTMENT at the time the notice is sent to the
Enrollee.

 

5.                                      Refusal of Re-enrollment

 

If a person is disenrolled because of violation of  responsibilities included in
the CONTRACTOR’s member handbook, the CONTRACTOR may refuse re-enrollment of
that Enrollee.

 

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6.                                       Automatic Re-enrollment

 

An Enrollee who is disenrolled from the Health Plan solely because he or she
loses Medicaid eligibility will be automatically re-enrolled if the Enrollee has
not been Medicaid eligible for two months or less.

 

G.                                    Enrollee Transition Between Health Plans

 

1.                                      Will Accept Pre-Enrollment Prior
Authorizations

 

For Covered Services other than inpatient, home health services, and medical
equipment, if authorization has been given for a Covered Service and an enrollee
transitions between Health Plans prior to the delivery of such Covered Service,
the receiving Health Plan will be bound by the relinquishing Health Plan’s prior
authorization until the receiving Health Plan has evaluated the medical
necessity of the service and agrees with the relinquishing Health Plan’s prior
authorization or has made a different determination. (See Article XII, Payments,
Section H, Clarification of Payment Responsibilities, Subsection 5, for
inpatient, home health services, and medical equipment explanations.)

 

2.                                      Will Provide Medical Records to
Enrollee’s New Health Plan

 

When enrollees are transitioned between Health Plans the relinquishing Health
Plan’s provider will submit, upon request of the new Health Plan’s provider, any
critical medical information about the transitioning enrollee prior to the
transition including, but not limited to, whether the member is hospitalized,
pregnant, involved in the process of organ transplantation, scheduled for
surgery or post-surgical follow-up on a date subsequent to transition, scheduled
for prior-authorized procedures or therapies on a date subsequent to transition,
receiving dialysis or is chronically ill (e.g. diabetic, hemophilic, HIV
positive).

 

H.                                    Enrollee Transition From FFS to Health
Plan or From Health Plan to FFS

 

1.                                       CONTRACTOR Will Accept Pre-Enrollment
Prior Authorizations

 

For Covered Services other than inpatient, home health services, and medical
equipment, if authorization has been given for a Covered Service and a Medicaid
client transitions from Medicaid fee-for-service to enrollment with the
CONTRACTOR’s health plan prior to the delivery of such Covered Service, the
CONTRACTOR will be bound by the DEPARTMENT’s fee-for-service prior authorization
until the CONTRACTOR has evaluated the medical necessity of the service and
agrees with the DEPARTMENT’s  fee-for-service prior authorization or has made a
different determination. (See Article XII, Payments, Section H, Clarification of
Payment Responsibilities, Subsection 6, for inpatient, home health services, and
medical equipment explanations.)

 

2.                                       DEPARTMENT Will Accept CONTRACTOR’s
Prior Authorization

 

For Covered Services other than inpatient, home health services, and medical
equipment, if authorization has been given for a Covered Service and an Enrollee
transitions to  Medicaid fee-for-service prior to the delivery of such Covered
Service,

 

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the DEPARTMENT will be bound by the CONTRACTOR’s prior authorization until the
DEPARTMENT has evaluated the medical necessity of the service and agrees with
the CONTRACTOR’s fee-for-service prior authorization or has made a different
determination. (See Article XII, Benefits, Section H, Clarification of Payment
Responsibilities, Subsection 6, for inpatient, home health services, and medical
equipment explanations.)

 

3.                                      Will Provide Medical Records to
Enrollee’s Health Plan or to the DEPARTMENT

 

When enrollees are transitioned from Health Plan to fee-for-service or from
fee-for-service to Health Plan, the relinquishing entity (Health Plan or
DEPARTMENT) will submit, upon request of the new entity, any critical medical
information about the transitioning Medicaid client prior to the transition
including, but not limited to, whether the member is hospitalized, pregnant,
involved in the process of organ transplantation, scheduled for surgery or
post-surgical follow-up on a date subsequent to transition, scheduled for
prior-authorized procedures or therapies on a date subsequent to transition,
receiving dialysis or is chronically ill (e.g. diabetic, hemophilic, HIV
positive).

 

Article IV - Benefits

 

A.                                   In General

 

1.                                       The CONTRACTOR will provide to
Enrollees under this Contract, directly or through arrangements with
subcontractors, all Medically Necessary Covered Services described in Attachment
C as promptly and continuously as is consistent with generally accepted
standards of medical practice.

 

2.                                       The CONTRACTOR will ensure that all
Covered Services are furnished in an amount, duration, and scope that is no less
than the amount, duration, and scope for the same services furnished to
beneficiaries under fee-for-service Medicaid (as set forth in 440.230). The
CONTRACTOR will ensure that the services are sufficient in amount, duration, or
scope to reasonably be expected to achieve the purpose for which the services
are furnished.

 

3.                                       The CONTRACTOR may not arbitrarily deny
or reduce the amount, duration, or scope of a required service solely because of
diagnosis, type of illness, or condition of the Enrollee.

 

4.                                       The CONTRACTOR may place appropriate
limits on a service on the basis of criterion applied under the State plan, such
as medical necessity, or for the purpose of utilization control, provided the
services furnished can reasonably be expected to achieve their purpose.

 

5.                                       The subcontractors will follow
generally accepted standards of medical care in diagnosing Enrollees who request
services from the CONTRACTOR.

 

B.                                    Scope of Services

 

1.                                      Responsible for all Benefits in
Attachment C (Covered Services)

 

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Except as otherwise provided for cases of Emergency Services, the CONTRACTOR has
the exclusive right and responsibility to arrange for all benefits listed in
Attachment C. The CONTRACTOR is responsible for payment of Emergency Services 24
hours a day and 7 days a week whether the service was provided by a network or
out-of-network provider and whether the service was provided in or out of the
CONTRACTOR’s Service Area.

 

2.                                      Changes to Benefits

 

Amendments, revisions, or additions to the State Plan or to State or Federal
regulations, guidelines, or policies and court or administrative orders will,
insofar as they affect the scope or nature of  benefits available to Enrollees,
be amendments to the Covered Services under Attachment C. The DEPARTMENT will
notify the CONTRACTOR, in writing, of any such changes and their effective date.

 

C.                                     Clarification of Covered Services

 

1.                                      Emergency Services

 

a.                                      In General

 

(1)                                  The CONTRACTOR will provide coverage for
Emergency Services without regard to prior authorizations or the emergency care
provider’s contractual relationship with the CONTRACTOR. The CONTRACTOR will
inform its Enrollees that access to Emergency Services is not restricted and
that if an Enrollee experiences a medical emergency, he or she may obtain
services from a non-plan physician or other qualified provider, without penalty.
An Enrollee who has an Emergency Medical Condition may not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient.

 

(2)                                  The CONTRACTOR may not limit what
constitutes an Emergency Medical Condition on the basis of lists of diagnoses or
symptoms.

 

(3)                                  The CONTRACTOR will pay for services where
the presenting symptoms are of sufficient severity that a person with average
knowledge of health and medicine would reasonably expect the absence of
immediate medical attention to result in placing the health of the individual
(or, with respect to a pregnant woman, the health of a woman or her unborn
child) in serious jeopardy; serious impairment to bodily functions; or serious
dysfunction of any bodily organ or part.

 

(4)                                  The CONTRACTOR may not retroactively deny a
claim for an emergency screening examination because the condition, which
appeared to be an emergency medical condition under the prudent layperson
standard, turned out to be non-emergency in nature.

 

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b.                                       Determining Liability for Emergency
Services

 

The CONTRACTOR may not deny payment for treatment obtained when an Enrollee had
an Emergency Medical Condition, including cases in which the absence of
immediate medical attention would not have had the outcomes specified in the
definition of Emergency Medical Condition.

 

(1)                                  Presence of a clinical emergency

 

If the screening examination leads to a clinical determination by the examining
physician that an actual emergency medical condition exists, the CONTRACTOR will
pay for both the services involved in the screening examination and the services
required to stabilize the Enrollee.

 

(2)                                  Emergency services continue until the
Enrollee can be safely discharged or transferred.

 

The CONTRACTOR will pay for all Emergency Services that are Medically Necessary
until the clinical emergency is stabilized. This includes all treatment that may
be necessary to assure, within reasonable medical probability, that no material
deterioration of the Enrollee’s condition is likely to result from, or occur
during, discharge of the Enrollee or transfer of the Enrollee to another
facility. If there is a disagreement between a hospital and the CONTRACTOR
concerning whether the Enrollee is stable enough for discharge or transfer, or
whether the medical benefits of an unstabilized transfer outweigh the risks, the
judgement of the attending physician(s) actually caring for the Enrollee at the
treating facility prevails and is binding on the CONTRACTOR. The CONTRACTOR may
establish arrangements with hospitals whereby the CONTRACTOR may send one of its
own physicians with appropriate ER privileges to assume the attending
physician’s responsibilities to stabilize, treat, and transfer the Enrollee.

 

(3)                                  Absence of a clinical emergency

 

If the screening examination leads to a clinical determination by the examining
physician that an actual emergency medical condition did not exist, then the
determining factor for payment liability should be whether the Enrollee had
acute symptoms of sufficient severity at the time of presentation. In these
cases, the CONTRACTOR will review the presenting symptoms of the Enrollee and
will pay for all services involved in the screening examination where the
presenting symptoms (including severe pain) were of sufficient severity to have
warranted emergency attention under the prudent layperson standard.

 

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(4)                                  Referrals

 

When an Enrollee’s Primary Care Physician or other plan representative instructs
the Enrollee to seek emergency care in or out of network, the CONTRACTOR is
responsible for payment of the medical screening examination and for other
Medically Necessary Emergency Services, without regard to whether the Enrollee
meets the prudent layperson standard.

 

(5)                                  Notification

 

The CONTRACTOR may not refuse to cover Emergency Services because the emergency
room provider, hospital, or fiscal agent did not notify the CONTRACTOR of the
Enrollee’s screening and treatment within ten calendar days of presentation for
Emergency Services.

 

c.                                       Post-Stabilization Services

 

The CONTRACTOR will comply with Medicare guidelines for post-stabilization of
care as found in 42 CFR 422.113(c). Generally, Post-Stabilization Services begin
when an Enrollee is admitted for an inpatient hospital stay after Emergency
Services to evaluate or stabilize the Emergency Medical condition have been
provided in the Emergency Room.

 

However, in situations where the hospital demonstrates the Enrollee received
Emergency Services related to an Emergency Medical Condition during the
inpatient admission, the CONTRACTOR will reimburse the hospital in accordance
with regulations governing Emergency Services as outlined in item b., Emergency
Services, above.

 

(1)                                  Pre-approved Post-Stabilization Services: 
The CONTRACTOR is financially responsible for Post-stabilization Services
obtained within or outside the CONTRACTOR’s plan that are pre-approved by a
CONTRACTOR provider or representative.

 

(2)                                  Post-Stabilization Services - Not
Pre-Approved – but CONTRACTOR is Responsible:  The CONTRACTOR is financially
responsible for Post-stabilization Services obtained within or outside the
CONTRACTOR organization that are not pre-approved by a CONTRACTOR provider or
other CONTRACTOR representative, but are administered to maintain the Enrollee’s
stabilized condition within one hour of a request to the CONTRACTOR for
pre-approval of further post-stabilization care services.

 

The CONTRACTOR is financially responsible for Post-stabilization Services
obtained within or outside the CONTRACTOR organization that are not pre-approved
by a CONTRACTOR

 

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provider or other CONTRACTOR representative, but are administered to maintain,
improve or resolve the Enrollee’s stabilized condition if:

 

(a)                                  the CONTRACTOR does not respond to a
request for pre-approval within one hour (of the request);

 

(b)                                 the CONTRACTOR cannot be contacted;

 

(c)                                  the CONTRACTOR representative and the
treating physician cannot reach an agreement concerning the Enrollee’s care and
a CONTRACTOR physician is not available for consultation. In this situation, the
CONTRACTOR will give the treating physician the opportunity to consult with a
CONTRACTOR physician and the treating physician may continue with the care of
the Enrollee until a CONTRACTOR physician is reached; or

 

one of the criteria outlined in 42 CFR 422.113(c)(3) is met:

 

(i)  a CONTRACTOR physician with privileges at the treating hospital assumes
responsibility for the Enrollee’s care;

 

(ii) a CONTRACTOR physician assumes responsibility for the Enrollee’s care
through transfer;

 

(iii) a CONTRACTOR representative and the treating physician reach an agreement
concerning the Enrollee’s care; or

 

(iv) the Enrollee is discharged.

 

2.                                      Care Provided in Skilled Nursing
Facilities

 

a.                                       In General:  Stays Lasting 30 Days or
Less

 

The CONTRACTOR may provide long term care for Enrollees in skilled nursing
facilities and then reimburse such facilities when the plan of care includes a
prognosis of recovery and discharge within 30 days. It is the responsibility of
a CONTRACTOR physician to make the determination if the patient will require the
services of a nursing facility for fewer or greater than 30 days.

 

b.                                       Process for Stays Longer than 30 Days

 

When the prognosis of an Enrollee indicates that long term care greater than 30
days will be required, the following process will occur:

 

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(1)                                  The CONTRACTOR will notify the Enrollee,
hospital discharge planner, and nursing facility that the CONTRACTOR will not be
responsible for the services provided for the Enrollee during the stay at the
skilled nursing facility.

 

(2)                                  The CONTRACTOR will notify the DHCF, Bureau
of Managed Health Care (BMHC) of this determination and the BMHC will change the
status of the Enrollee to fee-for-service.

 

c.                                       Process for Stays Less than 30 Days

 

When the prognosis of skilled nursing facility services is anticipated to be
less than 30 days, but during the 30-day period the CONTRACTOR determines that
the Enrollee will require skilled nursing facility services for greater than 30
days, the following process will be in effect:

 

(1)                                  The CONTRACTOR will notify the nursing
facility that a determination has been made that the Enrollee will require
services for more than 30 days.

 

(2)                                  The CONTRACTOR will notify the DHCF, Bureau
of Managed Health Care, of the determination that the Enrollee will require
services in a nursing facility for more than 30 days.

 

(3)                                  The CONTRACTOR will be responsible for
payment for three working days after the CONTRACTOR has notified the nursing
facility that skilled nursing care will be required for more than 30 days.

 

3.                                      Hospice

 

a.                                       If an Enrollee is receiving hospice
services at the time of enrollment in the Health Plan or if the Enrollee is
already enrolled in the Health Plan and has less than six months to live, the
Enrollee will be offered hospice services or the continuation of hospice
services if he or she is already receiving such services prior to enrollment in
the Health Plan.

 

b.                                      If the enrollee is admitted to a nursing
facility, ICF/MR, or a freestanding hospice facility, the Health Plan is
responsible to reimburse the hospice provider for both the hospice care and the
room and board until the Enrollee is disenrolled from the Health Plan by the
DEPARTMENT. At the point the Health Plan determines that the Enrollee will
require care in the hospice facility for greater than 30 days, the Health Plan
will notify the Enrollee, hospice agency, and hospice facility that the Health
Plan will no longer be responsible for hospice services. The CONTRACTOR will
also notify the DEPARTMENT’s Bureau of Managed Health Care (BMHC) of this
determination. The BMHC will change the status of the Enrollee to
fee-for-service.

 

c.                                       The CONTRACTOR is responsible for room
and board expenses of a hospice Enrollee receiving Medicare hospice care while
the Enrollee is a resident of a

 

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Medicare-certified nursing facility, ICF/MR, or freestanding hospice facility
until the Enrollee is disenrolled from the Health Plan by the BMHC.

 

4.                                      Inpatient Hospital Services for
Scheduled Admissions

 

a.                                       If a CONTRACTOR’s provider admits an
Enrollee for inpatient hospital care and has followed the CONTRACTOR’s
requirements for the admission, the CONTRACTOR has the responsibility for all
services needed by the Enrollee during the hospital stay that are ordered by the
CONTRACTOR’s provider. Needed services include but are not limited to diagnostic
tests, pharmacy, and physician services, including services provided by
psychiatrists.

 

b.                                      If diagnostic tests conducted during the
inpatient stay reveal that the Enrollee’s condition is outside the scope of the
CONTRACTOR’s responsibility, the CONTRACTOR remains financially responsible for
the Enrollee until the Enrollee is discharged or until responsibility is
transferred to another appropriate entity and the entity agrees to take
financial responsibility, including negotiating a payment for services.

 

c.                                       If the Enrollee is discharged and needs
further services, the admitting CONTRACTOR will coordinate with the other
appropriate entity to ensure continued care is provided. The CONTRACTOR and
appropriate entity will work cooperatively in the best interest of the Enrollee.
The appropriate entity includes, but is not limited to, a Prepaid Mental Health
Plan.

 

5.                                      Children in Custody of the Department of
Human Services

 

a.                                      In General

 

(1)                                  The CONTRACTOR will work with the Division
of Child and Family Services (DCFS) or the Division of Youth Corrections (DYC)
in the Department of Human Services (DHS) to ensure systems are in place to meet
the health needs of children in custody of the Department of Human Services. The
CONTRACTOR will ensure these children receive timely access to appointments
through coordination with DCFS or DYC. The CONTRACTOR will have available
providers who have experience and training in abuse and neglect issues.

 

(2)                                  The CONTRACTOR or its providers will make
every reasonable effort to ensure that a child who is in custody of the
Department of Human Services may continue to use the provider with whom the
child has an established professional relationship when the provider is part of
the CONTRACTOR’s network. The CONTRACTOR will facilitate timely appointments
with the provider of record to ensure continuity of care for the child.

 

(3)                                  While it is the CONTRACTOR’s responsibility
to ensure Enrollees who are children in the custody of DHS have access to needed
services, DHS personnel are primarily responsible to assist children in custody

 

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in arranging for and getting to medical appointments and evaluations with the
CONTRACTOR’s network of providers. DHS staff are primarily responsible for
contacting the CONTRACTOR to coordinate care for children in custody and
informing the CONTRACTOR of the special health care needs of these Enrollees.
The Fostering Healthy Children staff may assist the DHS staff in performing
these functions by communicating with the CONTRACTOR.

 

b.                                      Schedule of Visits

 

(1)                                  Where physical and/or sexual abuse is
suspected

 

In cases where the child protection worker suspects physical and/or sexual
abuse, the CONTRACTOR will ensure that the child has access to an appropriate
examination within 24 hours of notification that the child was removed from the
home. If the CONTRACTOR cannot provide an appropriate examination, the
CONTRACTOR will ensure thechild has access to a provider who can provide an
appropriate examination within the 24 hour period.

 

(2)                                  All other cases

 

In all other cases, the CONTRACTOR will ensure that the child has access to an
initial health screening within five calendar days of notification that the
child was removed from the home. The CONTRACTOR will ensure this exam identifies
any health problems that might determine the selection of a suitable placement,
or require immediate attention.

 

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(3)                                  CHEC exams

 

In all cases, the CONTRACTOR will ensure that the child has access to a Child
Health Evaluation and Care (CHEC) screening within 30 calendar days of
notification that the child was removed from the home. Whenever possible, the
CHEC screening should be completed within the five-day time frame. Additionally,
the CONTRACTOR will ensure the child has access to a CHEC screening according to
the CHEC periodicity schedule until age six, then annually thereafter.

 

6.                                      Organ Transplantations

 

a.                                      In General

 

All organ transplantation services are the responsibility of the CONTRACTOR for
all Enrollees in accordance with the criteria set forth in Rule R414-10A of the
Utah Administrative Code, unless amended under the provisions of Attachment B,
Article IV (Benefits), Section C, Subsection 7 of this Contract. The
DEPARTMENT’s criteria will be provided to the CONTRACTOR.

 

b.                                      Specific Organ Transplantations Covered

 

The following transplantations are covered for Enrollees under the Traditional
Medicaid Plan as described in Rule R414-10A: kidney, liver, cornea, bone marrow,
stem cell, heart, intestine, lung, pancreas, small bowel, combination
heart/lung, combination intestine/liver, combination kidney/pancreas,
combination liver/kidney, multi-visceral, and combination liver/small bowel.
Transplantations for Enrollees under the Non-Traditional Medicaid Plan are
limited to kidney, liver, cornea, bone marrow, stem cell, heart, and lung.

 

c.             Psychosocial Evaluation Required

 

(1)                                  Enrollees who have applied for organ
transplantations, except cornea or kidney, will undergo a comprehensive
psycho-social evaluation by a board-certified or board-eligible psychiatrist.
The evaluation will include a comprehensive history regarding substance abuse
and compliance with medical treatment. In addition, the parent(s) or guardian(s)
of Enrollees who are less than 18 years of age will undergo a psycho-social
evaluation that includes a comprehensive history regarding substance abuse, and
past and present compliance with medical treatment.

 

(2)                                  If a request is made for a transplantation
not listed above, the CONTRACTOR will contact the DEPARTMENT. Such requests will
be addressed as set forth in R414-10A-23.

 

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d.                                      Out-of-State Transplantations

 

When the CONTRACTOR arranges the transplantation to be performed out-of- state,
the CONTRACTOR is responsible for coverage of food, lodging, transportation and
airfare expenses for the Enrollee and attendant. The CONTRACTOR will follow, at
a minimum, the DEPARTMENT’s criteria for coverage of food, lodging,
transportation and airfare expenses.

 

7.                                      Mental Health Services

 

a.                                       When an Enrollee presents with a
possible mental health condition to his or her CONTRACTOR primary care
physician, it is the responsibility of the primary care provider to determine
whether the Enrollee should be referred to a psychologist, pediatric specialist,
psychiatrist, neurologist, or other specialist. Mental health conditions may be
handled by the CONTRACTOR primary care provider or referred to the Enrollee’s
Prepaid Mental Health Plan when more specialized services are required for the
Enrollee. CONTRACTOR primary care providers may seek consultation from the
Prepaid Mental Health Plan when the primary care provider chooses to manage the
Enrollee’s symptoms.

 

b.                                      An independent panel comprised of
specialists appropriate to the concern will be established by the DEPARTMENT
with representatives from the CONTRACTOR and Prepaid Mental Health Plan to
adjudicate disputes regarding which entity (the CONTRACTOR or Prepaid Mental
Health Plan) is responsible for payment and/or treatment of a condition. The
panel will be convened on a case-by-case basis. The CONTRACTOR and Prepaid
Mental Health Plan will adhere to the final decision of the panel.

 

8.                                      Developmental and Organic Disorders

 

a.                                      Covered Services for Child Enrollees
through Age 20

 

(1)                                  The CONTRACTOR is responsible for all
inpatient and physician outpatient Covered Services for child Enrollees with
developmental (ICD-9 codes 299.0 through 299.11, developmental disorders
included within the range 299.8 through 299.91, and 317 through 319.9) and
organic diagnoses (ICD-9 codes 290 through 290.99, 293 through 294.99, and and
310 through 310.9) including, but not limited to, diagnostic work-ups and other
medical care such as medication management services related to the developmental
or organic disorder.

 

(2)                                  The CONTRACTOR is responsible for all
psychological services for child Enrollees with developmental or organic
disorders and all other diagnoses not covered by a Prepaid Mental Health Plan.

 

b.                                      Covered Services for Adult Enrollees Age
21 and Older

 

The CONTRACTOR is responsible for all inpatient and physician outpatient Covered
Services for adult Enrollees with developmental (ICD-9 codes 299.0 through
299.11, developmental disorders included within the range 299.8 through 299.91,
and 317 through 319.9) and organic diagnoses (ICD-9

 

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codes 290 through 290.99, 293 through 294.99 and 310 through 310.9) including
diagnostic work-ups and other medical care such as medication management
services related to the developmental or organic disorder.

 

c.                                       Non-covered Services

 

(1)                                  Psychological evaluations and testing
including neuropsychological evaluations and testing for adult Enrollees is not
the responsibility of the CONTRACTOR.

 

(2)                                  Habilitative and behavioral management
services are not the responsibility of the CONTRACTOR. If habilitative services
are required, the Enrollee should be referred to the Division of Services for
People with Disabilities (DSPD), the school system, the Early Intervention
Program, or similar support program or agency. The Enrollee should also be
referred to DSPD for consideration of other benefits and programs that may be
available through DSPD. Habilitative services are defined in Section
1915(c)(5)(a) of the Social Security Act as “services designed to assist
individuals in acquiring, retaining and improving the self-help, socialization
and adaptive skills necessary to reside successfully in home and community based
settings.”

 

d.                                      Responsibility of the Prepaid Mental
Health Plan

 

The Prepaid Mental Health Plan is responsible for the treatment of the mental
illness to individuals with both an organic and a psychiatric diagnosis or with
both a developmental and a psychiatric diagnosis.

 

9.             Out-of-State Accessory Services

 

When the CONTRACTOR arranges a Covered Service to be performed out-of-state, the
CONTRACTOR is responsible for coverage of airfare, food and lodging for the
Enrollee and one attendant during the stay at the out-of-state facility. Ground
transportation costs only from the airport to the hotel or hospital and back to
the airport, one time only are also the responsibility of the CONTRACTOR. The
CONTRACTOR will follow, at a minimum, the DEPARTMENT’s criteria for coverage of
food, lodging, transportation, and airfare expenses.

 

10.                               Non-Contractor Prior Authorizations

 

a.                                      Prior Authorizations - General

 

The CONTRACTOR will honor prior authorizations for organ transplantations and
any other ongoing services initiated by the DEPARTMENT while the Enrollee was
covered under Medicaid fee-for-service until the Enrollee is evaluated by the
CONTRACTOR and a new plan of care is established.

 

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b.                                      When the CONTRACTOR has not Authorized
the Service and the Provider is not a Participating Provider

 

For services that require a prior authorization, the CONTRACTOR will pay the
provider of the service at the Medicaid rate, if all of the following conditions
are met:

 

(1)                                  the servicing provider is not a
participating provider under contract with the CONTRACTOR; and

 

(2)                                  the DEPARTMENT issued a prior authorization
for an Enrollee to the servicing provider; and

 

(3)                                  the provider filed an Appeal with the
CONTRACTOR within the required time frame for filing an Appeal; and

 

(4)                                  the servicing provider has completed the
CONTRACTOR’s appeals process without resolution of the claim, and has requested
a hearing with the State Formal Hearings Unit requesting payment for the
services rendered; and

 

(5)                                  in the hearing process it is determined
that the service rendered was a Medically Necessary service covered under this
Contract, and that the CONTRACTOR will be responsible for payment of the claim.

 

D.                                    Additional Services for Enrollees with
Special Health Care Needs

 

1.                                      In General

 

The CONTRACTOR will make case management programs available to Enrollees
identified with special health care needs. The CONTRACTOR will ensure there is
access to all Medically Necessary Covered Services to meet the health needs of
Enrollees with Special Health Care Needs. Individuals with special health care
needs are those who have or are at increased risk for chronic physical,
developmental, behavioral, or emotional conditions and who also require health
and related services of a type or amount beyond that required by adults and
children generally.

 

2.                                      Identification

 

The CONTRACTOR will identify Enrollees with Special Health Care Needs using a
process at the initial contact made by the CONTRACTOR Representative to educate
the client and will offer the client care coordination or case management
services. Care coordination services are services to assist the client in
obtaining Medically Necessary Covered Services from the CONTRACTOR or another
entity if the medical service is not covered under the Contract.

 

3.                                      Choosing a Primary Care Provider

 

The CONTRACTOR will have a mechanism to inform caregivers and, when

 

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appropriate, Enrollees with Special Health Care Needs about primary care
providers who have training in caring for such Enrollees so that an informed
selection of a provider can be made. The CONTRACTOR will have primary care
providers with skills and experience to meet the needs of Enrollees with Special
Health Care Needs. For Enrollees determined to need a course of treatment or
regular care monitoring, the CONTRACTOR will have a mechanism in place to allow
Enrollees to directly access a specialist (for example, through standing
referral or an approved number of visits) as appropriate for the Enrollee’s
condition and identified needs. The CONTRACTOR will allow an appropriate
specialist to be the primary care provider but only if the specialist has the
skills to monitor the Enrollee’s preventive and primary care services.

 

4.                                      Referrals and Access to Specialty
Providers

 

(1)                                  The CONTRACTOR will ensure there is access
to appropriate specialty providers to provide Medically Necessary Covered
Services for adults and children with special health care needs. If the
CONTRACTOR does not employ or contract with a specialty provider to treat a
special health care condition at the time the Enrollee needs such Covered
Services, the CONTRACTOR will have a process to allow the Enrollee to receive
Covered Services from a qualified specialist who may not be affiliated with the
CONTRACTOR. The CONTRACTOR will reimburse the specialist for such care at no
less than Medicaid’s rate for the service when the service is rendered. The
process for requesting specialist’s care will be clearly described by the
CONTRACTOR and explained to each Enrollee during the initial contact with the
Enrollee.

 

(2)                                  If the CONTRACTOR restricts the number of
referrals to specialists, the CONTRACTOR will not penalize those providers who
make such referrals for Enrollees with special health care needs.

 

5.                                      Survey of Enrollees with Special Health
Care Needs

 

At least every two years, the CONTRACTOR in conjunction with the DEPARTMENT will
survey a sample of Enrollees with special health care needs using a national
consumer assessment questionnaire to evaluate their perceptions of services they
have received. The survey process, including the survey instrument, will be
standardized and developed collaboratively between the DEPARTMENT and all
contracting Health Plans. The DEPARTMENT will analyze the results of the
surveys. The results and analysis of

 

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the surveys will be reviewed by the CONTRACTOR’s quality assurance committee for
action.

 

6.                                      Collaboration with Other Programs

 

a.                                       The CONTRACTOR will implement
procedures to share with other PIHPs and PAHPs, serving Enrollees with Special
health Care Needs the results of its identification and assessment of each
Enrollee’s needs to prevent duplication of those activities.

 

b.                                      If the Enrollee with Special Health Care
Needs is enrolled in the Prepaid Mental Health Plan or is enrolled in any of the
Medicaid home and community-based waiver programs and is receiving case
management services through that program, or is covered by one of the other
Medicaid targeted case management programs, the CONTRACTOR care coordinator will
collaborate with the appropriate program person, i.e., the targeted case
manager, etc., for that program once the program person has contacted the
CONTRACTOR care coordinator. When necessary, the CONTRACTOR care coordinator
will make an effort to contact the program person of those Enrollees who have
medical needs that require such coordination.

 

c.                                       The CONTRACTOR will coordinate health
care needs for Enrollees with Special Health Care Needs with the services of
other agencies (e.g., mental and substance abuse, public health departments,
transportation, home and community based care, developmental disabilities, Title
V, local schools, IDA programs, and child welfare), and with families,
caregivers, and advocates.

 

7.                                      Case Management and Coordination of Care
Program

 

a.                                       The CONTRACTOR will have a basic system
in place to assure continuity and coordination of overall health care for all
Enrollees including a mechanism to ensure that each Enrollee has an ongoing
source of primary care. The CONTRACTOR’s case management (CM) program will be
designed around a collaborative process of assessment, planning, facilitation
and advocacy using available resources to promote quality, timely, safe and cost
effective outcomes. The CM program will have sufficient resources to meet the
needs of the enrolled population and anticipated enrollment as needs change. The
CONTRACTOR will use the information the DEPARTMENT provides on Enrollees with
Special Health Care Needs to coordinate care and determine case management
needs.

 

b.                                      case management program includes, but is
not limited to:

 

(1)                                  Methods used to identify Enrollees with
Special Health Care Needs and Enrollees needing case management or coordination
on enrollment and ongoing methods for existing enrollees; e.g. a mechanism to
perform health needs assessments upon enrollment for all Enrollees within the
time frames required by the contract, to identify Enrollees with Special Health
Care needs, to identify Enrollees needing case management services and to help
facilitate

 

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care/services in accordance with treatment plans

 

(2)                                  Methodologies to determine the frequency
and duration of CM services through application of established criteria.

 

(3)                                  Mechanism to refer to and coordinate with
other state agencies and community resources as necessary (i.e., coordination of
medical and mental health care, transportation, aging services, waiver programs,
CSHCN clinics, DSPD, dental, WIC, etc.) when needed.

 

(4)                                  Assisting with and the monitoring of
Enrollees follow up and specialty care (tracking of referrals) to ensure
compliance with treatment plan and ensure that members receive recommended
follow up and specialty care.

 

e.                                       Protocols to address Enrollees who are
non-compliant.

 

f.                                         Linkages to the CONTRACTOR’s disease
management programs.

 

g.                                      Methods for sharing the results of
assessments of Enrollees with Special Health Care Needs in order to prevent
duplication of those services and coordinate care. (Efforts to share information
will be in accordance with privacy requirements in 45 CFR parts 160 and 164
subparts A and E, to the extent that they are applicable.)

 

8.                                      Specific Requirements for Children with
Special Health Care Needs

 

a.                                      DEPARTMENT’s Identification

 

The DEPARTMENT will implement mechanisms to identify Children with Special
Health Care Needs as defined in this Contract. These identification mechanisms
are specified in the DEPARTMENT’s Quality Assessment Performance Improvement
Plan. (See Attachment D.)

 

b.                                      Assessment

 

The CONTRACTOR will implement mechanisms to assess each Child with Special
Health Care Needs that the DEPARTMENT has reported to the CONTRACTOR in order to
identify any ongoing special conditions of the Enrollee that require a course of
treatment or regular care monitoring. The assessment mechanisms will use
appropriate health care professionals.

 

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Article V - Delivery Network

 

A.                                   Availability of Services

 

1.                                      Appropriate Network

 

The CONTRACTOR will maintain and monitor a network of appropriate providers that
is supported by written agreements and is sufficient to provide adequate access
to all services covered under this Contract. In establishing and maintaining the
network of providers, the CONTRACTOR will consider the following:

 

a.                                       the anticipated Medicaid enrollment;

 

b.                                      the expected utilization of services,
taking into consideration the characteristics and health care needs of specific
Medicaid populations represented in the CONTRACTOR’s Service Area;

 

c.                                       the numbers and types (in terms of
training, experience, and specialization) of providers required to furnish the
contracted Medicaid services; and

 

d.                                      the number of network providers who are
not accepting new Medicaid patients;

 

e.                                       the geographic locations of providers
and Enrollees, considering distance, travel time, the means of transportation
ordinarily used by Enrollees, and whether the location provides physical access
for Enrollees with disabilities.

 

2.                                      Direct Access

 

The CONTRACTOR will provide female Enrollees with direct access to a women’s
health specialist within the network for covered care necessary to provide
women’s routine and preventive health care services. (This is in addition to the
Enrollee’s designated source of primary care if that source is not a women’s
health specialist.)

 

3.                                       Second Opinion

 

The CONTRACTOR will provide for a second opinion from a qualified health care
professional within the network, or arrange for the Enrollee to obtain one
outside the network, at no cost to the Enrollee.

 

4.                                       Out of Network

 

If the network is unable to provide Necessary Covered Services under this
Contract to a particular Enrollee, the CONTRACTOR will adequately and timely
cover these services out of network for the Enrollee, for as long as the
CONTRACTOR is unable to provide them. The CONTRACTOR will require out-of-network
providers to coordinate with the CONTRACTOR with respect to payment and ensure
that cost to the Enrollee is no greater than it would be if the services were
furnished within the network.

 

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5.                                       Timely Access

 

The CONTRACTOR will require that its network providers offer hours of operation
that are no less than the hours of operation offered to commercial enrollees or
comparable to Medicaid fee-for-service, if the provider serves only Medicaid
enrollees. The CONTRACTOR will ensure that all Covered Serices are available 24
hours a day, 7 days a week, when medically necessary.

 

6.                                       Timely Access Monitoring

 

The CONTRACTOR will establish mechanisms to ensure compliance by its network
providers and will monitor its providers regularly to determine compliance by
providers. If there is failure to comply, the CONTRACTOR will take corrective
action.

 

B.                                     Subcontracts and Assurances

 

1.                                      General Assurances

 

Any Covered Service may be subcontracted. The CONTRACTOR will ensure that all
subcontracts are in writing and will include any general requirements of this
Contract that are appropriate to the service or activity delegated under the
subcontract including confidentiality requirements and will assure that all
duties of the CONTRACTOR under this Contract are performed. The CONTRACTOR will
monitor the subcontractor’s performance on an ongoing basis that will be subject
to formal review according to a periodic schedule established by the DEPARTMENT,
consistent with industry standards. If the CONTRACTOR identifies deficiencies or
areas for improvement, the CONTRACTOR and the subcontractor will take corrective
action. No subcontract terminates the legal responsibility of the CONTRACTOR to
the DEPARTMENT to assure that all activities under this Contract are carried
out. The CONTRACTOR will make all subcontracts available upon request.

 

2.                                       Written Agreement

 

The CONTRACTOR will oversee and be accountable for any functions and
responsibilities that it delegates to any subcontractor. Before any delegation,
the CONTRACTOR will evaluate the prospective subcontractor’s ability to perform
the activities to be delegated. There will be a written agreement between the
CONTRACTOR and subcontractor that:

 

a.                                       specifies the activities and report
responsibilities delegated to the subcontractor;

 

b.                                      includes a provision for revoking
delegation or imposing other sanctions if the subcontractor’s performance is
inadequate;

 

c.                                       includes a provision that if the
subcontractor becomes insolvent or bankrupt, Enrollees will not be liable for
the debt of the subcontractor; and

 

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d.                                      specifies that the subcontractor, acting
within the lawful scope of his or her practice, will not be prohibited from
advising or advocating on behalf of an Enrollee who is his or her patient for
the following:

 

(1)                                  the Enrollee’s health status, medical care,
or treatment options, including any alternative treatment that may be
self-administered;

 

(2)                                  any information the Enrollee needs in order
to decide among all relevant treatment options;

 

(3)                                  the risks, benefits, and consequences of
treatment or non-treatment; and

 

(4)                                  the Enrollee’s right to participate in
decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.

 

3.                                       Practice Guidelines

 

a.                                       The CONTRACTOR and its subcontractors
will adopt practice guidelines that meet the following requirements:

 

(1)                                  are based on valid and reliable clinical
evidence or a consensus of health care professionals in the particular field;

 

(2)                                  consider the needs of the Enrollees in the
CONTRACTOR’s health plan;

 

(3)                                  are adopted in consultation with
contracting health care professionals; and

 

(4)                                  are reviewed and updated periodically as
appropriate.

 

b.                                      The CONTRACTOR will disseminate the
practice guidelines to all affected providers and, upon request, to Enrollees
and Potential Enrollees.

 

c.                                       The CONTRACTOR will ensure that
decisions for utilization management, Enrollee education, coverage of services,
and other areas to which the guidelines apply are consistent with the practice
guidelines.

 

4.                                       No Provisions to Reduce or Limit
Medically Necessary Services

 

The CONTRACTOR will ensure that subcontractors abide by the requirements of
Section 1128(b) of the Social Security Act prohibiting the CONTRACTOR and other
such providers from making payments directly or indirectly to a physician or
other provider as an inducement to reduce or limit Medically Necessary services
provided to Enrollees.

 

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5.                                       Domestic Violence

 

The CONTRACTOR will ensure that providers and staff are knowledgeable about
methods to detect domestic violence, about mandatory reporting laws when
domestic violence is suspected, and about resources in the community to which
patients can be referred.

 

6.                                       Requirement of 60 Days Written Notice
Prior to Termination of Contract

 

All subcontracts and agreements will include a provision stating that if either
party (the subcontractor or CONTRACTOR) wishes to terminate the subcontract or
agreement, whichever party initiates the termination will give the other party
written notice of termination at least 60 calendar days prior to the effective
termination date. The CONTRACTOR will notify the DEPARTMENT of the termination
on the same day that the CONTRACTOR either initiates termination or receives the
notice of termination from the subcontractor.

 

7.                                       Compliance with CONTRACTOR’s Quality
Assurance Plan

 

All of the CONTRACTOR’s providers will be aware of the CONTRACTOR’s Quality
Assurance Plan and activities. All subcontracts with the CONTRACTOR will include
a requirement securing cooperation with the CONTRACTOR’s Quality Assurance Plan
and activities and will allow the CONTRACTOR access to the subcontractor’s
medical records of its Enrollees.

 

8.                                      Unique Identifier Required

 

All physicians who provide services under this Contract will have a unique
identifier in accordance with the system established under section 1173(b) of
the Social Security Act and in accordance with the Health Insurance Portability
and Accountability Act.

 

9.                                       Payment of Provider Claims

 

a.                                       The CONTRACTOR will pay its providers
on a timely basis consistent with the claims payment procedures described in
section 1902(a)(37)(A) of the Social Security Act and the implementing Federal
regulation at 42 CFR 447.45 and 447.46, unless the CONTRACTOR and its provider
establish an alternative payment schedule. A claim means:  1) a bill for
services, 2) a line item of services, or 3) all services for one Enrollee within
a bill.

 

b.                                      “Clean claim” means a claim that can be
processed without obtaining any additional information from the provider of the
service or from a third party. It includes a claim with errors originating from
the DEPARTMENT’s claims system. It does not include a claim from a provider who
is under investigation for fraud or abuse, or a claim under review for medical
necessity. The CONTRACTOR will pay 90 percent of all clean claims from
practitioners, who are in individual or group practice or who practice in shared
health facilities, within 90 days of receipt.

 

c.                                       The date receipt is the date the
CONTRACTOR receives the claim, as

 

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indicated by its date stamp on the claim, and the date of payment is the date of
the check or other form of payment.

 

C.                                     CONTRACTOR’s Selection of Providers

 

1.                                       Credentialing and Recredentialing of
Providers

 

The CONTRACTOR will maintain written policies and procedures for selection and
retention of providers. The CONTRACTOR will establish and follow a documented
credentialing and recredentialing process for providers who have signed
contracts or participation agreements to: (1) assure that clinical staff are
appropriately credentialed, e.g. that the individual has a current license, is
in good standing with licensing boards, etc., and (2) review records for any
adverse actions or sanctioning of CONTRACTOR’s staff by other states or the
federal government.

 

2.                                       No Discrimination

 

a.                                       The CONTRACTOR’s subcontractor
selection policies and procedures cannot discriminate against particular
providers who serve high-risk populations or specialize in conditions that
require costly treatment.

 

b.                                      The CONTRACTOR will not discriminate
against subcontracting providers with respect to participation, reimbursement,
or indemnification as to any provider who is acting within the scope of that
provider’s license or certification under applicable State law solely on the
basis of the provider’s license or certification. This may not be construed to
mean that the DEPARTMENT requires the CONTRACTOR to contract with providers
beyond the number necessary to meet the needs of its Enrollees; nor does it
preclude the CONTRACTOR from using different reimbursement amounts for different
specialities or for different practitioners in the same speciality; nor does it
preclude the CONTRACTOR from establishing measures that are designed to maintain
quality of services and control costs and are consistent with its
responsibilities to Enrollees.

 

c.                                       If the CONTRACTOR declines to include
individual or groups of providers in its network, it will give the affected
providers written notice of the reason for its decision.

 

3.                                       Ownership or Controlling Interest -
Disclosure to the DEPARTMENT

 

The CONTRACTOR will notify the DEPARTMENT of any person or corporation that has
five percent or more ownership or controlling interest in the entity.

 

4.                                       Excluded Entities and Providers

 

a.                                       The CONTRACTOR will not employ or
subcontract with any individual who is under a current federal debarment,
suspension, sanction or exclusion from participation in federal health care
programs under either section 1128 or section 1128A of the Social Security Act
(the Act), or who has had his or

 

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her license suspended or revoked by any state.

 

b.                                      The CONTRACTOR may not knowingly have a
relationship described in 4.c. with the following:

 

(1)                                  an individual who is debarred, suspended or
otherwise excluded from participating in procurement activities under the
Federal Acquisition Regulation or from participating in non-procurement
activities under regulations issued under Executive Order No.12549 or under
guidelines implementing Executive Order No.12549; or

 

(2)                                  an individual who is an affiliate, as
defined in the Federal Acquisition Regulation, of a person described in 4.b(1).

 

c.                                       The CONTRACTOR will not knowingly have
a relationship of the following types with individuals identified in 4.b. above:

 

(1)                                  a director, officer, or partner of the
CONTRACTOR;

 

(2)                                  a person with beneficial ownership of five
percent or more of the CONTRACTOR’s equity;

 

(3)                                  a person with an employment, consulting or
other arrangement with the CONTRACTOR for the provision of items and services
that are significant and material to the CONTRACTOR’s obligations under this
Contract with the DEPARTMENT.

 

d.                                      Effect of Non-Compliance  –  If the
DEPARTMENT finds that the CONTRACTOR is not in compliance with these
requirements, the DEPARTMENT will notify the Secretary of the Department of
Health and Human Services of the noncompliance.

 

(1)                                  The DEPARTMENT may continue the Contract
with the CONTRACTOR unless the Secretary directs otherwise.

 

(2)                                  The DEPARTMENT may not renew or otherwise
extend the duration of an existing Contract with the CONTRACTOR unless the
Secretary provides to the DEPARTMENT and to Congress a written statement
describing compelling reasons that exist for renewing or extending the Contract.

 

5.                                       Federally Qualified Health Centers
(FQHCs)

 

If  the CONTRACTOR enters into a subcontract with a Federally Qualified Health
Center (FQHC), the CONTRACTOR will reimburse the FQHC an amount not less than
what the CONTRACTOR pays comparable providers that are not FQHCs.

 

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Article VI - Authorization of Services and Notices of Action

 

F.                                      Service Authorization and Notice of
Action

 

1.                                       Policies and Procedures for Service
Authorizations

 

The CONTRACTOR will establish and follow written policies and procedure for
processing requests for initial and continuing authorization of Covered
Services.

 

a.                                       The CONTRACTOR will implement
mechanisms to ensure consistent application of review criteria for service
authorization decisions and consult with the requesting provider when
appropriate.

 

b.                                      The CONTRACTOR will ensure that any
decision to deny a service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested, be made by a health care
professional who has appropriate clinical expertise in treating the Enrollee’s
condition or disease.

 

c.                                       The CONTRACTOR will notify the
requesting provider, and give the Enrollee written notice of any decision to
deny a service authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. The notice to the provider need
not be in writing. (See Section III, Content of Notice of Action, below.)

 

2.                                      Process for the CONTRACTOR to Request
Payment Authorization of Services

 

Since this is a Non-risk Contract, the total payments the DEPARTMENT reimburses
the CONTRACTOR may not exceed the upper limit payments specified in 447.362 and
may be reimbursed by the State at the end of the Contract period based on the
CONTRACTOR’s incurred costs. The payment authorization process is to ensure
services will be included in the CONTRACTOR’s incurred costs and in the upper
payment limit when the DEPARTMENT determines whether payments it made to the
CONTRACTOR are more or less than the upper payment limit.

 

This process also ensures the CONTRACTOR is appropriately applying practice
guidelines, making utilization management decisions and is covering services for
Enrollees requiring special consideration based on their special needs.

 

a.                                       The CONTRACTOR may submit a request for
payment of services to the Bureau of Managed Health Care. The BMHC will review
payment requests when:

 

(1)                                  Medicaid does not have criteria, criteria
is not clearly defined, criteria does not address the unique medical condition,
or a procedure is a newly approved FDA procedure. Examples are:

 

(a)                                  Medicaid does not have criteria and it is a
unique condition – in order to save the life of a pregnant mother and acardiac
twin, patient needs highly specialized procedure only performed at an
out-of-state center of excellence; and

 

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(b)                                 new FDA-approved technology –
magnetoencephalography is used to diagnose and assist neurosurgeons when
performing corrective brain surgery for refractory epilepsy and gliomas.

 

(2)                                  the service is beyond the limits of the
covered benefit, but is medically necessary and is in lieu of more costly
services. Examples are:

 

(a)                                  in order to prevent hospitalization,
additional home health or physical therapy services are necessary;

 

(b)                                 in order to prevent infections leading to a
hospitalization, patient’s condition requires more tracheostomy supplies than
what Medicaid typically covers;

 

(c)                                  patient requires more insulin pump
reservoirs than Medicaid typically covers based on the type and amount of
insulin patient uses.

 

b.                                      The CONTRACTOR submits the necessary
information to a BMHC nurse for review.  The CONTRACTOR must include the
following information in a written request outlining:

 

(1)                                  the services the CONTRACTOR is asking the
BMHC to review;

 

(2)                                  the Enrollee’s name and Medicaid ID number;

 

(3)                                  Medicaid’s fee-for-service policy governing
the service;

 

(4)                                  information documenting medical necessity;

 

(5)                                  a copy of the practice guideline or medical
pathway the CONTRACTOR used to review the case;

 

(6)                                  a cost/benefit analysis with an outline of
any alternative solutions and associated costs;

 

(7)                                  the short term and long term plan for the
service and Enrollee;

 

(8)                                  verification that the CONTRACTOR’s medical
director has reviewed the case (including his/her recommendations); and

 

(9)                                  any additional pertinent documentation the
CONTRACTOR feels is necessary for the BMHC’s review.

 

c.                                       Once the BMHC has all necessary
information, a BMHC nurse reviews the request for approval or denial of payment.
The BMHC nurse may consult with medical and non-medical DEPARTMENT staff to
verify the

 

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appropriate interpretation of Medicaid coverage. The BMHC nurse makes a
recommendation to a physician consultant who then reviews the request for
approval or denial based on medical necessity. Appropriate DEPARTMENT staff
reviews high cost requests before they are authorized for payment. Once the
DEPARTMENT has determined whether the request is authorized for payment, the
BMHC nurse notifies the CONTRACTOR of the decision. The BMHC and CONTRACTOR
track all requests.

 

3.                                      Time Frames for Service Authorization
Decisions

 

The CONTRACTOR will adhere to the following time frames for making service
authorization decisions and mailing Notices of Action to Enrollees and
providers:

 

a.                                       Standard Service Authorization
Approvals

 

(1)                                  The CONTRACTOR will make a decision and
provide notice to the Enrollee and provider as expeditiously as the Enrollee’s
health condition requires, but no later than 14 calendar days from receipt of
the request for Service Authorization.

 

(2)                                  Extensions— The CONTRACTOR may extend the
time frame for making the decision by up to 14 additional calendar days if:

 

(a)                                  the Enrollee or the provider requests
extension; or

 

(b)                                 the CONTRACTOR justifies (to the DEPARTMENT
upon request) a need for additional information and how the extension is in the
Enrollee’s interest.

 

b.                                      Standard Service Authorization Decisions
to Deny or Authorize Less Than Requested and Notice of Action

 

(1)                                  If the CONTRACTOR denies a Service
Authorization request, or  authorizes a requested service in an amount, duration
or scope that is less than requested, the CONTRACTOR will make the decision and
give a Notice of Action to the Enrollee as expeditiously as the Enrollee’s
health condition requires, but no later than 14 calendar days from receipt of
the request for Service Authorization.

 

2)                                      The CONTRACTOR will also notify the
requesting provider, although the notice need not be in writing.

 

(3)                                  Extensions— The CONTRACTOR may extend the
time frame for making the decision by up to 14 additional calendar days if:

 

(a)                                  the Enrollee or the provider requests
extension; or

 

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(b)                                 the CONTRACTOR justifies (to the DEPARTMENT
upon request) a need for additional information and how the extension is in the
Enrollee’s interest.

 

c.                                       Extension of Time Frames for Standard
Service Authorization Decisions

 

If the CONTRACTOR extends the time frame for making standard Service
Authorization decisions in accordance with Section A.2 a. and A.2.b. above, the
CONTRACTOR will:

 

(1)                                  give the Enrollee written notice of the
reason for the decision to extend the time frame;

 

(2)                                  inform the Enrollee of his or her right to
file a Grievance, and how to do so, if the Enrollee disagrees with that decision
(See Article VII, Grievance System, Section I., Grievances); and

 

(3)                                  issue and carry out the determination as
expeditiously as the Enrollee’s health condition requires and no later than the
date the extension expires.

 

d.                                      Expedited Service Authorization
Decisions

 

(1)                                  For cases in which a provider indicates, or
the CONTRACTOR determines (on a request from an Enrollee), that following the
standard time frame above could seriously jeopardize the Enrollee’s life or
health or ability to attain, maintain, or regain maximum function, the
CONTRACTOR will make an expedited authorization decision and provide notice as
expeditiously as the Enrollee’s health condition requires, but no later than
three working days after receipt of the request for Service Authorization.

 

2)                                      The CONTRACTOR will follow notification
requirements outlined in  2. a. and 2.b. above.

 

(3)                                  Extensions– The CONTRACTOR may extend the
three working-day time period by up to 14 calendar days if:

 

(a)                                  the Enrollee requests an extension; or

 

(b)                                 the CONTRACTOR justifies (to the DEPARTMENT
upon request) a need for additional information and how the extension is in the
Enrollee’s interest.

 

e.                                       Service Authorization Decisions Not
Reached Within Required Time Frames

 

For Service Authorization decisions not reached within the time frames specified
in paragraphs 2.a, 2.b. and 2.d above, which constitutes a denial and is thus an
adverse Action, the CONTRACTOR will give a Notice of Action on the date that the
time frame expires.

 

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f.                                         Decisions to Terminate, Suspend or
Reduce Previously Authorized Medicaid-Covered Services

 

If the CONTRACTOR terminates, suspends or reduces previously authorized
Medicaid-covered services, and the Enrollee informs the CONTRACTOR that he or
she disagrees with the change in his or her treatment plan, this constitutes an
Action. The CONTRACTOR will notify the requesting provider and mail a Notice of
Action to the Enrollee as expeditiously as the Enrollee’s health condition
requires and within the following time frames:

 

(1)                                  at least 10 days before the date of the
Action; or

 

(2)                                  5 days before the date of the Action if the
CONTRACTOR has facts indicating that Action should be taken because of probable
fraud by theEnrollee, and the facts have been verified, if possible, through
secondary sources; or

 

(3)                                  by the date of the Action if:

 

(a)                                  the CONTRACTOR has factual information
confirming the death of the Enrollee;

 

(b)                                 the CONTRACTOR receives a clear written
statement signed by the Enrollee that:

 

(i)                                     he no longer wishes services; or

 

(ii)                                  he gives information that requires
termination or reduction of services and indicates that he understands that this
will be the result of supplying that information;

 

(c)                                  the Enrollee has been admitted to an
institution where he is ineligible for further services;

 

(d)                                 the Enrollee’s whereabouts are unknown and
the post office returns mail directed to him indicating no forwarding address.
In this case any discontinued services will be reinstated if his whereabouts
become known during the time is eligible for services;

 

(e)                                  the Enrollee has been accepted for Medicaid
services by another local jurisdiction; or

 

(f)                                    the Enrollee’s physician prescribes the
change in the level of medical care.

 

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B.                                     Other Actions Requiring Notice of Action

 

1.                                      Action to Deny Payment in Whole or Part
for a Service

 

a.                                       The CONTRACTOR will notify the
requesting provider of decisions to deny payment in whole or in part.

 

b.                                      The CONTRACTOR will also mail the
Enrollee a written Notice of Action at the time of the Action affecting a claim,
if the denial reason is that (1) the service was not authorized by the
CONTRACTOR, as the Enrollee could be liable for payment if the Enrollee gave
advance written consent to the provider that he or she would pay for the
specific service; (2) the Enrollee requested continued benefits (services )
during an Appeal or State fair hearing and the appeal or State fair hearing
decision was adverse to the Enrollee, or (3) the Enrollee was not eligible for
Medicaid when the service was provided.

 

A Notice of Action to the Enrollee is not necessary under the following
circumstances:

 

(1)                                  the provider billed the CONTRACTOR in error
for a non-authorized service; or

 

(2)                                  the claim included a technical error
(incorrect data including procedure code, diagnosis code,  Enrollee name or
Medicaid identification number, date of service, etc.); or

 

(3)                                  the Enrollee became eligible after the
first of the month, but received a service during that month before becoming
Medicaid eligible.

 

2.                                      Action Due to Failure to Provide Covered
Services in a Timely Manner

 

Failure of the CONTRACTOR’s subcontractors to provide services in a timely
manner constitutes an Action. The CONTRACTOR will provide a Notice of Action to
the Enrollee at the time either the Enrollee or provider informs the CONTRACTOR
that the provider failed to meet the performance benchmarks for appointment
waiting times as defined in Article IX - Contractor Assurances, Section E -
Access,  Subsection 4.e. - Waiting Time Benchmarks.

 

3.                                      Action Due to Failure to Resolve Appeals
and Grievances Within Required Time Frames

 

a.                                       Failure of the CONTRACTOR to act within
the time frames provided for resolving and giving resolution notice for Appeals
or Grievances constitutes an Action. The CONTRACTOR will provide a Notice of
Action to the Enrollee at the time the CONTRACTOR determines the time frame for
resolving the Appeal or the Grievance will not be met. (See Article VII,
Grievance Systems.)

 

b.                                      If the CONTRACTOR does not resolve an
Appeal within the required time frame, the Enrollee has already gone through the
CONTRACTOR’s appeal process. Therefore, by declaring the CONTRACTOR’s failure to
provide resolution of the Appeal within the required time frame an Action, the
Enrollee may now file a request for a State fair hearing as the Enrollee has

 

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already exhausted the CONTRACTOR’s internal appeals process. The Enrollee need
not go through the CONTRACTOR’s internal appeals process again.

 

c.                                       For Notice of Action due to failure to
resolve an Appeal within the required time frame, the CONTRACTOR will include in
the Notice of Action the information specified in Article VII, Grievance System,
Section C., #5, Format and Content of Notice of Appeal Resolution, regarding
procedures and time frames for filing a request for a State fair hearing (rather
than information on filing an Appeal). The CONTRACTOR will also attach to the
Notice of Action a copy of the “Request for a Hearing/Agency Action” form that
the Enrollee will submit to request a State fair hearing.

 

C.                                    Content of Notice of Action

 

1.                                       The CONTRACTOR’s Notice of Action to
the Enrollee will be in writing and meet the language and format requirements
outlined in Article III (Marketing ...), Section D (Member Services), Subsection
1 (Enrollee Information Requirements), to ensure ease of understanding. The
notice to the provider need not be in writing.

 

2.                                       The written Notice of Action will
explain the following:

 

a.                                       the Action the CONTRACTOR has taken or
intends to take;

 

b.                                      the reason for the Action;

 

c.                                       the date the Action will become
effective when the Action is to terminate, suspend, or reduce a previously
authorized Covered Service (see Section A.2. f., of this Article);

 

d.                                      the Enrollee’s or the provider’s right
to file an Appeal of the Action with the CONTRACTOR and that providers may file
an Appeal for the Enrollee only with the Enrollee’s written consent (see Article
VII, Grievance System, Section C. Standard Appeals Process, #1, Authority to
File, item b.);

 

e.                                       the procedures for filing an Appeal
(See Article VII, Grievance System, Section C. Standard Appeals Process, and
Section D., Process for Expedited Resolution of Appeals);

 

f.                                         the circumstances under which
expedited resolution of the Appeal is available and how to request an expedited
Appeal resolution (see Article VII, Grievance System, Section D., Process for
Expedited Resolution of Appeals);

 

g.                                      the Enrollee’s right to have benefits
continue pending resolution of the Appeal of an Action to terminate, suspend or
reduce a previously authorized course of treatment that was ordered by an
authorized provider;

 

h.                                      how to request that benefits be
continued, and the circumstances under which the Enrollee may be required to pay
the cost of these services if the

 

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Appeal decision is adverse to the Enrollee, to the extent that they were
furnished solely because of this Contract requirement which is based on federal
regulation in 42 CFR 438.420; and (438.404(b)(7), and 438.420(d).

 

i.                                          the time frames for filing an
Appeal:

 

(1)                                  If the Enrollee is not requesting
continuation of benefits pending resolution of an Appeal of an Action to
terminate, suspend or reduce a previously authorized course of treatment that
was ordered by an authorized provider, and the original period covered by the
original authorization has not expired, the Enrollee, or the provider with the
Enrollee’s written consent, will file the Appeal within 30 days from the date on
the CONTRACTOR’s Notice of Action; or

 

2)                                      If the Enrollee is requesting
continuation of benefits pending resolution of an Appeal of an Action to
terminate, suspend or reduce a previously authorized course of treatment that
was ordered by an authorized provider, and the original period covered by the
original authorization has not expired, the Enrollee or provider will file the
Appeal on or before the later of the following:

 

(a)                                  within 10 days of the CONTRACTOR mailing
the notice of Action; or

 

(b)                                 by the intended effective date of the
CONTRACTOR’s proposed Action.

 

Also see Article VII, Grievance Systems, Section C., Standard Appeals Process,
#2., Timing, and #3, Procedures, item b., and Section E., Continuation of
Benefits During the Appeal or State Fair Hearing Process.

 

D.                                    Attachment to Notice of Action - Written
Appeal Request Form

 

1.                                      General Requirements

 

The CONTRACTOR will develop and include as an attachment to the Notice of Action
an Appeal Request form that Enrollees may use as the written Appeal request for
standard Appeals. This form may also be used for expedited Appeal requests if
the Enrollee chooses to submit a written request for an expedited Appeal
resolution, even though an oral request is all that is required. (See Article
VI, Section D., 2.)

 

The CONTRACTOR will not include this attachment if the Notice of Action is due
to the circumstances in Section B. 3. above. For the Action specified in Section
B.3. above, the CONTRACTOR will provide a Notice of Action that informs
Enrollees of their State fair hearing rights and how to request a State fair
hearing.

 

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2.                                       Specific Content of Written Appeal
Request Form

 

The form will:

 

a.                                       provide a prompt (through use of check
boxes or other means) for Enrollees to:

 

(1)                                  request expedited Appeal resolution if they
choose to submit a written request for an expedited Appeal resolution; and

 

(2)                                  request  continuation of benefits, if
applicable;

 

b.                                      provide a statement that if continuation
of benefits is requested when a previously authorized service is terminated,
suspended or reduced, that the Enrollee agrees that the CONTRACTOR may recover
from the Enrollee the cost of the services furnished while the Appeal is pending
if the Appeal decision is adverse to the Enrollee, to the extent that the
services were furnished solely because of the requirements of this Contract that
are based on federal regulation in 42 CFR 438.420;

 

c.                                       summarize assistance the Enrollee may
request to complete the Appeal Request form and how to request the assistance
(see Article VII, Grievance System, Section C., Standard Appeals Process, #3
Procedures, item e.); and

 

d.                                      include a reminder that if the Enrollee
is not requesting an expedited Appeal resolution and the Enrollee files an
Appeal orally, that the oral Appeal will be followed by a  written Appeal
request within five working days from the date of the oral filing. (See Article
VII, Grievance System, Section C., Standard Appeals Process, #3., Procedures,
item b.)

 

E.                                    Compensation for Utilization Management
Activities

 

The CONTRACTOR will ensure compensation to individuals or entities that conduct
utilization management activities is not structured so as to provide incentives
for the individual or entity to deny, limit, or discontinue Medically Necessary
Services to any Enrollee.

 

F.                                    Medical Necessity Denials

 

When the CONTRACTOR determines that a service will not be covered due to the
lack of medical necessity, the CONTRACTOR will send all documentation supporting
their decision to the DEPARTMENT for its review before the CONTRACTOR’s
determination is deemed final, when the following conditions are met:

 

4.                                       there are no established national
standards for determining medical necessity, and

 

2.                                       the DEPARTMENT does not have medical
necessity criteria for the service.

 

The DEPARTMENT will review the documentation and determine what the DEPARTMENT’s
decision would be regarding coverage for the service. The DEPARTMENT and the
CONTRACTOR will work collaboratively in making a final decision on whether the
service is to be covered by the CONTRACTOR.

 

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Article VII - Grievance Systems

 

C.                                     Overall Grievance System

 

The CONTRACTOR will have a Grievance System for Enrollees that includes (1) a
grievance process whereby an Enrollee, or provider acting on behalf of an
Enrollee, may communicate a Grievance, (2) an appeals process whereby an
Enrollee, or provider acting on behalf of the Enrollee with the Enrollee’s
written consent, may file an Appeal of an Action (see Article I, Definitions,
definition of Action), and (3) procedures for an Enrollee, or a provider acting
on behalf of an Enrollee, to access the State’s fair hearing system.

 

D.                                    Special Requirements for Appeals

 

The CONTRACTOR’s process for appeals will:

 

1.                                       provide that oral inquiries seeking to
appeal an Action are treated as an Appeal, to establish the earliest possible
filing date for the Appeal;

 

2.                                       ensure that the Enrollee or provider
understands that the oral Appeal will be confirmed in writing, no later than
five working days from the date of the oral filing, unless the Enrollee or the
provider requests an expedited resolution to the Appeal. These requests do not
require a follow-up written request. (see Section C. regarding expedited
resolution of Appeals, and Section C., item #3.b., below.);

 

3.                                       provide the Enrollee reasonable
opportunity to present evidence, and allegations of fact or law, in person as
well as in writing. The CONTRACTOR will inform the Enrollee of the limited time
available for this in the case of an expedited Appeal resolution; and

 

4.                                       provide the Enrollee and his or her
authorized representative opportunity, before and during the appeals process, to
examine the Enrollee’s case file, including medical records, and any other
documents and records considered during the appeals process:

 

a.                                       include as parties to the Appeal the
Enrollee and his or her representative, or

 

b.                                      the legal representative of a deceased
Enrollee’s estate.

 

C.                                    Standard Appeals Process

 

1.                                      Authority to File

 

a.                                       An Enrollee or his or her legally
authorized representative may file an Appeal; or

 

b.                                      A provider, acting on behalf of the
Enrollee and with the Enrollee’s written consent, may file an Appeal.

 

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2.                                      Timing

 

c.                                       The Enrollee or provider may file an
Appeal of a Notice of Action within 30 calendar days from the date on the
CONTRACTOR’s Notice of Action (See Article VI, Authorization of Services and
Notices of Action.); or

 

b.                                      If the Action being appealed is to
terminate, suspend or reduce a previously authorized course of treatment, the
services were ordered by an authorized provider and the original period covered
by the original authorization has not expired, and the Enrollee want benefits to
continue during the Appeal process, then the Enrollee will file the Appeal on or
before the later of the following:

 

(1)                                  within 10 days of the Notice of Action; or

 

(2)                                  the intended effective date of the
CONTRACTOR’s proposed Action.

(See Section E. of this Article, Continuation of Benefits During the Appeal or
State Fair Hearing Process.)

 

3.                                      Procedures

 

a.                                       The Enrollee or the provider may file
an Appeal either orally or in writing.

 

b.                                      Unless the Enrollee or provider requests
an expedited resolution of the Appeal (which does not require a written
follow-up request), the oral Appeal will be followed with a written, signed
Appeal. The written, signed Appeal will be received within five working days
from the date of the oral Appeal. (See Section D regarding expedited Appeal
resolutions.)

 

c.                                       A provider may file the written, signed
Appeal on behalf of the Enrollee and will include the Enrollee’s signed written
consent.

 

d.                                      If an Enrollee or provider requests an
Appeal orally, the CONTRACTOR will inform or remind the Enrollee or provider of
the following:

 

(1)                                  that the oral filing of an Appeal will be
followed with a written, signed appeal within five working days from the date of
the oral Appeal;

 

(2)                                  if applicable, that the provider can file
an Appeal only with the Enrollee’s attached written consent;

 

(3)                                  of the standardized form that can be used
to submit the Appeal in writing;

 

(4)                                  that if the Enrollee wants continuation of
benefits when the Action is to terminate, suspend or reduce a previously
authorized course of treatment, that this will be requested; and

 

(5)                                  to whom or where to send the written,
signed Appeal.

 

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e.                                       The CONTRACTOR will give Enrollees any
reasonable assistance in completing required forms for submitting a written
Appeal or taking other procedural steps. Reasonable assistance includes, but is
not limited to, providing interpreter services and toll-free numbers that have
adequate TTY/TTD and interpreter capability.

 

f.                                         The CONTRACTOR will acknowledge
receipt of the Appeal either orally or in writing and explain to the Enrollee
the process that will be followed to resolve the Appeal.

 

g.                                      As per Section B. 3. of this Article,
provide the Enrollee reasonable opportunity to present evidence, and allegations
of fact or law, in person as well as in writing. The CONTRACTOR will inform the
Enrollee of the limited time available for this in the case of an expedited
Appeal resolution.

 

h.                                      As per Section B.4. of this Article,
provide the Enrollee and his or her authorized representative opportunity,
before and during the appeals process, to examine the Enrollee’s case file,
including medical records, and any other documents and records considered during
the appeals process:

 

(1)                                  include as parties to the Appeal the
Enrollee and his or her representative, or

 

(2)                                  the legal representative of a deceased
Enrollee’s estate.

 

i.                                          The CONTRACTOR will ensure that the
individuals who make the decision on an Appeal are individuals who (1) were not
involved in any previous level of review or decision-making and (2) who, if
deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the DEPARTMENT, in treating the
Enrollee’s condition or disease:

 

(1)                                  an Appeal of a denial that is based on lack
of medical necessity; or

 

(2)                                  an Appeal that involves clinical issues.

 

4.                                      Time Frames for Appeal Resolution and
Notification

 

a.                                       The CONTRACTOR will resolve each
Appeal, and provide notice of resolution to affected parties as expeditiously as
the Enrollee’s health condition requires, but no later than  30 calendar days
from the day the CONTRACTOR receives the Appeal whether orally or in writing.

 

b.                                      Extension of Time Frame – The CONTRACTOR
may extend the time frame for resolving the Appeal and providing notice by up to
14 calendar days if:

 

(1)                                  the Enrollee requests the extension; or

 

(2)                                  the CONTRACTOR shows that there is need for
additional

 

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information and how the delay is in the Enrollee’s interest (upon DEPARTMENT
request).

 

c.                                       If the CONTRACTOR extends the time
frame, and the extension was not requested by the Enrollee, the CONTRACTOR will
give the Enrollee written notice of the reason for the delay.

 

5.                                      Format and Content of Notice of Appeal
Resolution

 

The CONTRACTOR will provide a written Notice of Appeal Resolution to the
affected parties. The written Notice of Appeal Resolution will include the
following:

 

a.                                       the results of the Appeal resolution
process and the date it was completed; and

 

b.                                      for Appeals not resolved wholly in favor
of the Enrollee, the CONTRACTOR will include the following in the written Notice
of Appeal Resolution:

 

(1)                                  the right to request a State fair hearing
and how to do so;

 

(2)                                  the right to request continuation of
benefits if the Appeal decision is to terminate, suspend or reduce a previously
authorized course of treatment that was ordered by an authorized provider and
the original period covered by the original authorization has not expired;

 

(3)                                  how to request continuation of benefits;

 

(4)                                  a statement that the Enrollee may be liable
for the cost of services provided if the State fair hearing decision upholds the
CONTRACTOR’s Action;

 

(5)                                  the time frame for requesting a State fair
hearing when continuation of benefits is not requested and when continuation of
benefits is requested (see Section F, Duration of Continued or Reinstated
Benefits, #2, and Section H, State Fair Hearings, #1 and #2, of this Article);
and

 

(6)                                  a copy of either: (a) the “Request for a
Standard Sate Fair Hearing/Agency Action” form or (b) the “Request for an
Expedited State Fair Hearing/Agency Action form that the Enrollee must complete
and submit to the DHCF to request a State fair hearing, and continuation of
benefits, if applicable. The CONTRACTOR will include a copy of the “Request for
an Expedited State Fair Hearing/Agency Action” form if the Enrollee had an
expedited Appeal.

 

(See Section E., Continuation of Benefits During the Appeal or State Fair
Hearing Process, Section F., Duration of Continued or Reinstated Benefits, and
Section H., State Fair Hearings, of this Article, for additional information on
all of the above.)

 

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D.                                    Process for Expedited Resolution of
Appeals

 

1.                                      General Requirements

 

The CONTRACTOR will establish and maintain an expedited review process for
Appeals, when the CONTRACTOR determines (from a request from the Enrollee) or a
provider indicates (in making the Appeal request on the Enrollee’s behalf or
supporting the Enrollee’s request) that the time for a standard resolution could
seriously jeopardize the Enrollee’s life or health or ability to attain,
maintain, or regain maximum function.

 

2.                                      Authority to File

 

The Enrollee, or a provider with the Enrollee’s written consent, may file an
expedited Appeal request either orally or in writing.

 

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3.                                       Timing

 

a.                                       The Enrollee or provider may file an
Appeal of a Notice of Action within 30 days from the date on the CONTRACTOR’s
Notice of Action (See Article VI,  Authorization of Services and Notices of
Action.)

 

b.                                      If the Action being appealed is to
terminate, suspend or reduce a previously authorized course of treatment, the
services were ordered by an authorized provider and the original period covered
by the original authorization has not expired, and the Enrollee want benefits to
continue during the Appeal process, then the Enrollee will file the Appeal on or
before the later of the following:

 

(1)                                  within 10 days of the Notice of Action; or

 

(2)                                  the intended effective date of the
CONTRACTOR’s proposed Action.

(See Section E. of this Article, Continuation of Benefits During the Appeal or
State Fair Hearing Process.)

 

4.                                      Procedures

 

a.                                       When an Enrollee or provider requests
an expedited resolution of an Appeal, the CONTRACTOR will inform the Enrollee or
provider of the limited timeavailable for the Enrollee to present evidence and
allegations of fact or law, in person and in writing.

 

b.                                      The CONTRACTOR will ensure that punitive
action is not taken against a provider who either requests an expedited
resolution to an Appeal or supports an Enrollee’s Appeal.

 

c.                                       The CONTRACTOR will give Enrollees any
reasonable assistance in taking procedural steps. Reasonable assistance
includes, but is not limited to, providing interpreter services and toll-free
numbers that have adequate TTY/TTD and interpreter capability.

 

d.                                      The CONTRACTOR will acknowledge receipt
of the request for expedited Appeal resolution either orally or in writing and
explain to the Enrollee the process that will be followed to resolve the Appeal;

 

e.                                       The CONTRACTOR will ensure that the
individuals who make the decision on an Appeal are individuals who (1) were not
involved in any previous level of review or decision-making and (2) who, if
deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the DEPARTMENT, in treating the
Enrollee’s condition or disease:

 

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(1)                                  an Appeal of a denial that is based on lack
of medical necessity; or

 

(2)                                  an Appeal that involves clinical issues;

 

f.                                         Denial of a Request for Expedited
Appeal Resolution– If the CONTRACTOR denies a request for an expedited
resolution of an Appeal, the CONTRACTOR will:

 

(1)                                  transfer the Appeal to the standard time
frame of no longer than 30 calendar days from the day the CONTRACTOR receives
the Appeal, with a possible 14-calendar day extension for resolving the Appeal
and providing Notice of Appeal Resolution to affected parties;

 

(2)                                  make reasonable effort to give the Enrollee
prompt oral notice of the denial; and

 

(3)                                  mail written notice within two calendar
days explaining the denial, specifying the standard time frame that will be
followed, and informing the affected parties that the Enrollee may file a
Grievance regarding this denial of expedited resolution of the Appeal.

 

5.                                      Time Frame for Expedited Appeal
Resolution and Notification

 

a.                                       The CONTRACTOR will resolve each
expedited Appeal and provide notice to affected parties, as expeditiously as the
Enrollee’s health condition requires, but no later than  three working days
after the CONTRACTOR receives the expedited Appeal request.

 

b.                                      Extension of Time Frame– The CONTRACTOR
may extend the time frame for resolving the Appeal and providing notice by up to
14 calendar days if:

 

(1)                                  the Enrollee requests the extension; or

 

(2)                                  the CONTRACTOR shows that there is need for
additional information and how the delay is in the Enrollee’s interest (upon
DEPARTMENT request).

 

(3)                                  If the CONTRACTOR extends the time frame,
and the extension was not requested by the Enrollee, the CONTRACTOR will give
the Enrollee written notice of the reason for the delay.

 

6.                                      Format and Content of Expedited Appeal
Resolution Notice

 

a.                                       The CONTRACTOR will make reasonable
effort to provide oral notice of the expedited resolution in addition to
providing a written Notice of Appeal Resolution.

 

b.                                      The CONTRACTOR will provide a written
Notice of Appeal Resolution that meets the same format and content requirements
outlined in Section C.,

 

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Standard Appeals Resolution, #5., Format and Content of Notice of Appeal
Resolution.

 

E.                                    Continuation of Benefits During Appeal or
State Fair Hearing Processes

 

The CONTRACTOR will continue the Enrollee’s benefits during the Appeal process
if:

 

1.                                       the Action being appealed is to
terminate, suspend or reduce a previously authorized course of treatment;

 

2.                                       the services were ordered by an
authorized provider;

 

3.                                       the original period covered by the
original authorization has not expired;

 

4.                                       the Enrollee files the Appeal timely,
which means filing the Appeal on or before the later of the following:

 

a.                                       within 10 days of the Notice of Action;
or

 

b.                                      the intended effective date of the
CONTRACTOR’s proposed Action; and

 

5.                                       the Enrollee requests extension of
benefits in the Appeal.

 

F.                                    Duration of Continued or Reinstated
Benefits

 

If the CONTRACTOR continues or reinstates the Enrollee’s benefits, the
CONTRACTOR will continue benefits until one of the following occurs:

 

5.                                       the Enrollee withdraws the Appeal;

 

2.                                       10 days pass after the CONTRACTOR mails
the written Notice of Appeal Resolution and within that 10-day time period, the
Enrollee does not request a State fair hearing with continuation of benefits
until a State fair hearing decision is reached;

 

3.                                       a State fair hearing officer issues a
hearing decision adverse to the Enrollee; or

 

4.                                       the time period or service limits of a
previously authorized service has been met.

 

G.                                    Reversed Appeal Resolutions

 

1.                                      Services Not Furnished While the Appeal
is Pending

 

If the CONTRACTOR or State fair hearing officer reverses an Action to deny,
limit, or delay services that were not furnished while the Appeal was pending,
the CONTRACTOR will authorize or provide the disputed services promptly, and as
expeditiously as the Enrollee’s health condition requires.

 

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2.                                      Services Furnished While the Appeal is
Pending

 

If the CONTRACTOR or the State fair hearing officer reverses a decision to deny
authorization of services and the Enrollee received the disputed services while
the Appeal was pending, the CONTRACTOR will pay for those services in accordance
with State policy and regulations.

 

H.                                    State Fair Hearings

 

When the Enrollee or provider has exhausted the CONTRACTOR’s Appeal decision and
a final decision has been made, the CONTRACTOR will provide written notification
to the party who initiated the Appeal of the outcome and explain in clear terms
a detailed  reason for the denial.

 

The CONTRACTOR will provide notification to Enrollees and providers that the
final decision of the CONTRACTOR may be appealed to the DEPARTMENT and will give
to the Enrollee and provider the DEPARTMENT’s form to request a State fair
hearing. The Health Plan will inform the Enrollee and provider the time frame
for requesting a State fair hearing.

 

1.                                       The DEPARTMENT will permit Enrollees
and providers, acting as an Enrollee’s authorized representative, to request a
State fair hearing within 30 days from the date of the CONTRACTOR’s Notice of
Appeal Resolution.

 

2.                                       However, if the Enrollee wants to
continue benefits pending the outcome of the State fair hearing, when a
previously authorized course of treatment has been terminated, suspended or
reduced, the services were ordered by an authorized provider and the original
period covered by the original authorization has not expired, the request for a
State fair hearing and continuation of benefits will be submitted within 10 days
after the CONTRACTOR mails the Notice of Appeal Resolution. (See Section E.,
Duration of Continued or Reinstated Benefits, above.)

 

3.                                       The parties to the State fair hearing
include the CONTRACTOR as well as the Enrollee and his or her representative
which may include legal counsel, a relative, a friend or other spokesman, or the
representative of a deceased Enrollee’s estate.

 

4.                                       The Enrollee or his or her
representative, will be given an opportunity to examine at a reasonable time
before the date of the hearing and during the hearing, the content of the
Enrollee’s case file and all documents and records to be used by the

 

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CONTRACTOR.

 

5.                                       The Enrollee will also be given the
opportunity to:

 

a.                                       bring witnesses;

 

a.                                       establish all pertinent facts and
circumstances;

 

b.                                      present an argument without undue
interference; and

 

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c.                                       question or refute any testimony or
evidence, including opportunity to confront and cross-examine adverse witnesses.

 

6.                                       The State fair hearing with the
DEPARTMENT is a de novo hearing. If the Enrollee or provider requests a State
fair hearing with the DEPARTMENT, all parties to the hearing are bound by the
DEPARTMENT’s decision until any judicial reviews are completed and are in the
Enrollee’s or provider’s favor. Any decision made by the DEPARTMENT pursuant to
the hearing will be subject to appeal rights as provided by State and Federal
laws and rules.

 

7.                                       The Enrollee will be notified in
writing of the State fair hearing decision and any appeal rights as provided by
State and Federal laws and rules.

 

8.                                       Standard resolution requests– The
DEPARTMENT will reach its hearing decision within 90 (calendar) days from the
date the Enrollee filed the Appeal with the CONTRACTOR.

 

9.                                       Expedited Appeal resolution requests –
The DEPARTMENT will reach its hearing decision within three working days from
the date the DEPARTMENT receives a State fair hearing request for a denial of a
service that:

 

a.                                       meets the criteria for the expedited
appeal process but was not resolved using the CONTRACTOR’s required expedited
Appeal time frames; or

 

b.                                      was resolved wholly or partially
adversely to the Enrollee using the CONTRACTOR’s expedited Appeal time frames.

 

I.                                         Grievances

 

1.                                       Authority to File

 

b.                                      An Enrollee may file a Grievance; or

 

b.                                      A provider, acting on behalf of the
Enrollee as an authorized representative, may file a Grievance.

 

2.                                      Procedures

 

a.                                       The Enrollee or the provider may file a
Grievance either orally or in writing.

 

b.                                      The CONTRACTOR will give Enrollees any
reasonable assistance in completing required forms for submitting a written
Grievance or taking other procedural steps. Reasonable assistance includes, but
is not limited to providing interpreter services and toll-free numbers that have
adequate TTY/TTD and interpreter capability.

 

c.                                       The CONTRACTOR will acknowledge receipt
of the Grievance either orally or in writing.

 

d.                                      The CONTRACTOR will ensure that the
individuals who make the decision on a Grievance are individuals who (1) were
not involved in any previous

 

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level of review or decision-making, if applicable to the nature of the Grievance
and (2) who, if deciding any of the following, are health care professionals who
have the appropriate clinical expertise, as determined by the DEPARTMENT, in
treating the Enrollee’s condition or disease:

 

(1)                                  a Grievance regarding denial of a request
for an expedited resolution of an Appeal; or

 

(2)                                  a Grievance that involves clinical issues.

 

3.                                      Time Frames for Grievance Disposition
and Notification

 

a.                                       The CONTRACTOR will dispose of each
Grievance and provide notice to the affected parties as expeditiously as the
Enrollee’s health condition requires, but not to exceed 45 calendar days from
the day the CONTRACTOR receives the Grievance.

 

b.                                      For written Grievances, the CONTRACTOR
will notify the affected parties in writing of the disposition of the Grievance.
For Grievances received orally, the CONTRACTOR will notify the affected parties
of the disposition either orally or in writing.

 

c.                                       If the Enrollee, or a provider on
behalf of an Enrollee, files a Grievance with the DEPARTMENT, the DEPARTMENT
will apprize the Enrollee, or the provider on behalf of the Enrollee, of his or
her right to file the Grievance with the CONTRACTOR and how to do so.

 

1)                                      If the Enrollee or provider prefers, the
DEPARTMENT will promptly notify the CONTRACTOR both orally and in writing of the
Enrollee’s Grievance in his or her behalf.

 

2)                                      The CONTRACTOR will follow the
procedures and time frames outlined above for Grievances.

 

3)                                      The CONTRACTOR will notifying the
affected parties, including the DEPARTMENT, in writing of the disposition of the
grievance.

 

d.                                      Extension of Time Frame – The CONTRACTOR
may extend the time frame for disposing of the Grievance and providing notice by
up to 14 calendar days if:

 

(1)                                  the Enrollee requests the extension; or

 

(2)                                  the CONTRACTOR shows that there is need for
additional information and how the delay is in the Enrollee’s interest (upon
DEPARTMENT request).

 

(3)                                  If the CONTRACTOR extends the time frame,
and the extension was not requested by the Enrollee, the CONTRACTOR will give
the Enrollee written notice of the reason for the delay.

 

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J.                                        Documentation

 

The CONTRACTOR will maintain complete records of all Appeals and Grievances and
submit semi-annual reports summarizing Appeals and Grievances using
DEPARTMENT-specified reporting templates. The CONTRACTOR will separately track
Grievances and Appeals that are related to Children with Special Health Care
Needs and those related to Non-Traditional Medicaid Enrollees. (See Article
XIII, Records and Reporting Requirements, C.3.c.)

 

1.                                       Appeals

 

The CONTRACTOR will maintain documentation including but not limited to:

 

a.                                       written Notices of Action;

 

b.                                      a log of all oral Appeals and oral
requests for expedited resolution of Appeals, including:

 

(1)                                  date of the oral requests;

 

(2)                                  date of acknowledgment of oral requests for
expedited resolution of Appeals and method of acknowledgment (i.e., orally or in
writing);

 

(3)                                  date of denials of requests for expedited
Appeal resolution; and

 

4)                                      date of attempt to give prompt oral
notice;

 

c.                                       copies of written standard Appeal
requests;

 

d.                                      copies of written notices of denial of
requests for expedited Appeal resolution;

 

e.                                       date of acknowledgment of  written
standard Appeal requests and method of acknowledgment (i.e., orally or in
writing);

 

f.                                         copies of written notices when
extending the time frame for adjudicating standard or expedited Appeals when the
CONTRACTOR initiates the extension;

 

g.                                      copies of written Notices of Appeal
Resolution; and

 

h.                                      any other pertinent documentation needed
to maintain a complete record of all Appeals and to demonstrate that Appeals
were adjudicated according to the Contract provisions governing Appeals.

 

2.                                       Grievances

 

a.                                       Oral Grievances - Using its previously
established verbal complaint logging and tracking system, the CONTRACTOR will
log all oral Grievances and include the following:

 

(1)                                  date the Grievance was received;

 

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(2)                                  date and method of acknowledgment (i.e.,
orally or in writing);

 

(3)                                  name of person taking the Grievance;

 

(4)                                  date of resolution and summary of the
resolution;

 

(5)                                  name of person resolving the Grievance; and

 

(6)                                  date the Enrollee was notified of the
resolution and how the Enrollee was notified (either orally or in writing). If
the Enrollee was notified of the disposition in writing, the CONTRACTOR will
maintain a copy of the written notification.

 

b.                                      Written Grievances - The CONTRACTOR will
maintain all written Grievances and copies of the written notices of resolution
to the affected parties.

 

Article VIII - Enrollee Rights and Protections

 

A.                                    Written Information on Enrollee Rights and
Protections - General Requirements

 

1.                                       The CONTRACTOR will develop and
maintain written policies regarding Enrollee rights and protections.

 

2.                                       The CONTRACTOR will comply with any
applicable Federal and State laws that pertain to Enrollee rights and ensure
that its staff and subcontracting providers take those rights into account when
furnishing services to Enrollees.

 

3.                                       The CONTRACTOR will ensure information
on Enrollee rights and protections is provided to all Enrollees by including its
Patient Rights statement in its member handbook. (See Article III, Marketing
..., Section D, Member Education, 2.o.)

 

4.                                       The CONTRACTOR will ensure Enrollees
are free to exercise their rights, and that the exercise of those rights will
not adversely affect the way the CONTRACTOR and its subcontractors treat
Enrollees.

 

B.                                     Specific Enrollee Rights and Protections

 

The CONTRACTOR will include all of the following Enrollee rights and protections
in its written Patient Rights statement:

 

1.                                       the right to receive information about
this Health Plan;

 

2                                          the right to be treated with respect
and with due consideration for his or her dignity and privacy;

 

3.                                       the right to receive information on
available treatment options and alternatives, presented in a manner appropriate
to the Enrollee’s condition and ability to

 

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understand;

 

4.                                       the right to participate in treatment
decisions regarding his or her health care, including the right to refuse
treatment;

 

5.                                       the right to be free from any form of
restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation, as specified in other Federal regulations on the use of restraints
and seclusion;

 

6.                                       If the privacy rule, as set forth in 45
CFR parts 160 and 164 subparts A and E, applies, the right to request and
receive a copy of his or her medical records, and to request that they be
amended or corrected, as specified in 45 CFR, sections 164.524 and 154.526;

 

7.                                       the right to be furnished health care
services in accordance with access and quality standards; and

 

8.                                       the right to be free to exercise all
rights and that by exercising those rights, the Enrollee will not be adversely
treated by the CONTRACTOR and its providers.

 

C.                                     Provider - Enrollee Communications

 

1.                                       General Rules

 

The CONTRACTOR will communicate with its health care professionals that when
acting within the lawful scope of their practice, they will not be prohibited
from advising or advocating on behalf of an Enrollee for the following:

 

a.                                       the Enrollee’s health status, medical
care, or treatment options, including any alternative treatment that may be
self-administered;

 

b.                                      any information the Enrollee needs in
order to decide among all relevant treatment options;

 

c.                                       the risks, benefits, and consequences
of treatment or non-treatment; and

 

d.                                      the Enrollee’s right to participate in
decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.

 

2.                                       Objection to Services on Moral or
Religious Grounds

 

Subject to the information requirements below, if the CONTRACTOR that would
otherwise be required to provide, reimburse for, or provide coverage of, a
counseling or referral service because of the requirement  in C.1 in this
section, is not required to do so if the CONTRACTOR objects to the service on
moral or religious grounds. If the CONTRACTOR elects this option, the CONTRACTOR
will

 

a.                                       furnish information to the DEPARTMENT
about the services it does not cover prior to signing this Contract or whenever
it adopts the policy during

 

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the term of the Contract; and

 

b.                                      furnish the information to Potential
Enrollees, before and during enrollment and to Enrollees, within 90 days after
adopting the policy with respect to any service.

 

Article IX - Contractor Assurances

 

A.                                    Nondiscrimination

 

The CONTRACTOR will designate a nondiscrimination coordinator who will 1) ensure
the CONTRACTOR complies with Federal Laws and Regulations regarding
nondiscrimination, and 2) take Grievances from Enrollees alleging
nondiscrimination violations based on race, color, national origin, disability,
or age. The nondiscrimination coordinator may also handle Grievances regarding
the violation of other civil rights (sex and religion) as other Federal laws and
Regulations protect against these forms of discrimination. The CONTRACTOR will
develop and implement a written method of administration to assure that the
CONTRACTOR’s programs, activities, services, and benefits are equally available
to all persons without regard to race, color, national origin, disability, or
age.

 

B.                                    Member Services Function

 

The CONTRACTOR will operate a Member Services function during regular business
hours. Ongoing training, as necessary, will be provided by the CONTRACTOR to
ensure that the Member Services staff is conversant in the CONTRACTOR’s policies
and procedures as they relate to Enrollees. At a minimum, Member Services staff
will be responsible for the following:

 

1.                                       Explaining the CONTRACTOR’s rules for
obtaining services;

 

2.                                       Assisting Enrollees to select or change
primary care providers;

 

3.                                       Fielding and responding to Enrollee
questions and the Grievance System.

 

The CONTRACTOR will conduct ongoing assessment of its orientation staff to
determine staff members’ understanding of the Health Plan and its Medicaid
managed care policies and provide training, as needed.

 

C.                                     Provider Services Function

 

The CONTRACTOR will operate a Provider Services function during regular business
hours. At a minimum, Provider Services staff will be responsible for the
following:

 

1.                                       Training, including ongoing training,
of the CONTRACTOR’s providers on Medicaid rules and regulations that will enable
providers to appropriately render services to Enrollees;

 

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2.                                       Assisting providers to verify whether
an individual is enrolled with the Health Plan;

 

3.                                       Assisting providers with prior
authorization and referral protocols;

 

4.                                       Assisting providers with claims payment
procedures;

 

5.                                       Fielding and responding to provider
questions and the Grievance System.

 

D.                                    Enrollee Liability

 

The CONTRACTOR will not hold an Enrollee liable for the following:

 

1.                                       The debts of the CONTRACTOR if it
should become insolvent.

 

2.                                       Payment for services provided by the
CONTRACTOR if the CONTRACTOR has not received payment from the DEPARTMENT for
the services, or if the provider, under contract with the CONTRACTOR, fails to
receive payment from the CONTRACTOR.

 

3.                                       The payments to providers that furnish
Covered Services under a contract or other arrangement with the CONTRACTOR that
are in excess of the amount that normally would be paid by the Enrollee if the
service had been received directly from the CONTRACTOR.

 

E.                                    Access

 

1.                                       Basic Rule

 

The CONTRACTOR will provide the DEPARTMENT adequate assurances and supporting
documentation that demonstrates the CONTRACTOR has the capacity to serve the
expected enrollment in its Service Area in accordance with the DEPARTMENT’s
standards for access to care.

 

2.                                       Nature of Supporting Documentation

 

The CONTRACTOR will provide the DEPARTMENT documentation, in a format specified
by the DEPARTMENT that the CONTRACTOR offers an appropriate range of preventive,
primary care and speciality services that is adequate for the anticipated number
of Enrollees for the Service Area, maintains a network of providers that is
sufficient in number, mix and geographic distribution to meet the anticipated
number of Enrollees in the Service Area.

 

3.                                       Timing of Documentation

 

The CONTRACTOR will submit to the DEPARTMENT the documentation assuring adequate
capacity and services in the DEPARTMENT-specified format no less frequently
than:

 

a.                                       at the time it enters into a contract
with the DEPARTMENT;

 

b.                                      at any time there has been a significant
change (as defined by the

 

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DEPARTMENT) in the CONTRACTOR’s operations that would affect adequate capacity
and services including changes in services, benefits, geographic Service Area or
payments, or enrollment of a new population in the Health Plan.

 

4.                                      Specific Provisions

 

a.                                      Elimination of Access Problems Caused by
Geographic, Cultural and Language Barriers and Physical Disabilities

 

The CONTRACTOR will minimize, with a goal to eliminate, Enrollee’s access
problems due to geographic, cultural and language barriers, and physical
disabilities. The CONTRACTOR will provide assistance to Enrollees who have
communication impediments or impairments to facilitate proper diagnosis  and
treatment. The CONTRACTOR will guarantee equal access to services and benefits
for all Enrollees by making available interpreters, Telecommunication Devices
for the Deaf (TDD), and other auxiliary aids to all Enrollees as needed. The
CONTRACTOR will accommodate Enrollees with physical and other disabilities in
accordance with the American Disabilities Act of 1990 (ADA), as amended. If the
CONTRACTOR’s facilities are not accessible to Enrollees with physical
disabilities, the CONTRACTOR will provide services in other accessible
locations.

 

b.                                      Interpretive Services

 

The CONTRACTOR will provide oral interpretive services available free of charge
for all non-English languages, not just those the DEPARTMENT identifies as
prevalent, on an as needed basis. These requirements will extend to both
in-person and telephone communications to ensure that Enrollees are able to
communicate with the CONTRACTOR and CONTRACTOR’s providers and receive Covered
Services. Professional interpreters will be used when needed where technical,
medical, or treatment information is to be discussed, or where use of a Family
Member or friend as interpreter is inappropriate. A family member or friend may
be used as an interpreter if this method is requested by the patient, and the
use of such a person would not compromise the effectiveness of services or
violate the patient’s confidentiality, and the patient is advised that a free
interpreter is available.

 

c.                                       Cultural Competence Requirements

 

The CONTRACTOR will participate in the DEPARTMENT’s efforts to promote

 

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the delivery of services in a culturally competent manner to all Enrollees,
including those with limited English proficiency and diverse cultural and ethnic
backgrounds. The CONTRACTOR will incorporate in its policies, administration,
and delivery of services the values of honoring Enrollee’s beliefs; being
sensitive to cultural diversity; and promoting attitudes and interpersonal
communication styles with staff and providers which respect Enrollees’ cultural
backgrounds. The CONTRACTOR will foster cultural competency among its providers.
Culturally competent care is care given by a provider who can communicate with
the Enrollee and provide care with sensitivity, understanding, and respect for
the Enrollee’s culture, background and beliefs. The CONTRACTOR will strive to
ensure its providers provide culturally sensitive services to Enrollees. These
services will include but are not limited to providing training to providers
regarding how to promote the benefits of health care services as well as
training about health care attitudes, beliefs, and practices that affect access
to health care services.

 

d.                                      No Restrictions of Provider’s Ability to
Advise and Counsel

 

The CONTRACTOR may not restrict a health care provider’s ability to advise and
counsel Enrollees about Medically Necessary treatment options. All contracting
providers acting within his or her scope of practice, will be permitted to
freely advise an Enrollee about his or her health status and discuss appropriate
medical care or treatment for that condition or disease regardless of whether
the care or treatment is a Covered Service.

 

e.                                       Waiting Time Benchmarks

 

The CONTRACTOR will adopt benchmarks for waiting times for physician
appointments as follows:

 

Waiting Time for Appointments

 

(1)                                  Primary Care Providers:

 

(a)                                  within 30 days for routine, non-urgent
appointments

 

(b)                                 within 60 days for school physicals

 

(c)                                  within 2 days for urgent, symptomatic, but
not life-threatening care (care that can be treated in the doctor’s office)

(2)                                  Specialists:

 

(a)                                  within 30 days for non-urgent care

 

(b)                                 within 2 days for urgent, symptomatic, but
not life-threatening care (care that can be treated in a doctor’s office)

 

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These benchmarks do not apply to appointments for regularly scheduled visits to
monitor a chronic medical condition if the schedule calls for visits less
frequently than once every month.

 

F.                                    Coordination and Continuity of Care

 

1.                                      In General

 

The CONTRACTOR will ensure access to a coordinated, comprehensive and continuous
array of needed services through coordination with other appropriate entities.
The CONTRACTOR will implement procedures to coordinate the services the
CONTRACTOR furnishes to the Enrollee with the services the Enrollee receives
from any other MCO, PIHP, or PAHP. The CONTRACTOR will ensure that in the
process of coordinating care, each Enrollee’s privacy is protected in accordance
with the privacy requirements in 45 CFR parts 160 and 164, subparts A and E, to
the extent that they are applicable. The CONTRACTOR’s providers are not
responsible for rendering Home and Community-Based Waiver services.

 

2.                                       Primary Care

 

a.                                       The CONTRACTOR will implement
procedures to deliver primary care to and coordinate health care services for
all Enrollees. The CONTRACTOR will implement procedures to ensure that each
Enrollee has an ongoing source of primary care appropriate to his or her needs
and a person or entity formally designated as primarily responsible for
coordinating the health care services furnished to the Enrollee.

 

b.                                      The CONTRACTOR will allow Enrollees the
opportunity to select a participating Primary Care Provider. This excludes
clients who are under the Restriction Program. If an Enrollee’s Primary Care
Provider ceases to participate in the CONTRACTOR’s network, the CONTRACTOR will
offer the Enrollee the opportunity to select a new Primary Care Provider.

 

3.                                       Prepaid Mental Health Plan

 

a.                                       When an Enrollee is also enrolled in a
Prepaid Mental Health Plan, the CONTRACTOR and Prepaid Mental Health Plan will
share appropriate information regarding the Enrollee’s health care to ensure
coordination of physical and mental health care services.

 

b.                                      The CONTRACTOR will educate its
subcontracted providers regarding an effective model of coordination such as the
model developed by the PMHP/Health Plan Coordination of Care Committee. The
CONTRACTOR will ensure its subcontracted providers coordinate the provision of
physical health care services with mental health care services as appropriate.

 

a.                                       When an Enrollee is also enrolled in a
Prepaid Mental Health Plan, the CONTRACTOR will not delay an Enrollee’s access
to needed services in disputes regarding responsibility for payment. Payment
issues should be

 

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addressed only after needed services are rendered. As described in Attachment B,
IV (Benefits), Section E (Clarification of Covered Services), Subsection 8 of
this Contract, the independent panel established by the DEPARTMENT will assist
in adjudicating such disputes when requested to do so by either party.

 

b.                                      Clients enrolled in the Health Plan and
a Prepaid Mental Health Plan who due to a psychiatric condition require lab,
radiology and similar outpatient services covered under this Contract, but
prescribed by the Prepaid Mental Health Plan physician, will have access to such
services in a timely fashion. The CONTRACTOR and Prepaid Mental Health Plan will
reduce or eliminate unnecessary barriers that may delay  the Enrollee’s access
to these critical services.

 

4.                                       Restriction Program

 

a.                                       The CONTRACTOR will provide care
coordination for its Restricted Enrollees. The CONTRACTOR will provide staff who
will ensure that all Enrollees who are on the Restriction Program have a contact
person to call when they have access problems, physician or pharmacy change
request, or other questions or problems. The CONTRACTOR will provide the
following services related to the Restriction Program:

 

(1)                                  Provide the Enrollee an initial orientation
about the Restriction Program and ongoing education on the appropriate use of
medical services;

 

(2)                                  Ensure access to necessary care, including
urgent care and emergent care;

 

(3)                                  Maintain a standardized care coordination &
Restriction plan in conjunction with the Enrollee’s Primary Care Provider (PCP).
Review and update as needed. When a personalized care plan is developed, submit
copies to the DEPARTMENT to be included in the Enrollee’s Restriction case file;

 

(4)                                  Work with the Restriction pharmacy,
specialists, dentists, etc. by sharing pertinent information regarding the
Enrollee;

 

(5)                                  Provide information to the DEPARTMENT’s
Restriction staff that will help assess Restriction Enrollees’ progress and that
may include periodic written or telephonic evaluations when requested by the
Restriction staff;

 

(6)                                  Ensure a single point of contact for
restricted members to allow effective care coordination by the CONTRACTOR staff.
The CONTRACTOR is authorized to accept, approve or forward the following to the
DEPARTMENT’s Restriction Program staff:

 

(a)                                  Accept and forward requests for overrides
on pharmacy

 

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claims according to DUR regulations (i.e. cumulative, early refill, non-covered,
non-concurrent policies, etc.) to the DEPARTMENT.

 

(b)                                 Accept and approve PCP changes according to
program guidelines; contact the PCP for affirmation of his/her acceptance on
each individual enrollee prior to approving them as an Enrollee’s PCP; and
coordinate changes with the Restriction Program staff.

 

(c)                                  Accept and forward pharmacy change requests
to the DEPARTMENT’s Restriction staff and coordinate changes with the
Restriction Program staff.

 

b.                                      The CONTRACTOR will ensure that
Enrollees who are on the Restriction Program are linked to a PCP who agrees to
serve as a Restriction PCP. The Restriction PCP will agree to the following:

 

(1)                                  manage all of the Enrollee’s medical care;

 

(2)                                  educate the Enrollee regarding appropriate
use of medical services;

 

(3)                                  provide a referral to another physician
when needed care is not within the PCP’s field of expertise, or when for some
other reason the care cannot be provided by the PCP;

 

(4)                                  will be telephonically available 24 hours a
day, seven days a week (or make certain a provider of comparable specialty is
available) for urgent/emergent medical situations to assure the availability of
prompt, quality, medical services and continuity of care;

 

(5)                                  manage acute and/or chronic long term pain
through a variety of services or treatment options including office calls,
medication administration, physical therapy, counseling and mental health
referral with emphasis on teaching Enrollees to manage their pain by adapting
actions and behaviors;

 

(6)                                  approve or deny drugs prescribed by other
providers when contacted by the pharmacy to which the Enrollee is restricted;

 

(7)                                  work with the Restriction pharmacy,
specialists, dentists, etc. sharing pertinent information regarding the
Enrollee; and

 

(8)                                  provide information to the DEPARTMENT’s
Restriction staff that will help assess Restriction Enrollees’ progress and that
may include periodic written or telephonic evaluations when requested by the
Restriction staff.

 

c.                                       If the Restricted Enrollee’s PCP
chooses to no longer serve as the Enrollee’s PCP, the CONTRACTOR will assist the
Enrollee in finding a new PCP and

 

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coordinate with the DEPARTMENT’s Restriction staff.

 

d.                                      If a Restriction PCP ceases
participation with the CONTRACTOR, the CONTRACTOR will communicate this
immediately to the DEPARTMENT’s Restriction staff. The CONTRACTOR will assist
all affected Enrollees in finding a new PCP and notify the DEPARTMENT when the
new PCP is selected.

 

G.                                    Billing Enrollees

 

1.                                      In General

 

Except as provided in this Article IX, Section G,, Subsection 2, no claim for
payment will be made at any time by the CONTRACTOR or its providers to an
Enrollee accepted by that provider as an Enrollee for any Covered Service. When
a provider accepts an Enrollee as a patient he or she will look solely to the
CONTRACTOR and any third party coverage for reimbursement. If the provider fails
to receive payment from the CONTRACTOR, the Enrollee cannot be held responsible
for these payments.

 

2.                                      Circumstances When an Enrollee May be
Billed

 

An Enrollee may in certain circumstances be billed by the provider for
non-Covered Services and/or for unpaid Medicaid co-payments or Medicaid
co-insurance. A non-Covered Service is one that is not covered under this
Contract, or includes special features or characteristics that are desired by
the Enrollee, such as more expensive eyeglass frames, hearing aids, custom
wheelchairs, etc., but do not meet the Medical Necessity criteria for amount,
duration, and scope as set forth in the Utah State Plan or is not authorized by
the CONTRACTOR. The  DEPARTMENT will specify to the CONTRACTOR the extent of
Covered Services and items under the Contract, as well as services not covered
under the Contract but provided by Medicaid on a fee-for-service basis that
would effect the CONTRACTOR’s Covered Services. An Enrollee may be billed for a
service not covered under this Contract and/or for unpaid Medicaid co-payment or
co-insurance only when all of the following conditions are met:

 

a.                                       the provider has an established policy
for billing all patients for services not covered by a third party and/or for
billing all patients for unpaid co-payment or co-insurance (non-Covered Services
cannot be billed only to Enrollees.);

 

b.                                      the provider has informed the Enrollee
of its policy and the services and items that are not covered under this
Contract and/or Medicaid co-payment or co-insurance requirements and included
this information in the Enrollee’s member handbook;

 

c.                                       the provider has advised the Enrollee
prior to rendering the service that the service is not covered under this
Contract and/or that a Medicaid co-payment or co-insurance is required and that
the Enrollee will be personally responsible for making payment; and

 

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d.                                      in the case of non-Covered Services, the
Enrollee agrees to be personally responsible for the payment of the non-Covered
Service and an agreement is made in writing between the provider and the
Enrollee which details the service and the amount to be paid by the Enrollee.

 

3.                                      CONTRACTOR May Not Hold Enrollee’s
Medicaid Card

 

The CONTRACTOR or its providers will not hold the Enrollee’s Medicaid card as
guarantee of payment by the Enrollee, nor may any other restrictions be placed
upon the Enrollee.

 

4.                                      Criminal Penalties

 

Criminal penalties will be imposed on Health Plan providers as authorized under
section 1128B(d)(1)of the Social Security Act if the provider knowingly and
willfully charges an Enrollee at a rate other than those allowed under this
Contract.

 

H.                                    Survey Requirements

 

Surveys will be conducted of the CONTRACTOR’s Enrollees that will include
questions about  Enrollees’ perceptions of access to and the quality of care
received through the CONTRACTOR. The survey process, including the survey
instrument, will be standardized and developed collaboratively among the
DEPARTMENT and all contracting Health Plans. The DEPARTMENT will analyze the
results of the surveys. The CONTRACTOR’s quality assurance committee will review
the results of the surveys, identify areas needing improvement, outline action
steps to follow up on findings, and inform (at a minimum), subcontractors, and
member and provider services staff, when applicable.

 

9.                                       General Population Survey

 

At least every two years, the CONTRACTOR in conjunction with the DEPARTMENT will
survey a sample of its general population Enrollees; i.e., Enrollees who do not
meet the definition of those with special health care needs.

 

2.                                       Special Needs Survey

 

At least every two years, the CONTRACTOR, in conjunction with the DEPARTMENT,
will survey a sample of Enrollees with special health care needs.

 

Article X - Measurement and Improvement Standards

 

A.                                    Practice Guidelines

 

The CONTRACTOR and its subcontractors will adopt practice guidelines that meet
the following requirements:

 

5.                                       are based on valid and reliable
clinical evidence or a consensus of health care professionals in the particular
field;

 

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6.                                       consider the needs of the CONTRACTOR’s
Health Plan’s Enrollees;

 

7.                                       are adopted in consultation with
contracting health care professionals; and

 

8.                                       are reviewed and updated periodically
as appropriate.

 

The CONTRACTOR will disseminate the practice guidelines to all affected
providers and, upon request, to Enrollees and Potential enrollees.

 

The CONTRACTOR will ensure that decisions for utilization management, Enrollee
education, coverage of services, and other areas to which the guidelines apply
are consistent with the practice guidelines.

 

B.                                    Quality Assessment and Performance
Improvement Program

 

1.                                      In General

 

a.                                       The Quality Assessment and Performance
Improvement Program will include a policymaking body which oversees the Quality
Assessment and Performance Improvement Program, a designated senior official
responsible for administration of the program, an interdisciplinary quality
assessment and performance improvement committee that has the authority to
report its findings and recommendations for improvement to the CONTRACTOR’s
executive director, and a mechanism for ongoing communication and collaboration
among the executive director, the policymaking body and other functional areas
of the organization.

 

b.                                      The CONTRACTOR will establish an ongoing
quality assessment and performance improvement program for the services it
furnished to its Enrollees. CMS, in consultation with States and other
stakeholders, may specify performance measures and topics for performance
improvement projects that would be required for the CONTRACTOR to implement.
Prior to the effective date of the Contract, all plans will be reviewed by the
DEPARTMENT.

 

2.                                      Basic  Elements of Quality Assessment
and Performance Improvement Programs

 

At a minimum, the CONTRACTOR will comply with the following requirements:

 

a.                                       Conduct performance improvement
projects that are designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in clinical and
nonclinical areas that are expected to have a favorable effect on health
outcomes and Enrollee satisfaction.

 

b.                                      Submit performance measurement data.

 

c.                                       Have in effect mechanisms to detect
both underutilization and overutilization of services.

 

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d.                                      Have in effect mechanisms to assess the
quality and appropriateness of care furnished to Enrollees with special health
care needs.

 

e.                                       Have in effect a process for evaluating
the impact and effectiveness of the quality assessment and performance
improvement program.

 

3.                                       Performance Measurement

 

Annually, the CONTRACTOR will:

 

a.                                       Measure and report to the DEPARTMENT
its performance, using standard measures required by the DEPARTMENT and/or CMS;

 

b.                                      Submit to the DEPARTMENT, data specified
by the DEPARTMENT, that enables the DEPARTMENT to measure the CONTRACTOR’s
performance; or

 

c.                                       Perform a combination of the above
activities.

 

4.                                       Required areas and reporting of
Performance Improvement Projects

 

a.                                       The CONTRACTOR will have an ongoing
program of performance improvement projects that focus on clinical and
non-clinical areas, and that involve the following:

 

(1)                                  Measurement of performance using objective
quality indicators.

 

(2)                                  Implementation of system interventions to
achieve improvement in quality.

 

(3)                                  Evaluation of the effectiveness of the
interventions.

 

(4)                                  Planning and initiation of activities for
increasing or sustaining improvement.

 

b.                                      The CONTRACTOR will report the status
and results of each project, including those required by CMS, to the DEPARTMENT
as requested. Each performance improvement project will be completed in a
reasonable time period so as to generally allow information on the success of
performance improvement projects in the aggregate to produce new information on
quality of care every year.

 

Article XI - Other Requirements

 

A.                                    Compliance with Public Health Service Act

 

The CONTRACTOR will comply with all requirements of Section 1301 to and
including 1318 of the Public Health Service Act, as applicable. The CONTRACTOR
will provide

 

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verification of such compliance to the DEPARTMENT upon the DEPARTMENT’s request.

 

B.                                    Advance Directives

 

The CONTRACTOR will comply with the requirements of 42 CFR 434.28 relating to
maintaining written Advance Directives as outlined under Subpart I of 489.100
through 489.102.

 

C.                                    Fraud and Abuse Requirements

 

1.                                       In General

 

The CONTRACTOR will have administrative and management arrangements or
procedures, including a mandatory compliance plan, that are designed to guard
against fraud and abuse. The CONTRACTOR will have a compliance program to
identify and refer suspected fraud and abuse activities.

 

2.                                       Components of arrangements or
procedures

 

The arrangements or procedures will include the following:

 

a.                                       Written policies, procedures, and
standards of conduct that articulate the CONTRACTOR’s commitment to comply with
all applicable Federal and State Standards;

 

b.                                      The designation of a compliance officer
and a compliance committee that are accountable to senior management;

 

c.                                       Effective training and education for
the compliance officer and the CONTRACTOR’s employees;

 

d.                                      Effective lines of communication between
the compliance officer and the CONTRACTOR’s employees;

 

e.                                       Enforcement of standards through
well-publicized disciplinary guidelines;

 

f.                                         Provision for internal monitoring and
auditing; and

 

g.                                      Provision for prompt response to
detected offenses, and for development of corrective action initiatives relating
to this Contract.

 

3.                                       Reporting requirements related to fraud
and abuse

 

The CONTRACTOR will:

 

a.                                       Refer in writing to the DEPARTMENT all
detected incidents of potential fraud or abuse on the part of providers of
services to Enrollees or to other patients.

 

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b.                                      Refer in writing to the DEPARTMENT all
detected incidents of patient fraud or abuse involving Covered Services provided
which are paid for in whole, or in part, by the DEPARTMENT.

 

c.                                       Refer in writing to the DEPARTMENT the
names and Medicaid ID numbers of those Enrollees that the CONTRACTOR suspects of
inappropriate utilization of services, and the nature of the suspected
inappropriate utilization.

 

d.                                      Inform the DEPARTMENT in writing when a
provider is removed from the CONTRACTOR’s panel for reasons relating to
suspected fraud, abuse or quality of care concerns.

 

D.                                    Disclosure of Ownership and Control
Information

 

The CONTRACTOR agrees to meet the requirements of 42 CFR 455, Subpart B related
to disclosure by the CONTRACTOR of ownership and control information and
information related to business transactions.

 

E.                                    Safeguarding Confidential Information on
Enrollees

 

The CONTRACTOR and the CONTRACTOR’s subcontractors will follow all federal and
state laws, regulations, and policies governing confidential information
including the applicable requirements set forth in 42 CFR part 431, subpart F;
and 45 CFR parts 160 and 164, subparts A and E (Health Insurance Portability and
Accountability Act).

 

F.                                    Disclosure of Provider Incentive Plans

 

1.                                       The CONTRACTOR will submit to the
DEPARTMENT information on its physician incentive plans as listed in 42 CFR
417.479(h)(1) and summarized in this Article VII, Section F, Subsections 1
through 7, by May 1 of each year. The CONTRACTOR will provide to the DEPARTMENT
the enrollee/disenrollee survey results when beneficiary surveys are required as
specified in 42 CFR 417.479(g) by October 1 or three months after the end of the
Contract year. The CONTRACTOR will submit to the DEPARTMENT information on
capitation payments paid to primary care physicians as specified in 42 CFR
417.479(h)(1)(vi).

 

2.                                       Per 42 CFR 417.479(a), no specific
payment may be made directly or indirectly under a physician incentive plan to a
physician or physician group as an inducement to reduce or limit Medically
Necessary services furnished to an Enrollee.

 

3.                                       The CONTRACTOR may operate a physician
incentive plan only if the stop-loss protection, Enrollee survey, and disclosure
requirements are met. The CONTRACTOR will disclose to the DEPARTMENT the
following information on provider incentive plans in sufficient detail to
determine whether the incentive plan complies with the regulatory requirements.
The disclosure will contain:

 

a.                                       Whether services not furnished by the
physician or physician group are covered by the incentive plan. If only the
services furnished by the physician or physician group are covered by the
incentive plan, disclosure of

 

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other aspects of the plan need not be made.

 

b.                                      The type of incentive arrangement (i.e.,
withhold, bonus, capitation).

 

c.                                       If the incentive plan involves a
withhold or bonus, the percent of the withhold or bonus.

 

d.                                      Proof that the physician or physician
group has adequate stop-loss protection, including the amount and type of
stop-loss protection.

 

e.                                       The panel size and, if patients are
pooled; the method used.

 

f.                                         To the extent provided for in the
Department of Health and Human Services, Centers for Medicare and Medicaid
Services’ (CMS’) implementation guidelines, capitation payments paid to primary
care physicians for the most recent year broken down by percent for primary care
services, referral services to specialists, and hospital and other types of
provider services (i.e., nursing home and home health agency) for capitated
physicians or physician groups.

 

g.                                      In the case of those prepaid plans that
are required to conduct beneficiary surveys, the survey results. (The CONTRACTOR
will conduct a customer satisfaction of both Enrollees and disenrollees if any
physicians or physicians groups contracting with the CONTRACTOR are placed at
substantial financial risk for referral services. The survey will include either
all current  Enrollees and those who have disenrolled in the past twelve months,
or a sample of these same Enrollees and disenrollees. Recognizing that different
questions are asked of the disenrollees than those asked of Enrollees, the same
survey cannot be used for both populations.)

 

4.                                       The CONTRACTOR will disclose this
information to the DEPARTMENT (1) prior to approval of its Contract or agreement
and (2) upon the Contract or agreements anniversary or renewal effective date.
The CONTRACTOR will provide the capitation data required (see 6 above) for the
previous Contract year to the DEPARTMENT three months after the end of the
Contract year. The CONTRACTOR will provide to the Enrollee upon request whether
the CONTRACTOR uses a physician incentive plan that affects the use of referral
services, the type of incentive arrangement, whether stop-loss protection is
provided, and the survey results of any enrollee/disenrollee surveys conducted.

 

Article XII - Payments

 

A.                                   Non-Risk Contract

 

This Contract is a non-risk contract as described in 42 CFR 447.362. Aggregate
payments made to the CONTRACTOR may not exceed what the DEPARTMENT would have
paid, on a fee-for-service basis, in aggregate, for the services actually
furnished to recipients.

 

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B.                                     Payment Methodology

 

The payment methodology is described in Attachment F of this Contract.

 

C.                                    Contract Maximum

 

In no event will the aggregate amount of payments to the CONTRACTOR exceed the
Contract maximum amount. If payments to the CONTRACTOR approach or exceed the
Contract amount before the renewal date of the Contract, the DEPARTMENT will
make a good faith effort to execute a Contract amendment to increase the
Contract amount within 30 calendar days of the date the Contract amount is
exceeded.

 

D.                                    Medicare

 

1.                                      Payment of Medicare Part B Premiums

 

The DEPARTMENT will pay the Medicare Part B premium for each Enrollee who is on
Medicare. The Enrollee will assign to the CONTRACTOR his or her Medicare
reimbursement for benefits received under Medicare. The Eligibility Transmission
includes and identifies those Enrollees who are covered under Medicare.

 

2.                                      Payment of Medicare Deductible and
Coinsurance

 

The CONTRACTOR is responsible for payment of either the Medicare coinsurance and
deductible billed by Medicare or the Medicare deductible and coinsurance up to
the CONTRACTOR’s allowed amount for Enrollees, whichever is lower. When a
service is paid for by Medicare, the CONTRACTOR will pay whether or not the
service is covered under this Contract. The CONTRACTOR is responsible for
payment whether or not the Medicare covered service is rendered by a network
provider or has been authorized by the CONTRACTOR. Attachment E, Table 2, will
be used to identify the total cost to the CONTRACTOR of providing care for
Enrollees who are also covered by Medicare.

 

a.                                      The DEPARTMENT’s financial obligation

 

The DEPARTMENT’s financial obligation under this Contract for Enrollees who are
covered by both Medicare and the Health Plan is limited to the Medicare Part B
premium and the CONTRACTOR premium.

 

b.                                      When CONTRACTOR will pay up to the
Medicaid payment rate

 

For specified services, the CONTRACTOR is responsible to pay the lower

 

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of the allowed CONTRACTOR payment rate less the amounts paid by Medicare and
other payers, or the Medicare coinsurance and deductibles. The specified
services are billings from:

 

(1)                                  inpatient hospitals;

 

(2)                                  outpatient hospitals;

 

(3)                                  medical supplies defined as billings from
medical suppliers and pharmacies that bill medical supplies; and

 

(4)                                  physicians defined as all physician
specialists except anesthesiologists, osteopaths, podiatrists, independent
laboratories and independent radiology providers; and

 

(5)                                  certified nurse midwives and nurse
practitioners.

 

c.                                       When CONTRACTOR will pay the Medicare
coinsurance and deductibles

 

For crossover claims other than those listed in 2.b above, the CONTRACTOR may
choose when to pay either 1) the lower of the allowed Medicaid payment rate less
the amounts paid by Medicare or other payors or the Medicare coinsurance and
deductibles, or 2) the coinsurance and deductibles billed by Medicare even if
Medicaid’s allowed amount is less than what Medicare paid.

 

 In the event Medicaid does not have a price for a procedure code on a Medicare
crossover claim, the CONTRACTOR will pay the amount of coinsurance and
deductible billed by Medicare.

 

3.                                      Will Not Balance Bill Enrollees

 

The CONTRACTOR or its providers will not Balance Bill the Enrollee and will
consider  reimbursement from Medicare and from the CONTRACTOR as payment in
full.

 

E.                                      Third Party Liability (Coordination of
Benefits)

 

The DEPARTMENT will provide the CONTRACTOR a monthly listing of Enrollees
covered under the Buy-out Program, including the premium amount paid by the
DEPARTMENT.

 

1.                                      TPL Collections

 

The CONTRACTOR will be responsible to coordinate benefits and collect third
party liability (TPL). The CONTRACTOR will keep TPL collections. The
DEPARTMENT’s  audit staff will monitor collections to ensure the

 

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CONTRACTOR is making a good faith effort to pursue TPL.

 

2.                                      Duplication of Benefits

 

This provision applies when, under another health insurance plan such as a
prepaid plan, insurance contract, mutual benefit association or employer’s
self-funded group health and welfare program, etc., an Enrollee is entitled to
any benefits that would totally or partially duplicate the benefits that the
CONTRACTOR is obligated to provide under this Contract. Duplication exists when
(1) the CONTRACTOR has a duty to provide, arrange for or pay for the cost of
Covered Services, and (2) another health insurance plan, pursuant to its own
terms, has a duty to provide, arrange for or pay for the same type of Covered
Services regardless of whether the duty of the CONTRACTOR is to provide the
Covered Services and the duty of the other health insurance plan is only to pay
for the Covered Services. Under State and Federal laws and regulations, Medicaid
funds are the last dollar source and all other health insurance plans as
referred to above are primarily responsible for the costs of providing Covered
Services.

 

3.                                      Reconciliation of Other TPL

 

In order to assist the CONTRACTOR in billing and collecting from other health
insurance plans the DEPARTMENT will include on the Eligibility Transmission
other health insurance plans of each Enrollee when it is known. The CONTRACTOR
will review the Eligibility Transmission and will report to the Office of
Recovery Services or the DEPARTMENT any TPL discrepancies identified within 30
working days of receipt of the Eligibility Transmission. The CONTRACTOR’s report
will include a listing of

 

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Enrollees that the CONTRACTOR has independently identified as being covered by
another health insurance plan.

 

4.                                      When TPL is Denied

 

On a monthly basis,  the CONTRACTOR will report to the Office of Recovery
Services (ORS) claims that have been billed to other health care plans but have
been denied which will include the following information:

 

a.                                       patient name and Medicaid
identification number;

 

b.                                      ICD-9-CM code;

 

c.             procedure codes; and

 

d.                                      insurance company.

 

5.                                      Notification of Personal Injury Cases

 

The CONTRACTOR will be responsible to notify ORS of all personal injury cases,
as defined by ORS and agreed to by the CONTRACTOR, no later than 30 days after
the CONTRACTOR has received a “clean” claim. A clean claim is a claim that is
ready to adjudicate. The diagnosis codes to identify personal injury cases
include the ICD-9-CM codes 800 through 999 (regardless of any prefix, e.g. E800)
except the following codes: 900-919.5, 931-939.9, 942.22, 944.20, 946.2,
E950-958.8, 958.3, 960-979.9, 981, 986, 989.5, 990-995.89, 996-998.9, and 999.8.

 

The following data elements will be provided by the CONTRACTOR to ORS:

 

a.                                       patient name and Medicaid
identification number;

 

b.                                      CONTRACTOR’s patient number;

 

c.                                       dates of service;

 

d.                                      provider billed amount;

 

e.                                       TPL collected amount;

 

f.                                         TPL name;

 

g.                                      amount paid by CONTRACTOR;

 

h.                                      amount paid by Medicaid;

 

i.                                          servicing provider name;

 

j.                                          specific type of injury by ICD-9-CM
code; and

 

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k.                                       procedure codes.

 

6.                                      ORS to Pursue Collections

 

ORS will pursue collection on all claims described in this Article XII
(Payments), Section E, Subsections 4 and 5 of this Contract. The DEPARTMENT will
retain, for administrative costs, one third of the collections received for the
period during which medical services were provided by the CONTRACTOR, and remit
the balance to the CONTRACTOR.

 

7.                                      Insurance Buy-Out Program

 

The Insurance Buy-out Program is an optional program in which the DEPARTMENT
purchases group health insurance for a recipient who is eligible for Medicaid
when it is determined cost-effective for the Medicaid program to do so. The
insurance buy-out process will be coordinated by the DEPARTMENT in cooperation
with the Office of Recovery Services, and Medicaid eligibility workers. The
CONTRACTOR will file claims against group Health Plan’s first before claiming
services against the CONTRACTOR or other Health Plans.

 

8.                                      CONTRACTOR Will Pay Provider
Administrative Fee for Immunizations

 

When an Enrollee has third party coverage for immunizations, the CONTRACTOR will
pay the provider the administrative fee for providing the immunization and not
require the provider to bill the third party as a cost avoidance method. The
CONTRACTOR may choose to pursue the third party amount for the administrative
fee after payment has been made to the provider.

 

F.                                    Third Party Responsibility (Including
Worker’s Compensation)

 

1.                                      CONTRACTOR to Bill Usual and Customary
Charges

 

When a third party has an obligation to pay for Covered Services provided by the
CONTRACTOR to an Enrollee pursuant to this Contract, the CONTRACTOR will bill
the third party for the usual and customary charges for Covered Services
provided and costs incurred. Should any sum be recovered by the Enrollee or
otherwise, from or on behalf of the person responsible for payment for the
service, the CONTRACTOR will be paid out of such recovery for the charges for
service provided and costs incurred by the CONTRACTOR.

 

2.                                      Third Party’s Obligation to Pay for
Covered Services

 

Examples of situations where a third party has an obligation to pay for Covered
Services provided by the CONTRACTOR are when (a) the Enrollee is injured by a
person due to the negligent or intentional acts (or omissions) of the person; or
(b) the Enrollee is eligible to receive payment through Worker’s Compensation
Insurance. If the Enrollee does not diligently seek such recovery, the
CONTRACTOR may institute such rights that it may have.

 

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3.                                      First Dollar Coverage for Accidents

 

In addition, both parties agree that the following will apply regarding first
dollar coverage for accidents:  if the injured party has additional insurance,
primary coverage may be given to the motor insurance effective at the time of
the accident. Once the motor vehicle policy is exhausted, the CONTRACTOR will be
the secondary payer and pay for all of the Enrollee’s Covered Services. If
medical insurance does not exist, the CONTRACTOR will be the primary payer for
all Covered Services.

 

G.                                    Changes in Covered Services

 

If Covered Services are amended under the provisions of Attachment B, Article IV
(Benefits),  rates may be renegotiated, if applicable.

 

H.                                   Clarification of Payment Responsibilities

 

1.                                      Covered Services Received Outside
CONTRACTOR’s Network but Paid by CONTRACTOR

 

The CONTRACTOR will not be required to pay for Covered Services, defined in
Attachment C, which the Enrollee receives from sources outside the CONTRACTOR’s
network, not arranged for and not authorized by, the CONTRACTOR except as
follows:

 

a.                                       Emergency Services;

 

b.                                      Court ordered services that are Covered
Services defined in Attachment C and which have been coordinated with the
CONTRACTOR; or

 

c.                                       Cases where the Enrollee demonstrates
that such services are Medically Necessary Covered Services and were unavailable
from the CONTRACTOR.

 

2.                                      Payment to Non-Network Providers and to
Providers out of the Service Area

 

Payment by the CONTRACTOR to an out-of-network provider for emergency services
and/or to a provider out of the Service Area for services that are approved for
payment by the CONTRACTOR will not exceed the lower of the following rates
applicable at the time the services were rendered to an Enrollee, unless there
is a negotiated arrangement:

 

a.                                       The usual charges made to the general
public by the provider;

 

b.                                      The rate equal to the applicable
Medicaid fee-for-service rate; or

 

c.                                       The rate agreed to by the CONTRACTOR
and the provider.

 

3.                                       When Covered Services are not the
CONTRACTOR’s Responsibility

 

a.                                       The CONTRACTOR is not responsible for
payment when family planning

 

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services are obtained by an Enrollee from sources other than the CONTRACTOR.

 

b.                                      The CONTRACTOR will not be required to
provide, arrange for, or pay for Covered Services to Enrollees whose illness or
injury results directly from a catastrophic occurrence or disaster, including,
but not limited to, earthquakes or acts of war. The effective date of excluding
such Covered Services will be the date specified by the Federal Government or
the State of Utah that a Federal or State emergency exists or disaster has
occurred.

 

4.                                      The DEPARTMENT’s Responsibility

 

Except as described in Attachment F (Payment Methodologies) of this Contract,
the DEPARTMENT will not be required to pay for any Covered Services under
Attachment C which the Enrollee received from any sources outside the CONTRACTOR
except for family planning services.

 

5.                                      Covered Services Provided by the
Department of Health, Division of Community and Family Health Services

 

a.                                       For Enrollees who qualify for special
services offered by or through the Department of Health, Division of Community
and Family Health Services (DCFHS), the CONTRACTOR agrees to reimburse DCFHS at
the standard Medicaid rate in effect at the time of service for one outpatient
team evaluation and one follow-up visit for each Enrollee upon each instance
that the Enrollee both becomes Medicaid eligible and selects the CONTRACTOR as
its provider.

 

(1)                                  The CONTRACTOR agrees to waive any prior
authorization requirement for one outpatient team evaluation and one follow-up
visit.

 

(2)                                  The services provided in the outpatient
team evaluation and follow-up visit for which the CONTRACTOR will reimburse
DCFHS are limited to the services that the CONTRACTOR is otherwise obligated to
provide under this Contract.

 

b.                                      If the CONTRACTOR desires a more
detailed agreement for additional services to be provided by or through DCFHS
for children with special health care needs, the CONTRACTOR may subcontract with
DCFHS. The CONTRACTOR agrees that the subcontract with DCFHS will acknowledge
and address the specific needs of DCFHS as a government provider.

 

6.                                      Enrollee Transition Between Health
Plans, or Between Fee-For-Service and CONTRACTOR

 

a.                                      Inpatient Hospital

 

(1)                                  When an Enrollee is in an inpatient
hospital setting and selects another Health Plan or becomes fee-for-service
anytime prior to

 

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discharge from the hospital, the CONTRACTOR is financially responsible for the
entire hospital stay including all services related to the hospital stay (i.e.
physician, etc.), unless responsibility is transferred to another appropriate
entity and the entity agrees to take financial responsibility, including
negotiating a payment for services (see Article IV, Benefits, Section C.4.,
Inpatient Hospital Services for Scheduled Admissions).

 

(2)                                  The Health Plan in which the individual is
enrolled when discharged from the hospital is financially responsible for
services provided during the remainder of the month when the individual was
discharged.

 

(a)                                  If such individual is fee-for-service when
discharged from the hospital, the DEPARTMENT is financially responsible for the
remainder of the month when the individual was discharged.

 

(b)                                 If a Medicaid eligible is fee-for-service
when admitted to the hospital and selects a Health Plan anytime prior to
discharge from the hospital, the DEPARTMENT is financially responsible for the
entire hospital stay including all services related to the hospital stay, i.e.
physician, etc.

 

(3)                                  When an Enrollee is in an inpatient
hospital setting at the time the CONTRACTOR terminates this Contract and the
Enrollee selects another Health Plan anytime prior to discharge from the
hospital, the receiving Health Plan is financially responsible for the hospital
stay beginning 30 days after termination of the Contract.

 

b.                                      Home Health Services

 

(1)                                  Medicaid clients who are under
fee-for-service or are enrolled in a Health Plan other than this Health Plan and
are receiving home health services from an agency not contracting with the
CONTRACTOR will be transitioned to the CONTRACTOR’s home health agency.

 

(2)                                  The CONTRACTOR is responsible for payment,
not to exceed Medicaid payment, for a period not to exceed seven calendar days,
unless the CONTRACTOR notifies the non-participating home health agency of the
change in status or the non-participating home health agency notifies the
CONTRACTOR that services are bing provided by its agency.

 

(3)                                  The CONTRACTOR will assess the needs of the
Enrollee at the time the CONTRACTOR provides the orientation to the Enrollee.

 

(4)                                  The CONTRACTOR will include the Enrollee in
developing the plan of care to be provided by the CONTRACTOR’s home health
agency before the transition is complete. The CONTRACTOR will address

 

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Enrollee’s concerns regarding Covered Services provided by the CONTRACTOR’s home
health agency before the new plan of care is implemented.

 

c.                                       Medical Equipment

 

(1)                                  When medical equipment is ordered for an
Enrollee by the CONTRACTOR and the Enrollee enrolls in a different Health Plan
or becomes fee-for-service before receiving the equipment, the CONTRACTOR is
responsible for payment of such equipment.

 

(2)                                  When medical equipment is ordered for a
Medicaid eligible by the DEPARTMENT and the Enrollee selects a Health Plan, the
DEPARTMENT is responsible for payment of such equipment.

 

(3)                                  Medical equipment includes, but is not
limited to, specialized wheelchairs or attachments, prostheses, and other
equipment designed or modified for an individual client. Any attachments to the
equipment, replacements, or new equipment is the responsibility of the Health
Plan in which the client is enrolled at the time such equipment is ordered.

 

7.                                      Surveys

 

e.                                       All surveys required under this
Contract will be funded by the CONTRACTOR unless funded by another source such
as the Utah Department of Health, Office of Health Care Statistics.

 

f.                                         The surveys will be conducted by an
independent vendor mutually agreed upon by the DEPARTMENT and CONTRACTOR.

 

g.                                      The DEPARTMENT or designee will analyze
the results of the surveys. Before publishing articles, data, reports, etc.
related to surveys, the DEPARTMENT will provide drafts of such material to the
CONTRACTOR for review and feedback.

 

h.                                      The CONTRACTOR will not be responsible
for the costs incurred for such publishing by the DEPARTMENT.

 

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Article XIII - Records and Reporting Requirements

 

A.                                    Health Information Systems

 

The CONTRACTOR will retain records in accordance with requirements of 45 CFR 74
(three years after the final payment is made and all pending matters closed,
plus additional time if an audit, litigation, or other legal action involving
the records is started before or during the original three year period ends).

 

1.                                       General Rule

 

The CONTRACTOR will maintain a health information system that collects,
analyzes, integrates, and reports data. The system will provide information on
areas including, but not limited to, utilization, Grievances and Appeals, and
disenrollments for other than loss of Medicaid eligibility.

 

2.                                       Basic Elements of a Health Information
System

 

In accordance with Section 4752 of OBRA ‘90 (amended section 1903 (m)(2)(A) of
the Social Security Act), the CONTRACTOR agrees to maintain sufficient patient
encounter data to identify the physician who delivers Covered Services to
Enrollees.

 

a.                                       The CONTRACTOR agrees to provide this
encounter data, upon request of the DEPARTMENT, within 30 days of the request.

 

b.                                      At a minimum, the CONTRACTOR will
collect data on Enrollee and provider characteristics as specified by the
DEPARTMENT and on services furnished to Enrollees through an encounter data
system.

 

3.                                       Accuracy of Data

 

a.                                       The CONTRACTOR will ensure that data
received from providers is accurate and complete by:

 

(1)                                  verifying the accuracy of reported data;

 

(2)                                  screening the data for completeness, logic,
and consistency; and

 

(3)                                  collecting service information in
standardized formats to the extent feasible and appropriate.

 

b.                                      The CONTRACTOR will make all collected
data available to the DEPARTMENT and upon request to CMS.

 

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4.                                       Medical Records

 

The CONTRACTOR agrees that medical records are considered confidential
information and agrees to follow Federal and State confidentiality requirements.

 

a.                                       The CONTRACTOR will require that its
providers maintain a medical record keeping system through which all pertinent
information relating to the medical management of the Enrollee is maintained,
organized, and is readily available to appropriate professionals.

 

b.                                      Notwithstanding any other provision of
this Contract to the contrary, medical records covering Enrollees will remain
the property of the provider, and the provider will respect every Enrollee’s
privacy by restricting the use and disclosure of information in such records to
purposes directly connected with the Enrollee’s health care and administration
of this Contract.

 

c.                                       The CONTRACTOR will use and disclose
information pertaining to individual Enrollees and prospective Enrollees only
for purposes directly connected with the administration of the Medicaid Program
and this Contract.

 

B.                                     Federally Required Reports

 

1.                                       CHEC/EPSDT Reports

 

The CONTRACTOR agrees to act as a continuing care provider for the CHEC/EPSDT
program in compliance with OBRA ‘89 and Social Security Act Sections 1902
(a)(43), 1905 (a)(4)(B) and 1905 (r).

 

a.                                       CHEC/EPSDT Screenings

 

(1)                                  Annually, the CONTRACTOR will submit to the
DEPARTMENT information on CHEC/EPSDT screenings to meet the Federal EPSDT
reporting requirements (Form CMS-416). The data will be in a mutually agreed
upon format.

 

(2)                                  The CHEC/EPSDT information is due December
31 for the prior federal fiscal year’s data (October 1 through September 30).

 

b.                                      Immunization Data

 

The CONTRACTOR will submit immunization data as part of the CHEC/EPSDT
reporting. Enrollee name, Medicaid ID, type of immunization identified by
procedure code, and date of immunization will be reported in the same format as
the CHEC/EPSDT data.

 

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1.                                       Disclosure of Physician Incentive Plans

 

a.                                       The CONTRACTOR will submit to the
DEPARTMENT information on its physician incentive plans as listed in 42 CFR
417.479(h)(1) by May 1 of each year.

 

b.                                      The CONTRACTOR will provide to the
DEPARTMENT the enrollee/disenrollee survey results when beneficiary surveys are
required as specified in 42 CFR 417.479(g) by October 1 or three months after
the end of the Contract year.

 

c.                                       The CONTRACTOR will submit to the
DEPARTMENT information on capitation payments paid to primary care physicians as
specified in 42 CFR 417.479(h)(1)(vi).

 

C.                                    Periodic Reports

 

1.                                      Enrollment, Cost and Utilization Reports
(Attachment E)

 

a.                                       Enrollment, cost and utilization
reports will be submitted on diskettes or CDs in Excel and in the format
specified in Attachment E. A hard copy of the report will be submitted as well.
The DEPARTMENT will send to the CONTRACTOR a template of the Attachment E format
on a diskette, CD, or electronically.

 

b.                                      The CONTRACTOR may not customize or
change the report format. The financial information for these reports will be
reported as defined in CMS Publication 75, and if applicable, CMS 15-1.

 

c.                                       The CONTRACTOR will certify in writing
the accuracy and completeness, to the best of its knowledge, of all costs and
utilization data provided to the DEPARTMENT on Attachment E.

 

d.                                      Two Attachment E reports will be
submitted covering dates of service for each Contract year.

 

(1)                                  Attachment E is due May 1 for the preceding
six-month reporting period (July through December).

 

(2)                                  Attachment E  is due November 1 for the
preceding 12-month reporting period (July through June).

 

e.                                       If necessary, the CONTRACTOR may
request, in writing, an extension of the due date up to 30 days beyond the
required due date. The DEPARTMENT will approve or deny the extension request
writing within seven calendar days of receiving the request.

 

2.                                       Interpretive Services

 

Annually, on November 1, the CONTRACTOR will submit summary information about
the use of interpretive services during the previous Contract year (July 1

 

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through June 30). The information will include the following:

 

a.                                       a list of all sources of interpreter
services;

 

b.                                      total expenditures for each language;

 

c.                                       total expenditures for clinical versus
administrative;

 

d.                                      number of Enrollees who used
interpretive services for each language; and

 

e.                                       number of services provided categorized
by clinical versus administrative.

 

3.                                      Semi-Annual Reports

 

The following semi-annual reports are due May 1 for the preceding six-month
reporting period ending December 31 (July through December) and are due November
1 for the preceding six month period ending June 30 (January through June).

 

a.                                      Organ Transplants: Report the total
number of organ transplants by type of transplant.

 

b.                                      Obstetrical Information: Report
obstetrical information including:

 

(1)                                  total number of obstetrical deliveries by
aid category grouping;

 

(2)                                  total number of caesarean sections and
total number of vaginal deliveries;

 

(3)                                  total number low birth weight infants; and

 

(4)                                  total number of Enrollees requiring
prenatal hospital admission.

 

c.                                       Appeals and Grievances

 

The CONTRACTOR will maintain complete records of all Appeals and Grievances and
submit semi-annual reports summarizing Appeals and Grievances using
DEPARTMENT-specified reporting templates.

 

(1)                                  Separate reports of Appeals and Grievances
are required for adults and children; and for Traditional Medicaid Plan
Enrollees and Non-Traditional Plan Enrollees.

 

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(2)                                  Each report will distinguish between those
Enrollees with special health care needs and the general population of children.

 

(3)                                  Report summary information on the number of
Appeals and Grievances by type of Appeals and Grievance and indicate the number
that have been resolved. Include an analysis of the type and number of Appeals
and Grievances received by the CONTRACTOR.

 

d.                                      Aberrant Physician Behavior

 

Report summary information of corrective actions taken on physicians who have
been identified by the CONTRACTOR as exhibiting aberrant physician behavior and
the names of physicians who have been removed from the CONTRACTOR’s network due
to aberrant behavior. The summary will include the reasons for the corrective
action or removal.

 

4.                                      Annual Quality Improvement Program
Documentation

 

a.                                       Annually, the CONTRACTOR will submit to
the DEPARTMENT the following documents:

 

(1)                                  the CONTRACTOR’s quality improvement
program description;

 

(2)                                  the CONTRACTOR’s quality improvement work
plan;

 

(3)                                  the CONTRACTOR’s quality improvement work
plan evaluation for previous calendar year.

 

b.                                      These reports will be in the format
developed by the DEPARTMENT and include signature(s) of approval by the
CONTRACTOR’s designated authorizing authority. Reports will be on a Contract
year basis and will be due no later that October 1st of each year.

 

5.                                      Documents Due Prior to Quality
Monitoring Reviews

 

a.                                       The following documents are due at
least 60 days prior to the DEPARTMENT’s quality assurance monitoring review, or
earlier on request, unless the DEPARTMENT has already received documents that
are in effect:

 

(1)                                  the CONTRACTOR’s most current (may be in
draft stage) written quality improvement program description;

 

(2)                                  the CONTRACTOR’s most current (may be in
draft stage) annual quality improvement work plan;

 

(3)                                  the CONTRACTOR’s most current (may be in
draft stage) quality improvement work plan evaluation for the previous calendar
year;

 

(4)                                  documentation of the CONTRACTOR’s
compliance to standards

 

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defined in Utah’s Quality Assessment and Performance Improvement Plan for
contracted medical health plans (Attachment D).

 

(5)                                  all other information requested by the
DEPARTMENT to facilitate the DEPARTMENT’s review of the CONTRACTOR’s compliance
to standards defined in Utah’s Quality Assessment and Performance Improvement
Plan for contracted medical health plans (Attachment D).

 

b.                                      The above documents will show evidence
of a well defined, organized program designed to improve client care.

 

6.                                      Impact of Co-payments

 

a.                                       The following semi-annual report is due
May 1 for the preceding six-month reporting period ending April 30 (November of
previous year through April of current year) and November 1 for the preceding
six-month period ending October 31 (May through October of the current year):

 

b.                                      Report will document all instances when
Enrollees have contacted the CONTRACTOR with a complaint about being denied
services because they did not pay their Medicaid co-payment or co-insurance. For
each instance, report the Enrollee’s name, Medicaid ID, provider, and the
service the Enrollee was scheduled to receive.

 

7.                                      HEDIS

 

Audited Health Plan Employer Data and Information Set (HEDIS) performance
measures will cover services rendered to Enrollees and will be reported as set
forth in State rules by the Office of Health Data Analysis. For example,
calendar year 2003 HEDIS measures will be reported in 2004.

 

8.                                       Encounter Data

 

a.                                       Encounter data will be submitted in
accordance with the instructions detailed in the Encounter Records 837
Institutional Guide and Encounter Records 837, Professional Companion Guide, for
dates of service beginning July 1, 2002.

 

b.                                      The CONTRACTOR will receive
certification from an independent, credible vendor that their electronic
submissions of encounter data are compliant with the Health Insurance
Portability and Accountability Act (HIPAA) requirements.

 

c.                                       At a minimum, the CONTRACTOR will be
HIPAA-compliant in the first four levels of HIPAA compliance: Level 1 -
Integrity Testing, Level 2 - Requirement Testing, Level 3 - Balancing, and Level
4 - Situation Testing.

 

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9.                                      Audit of Abortions, Sterilizations and
Hysterectomies

 

a.                                      The CONTRACTOR will conduct an annual
audit of abortion, hysterectomy and sterilization procedures performed by the
CONTRACTOR’s providers. The purpose of the audit is to monitor compliance with
federal and state requirements for the reimbursement of these procedures under
Medicaid. The CONTRACTOR will audit all abortions and a sample of hysterectomy
and sterilization procedures as defined by the DEPARTMENT.

 

b.                                      On November 1 of each year, the
CONTRACTOR will submit to the DEPARTMENT the following information on the
results of the abortion, sterilization and hysterectomy audit for the previous
calendar year.

 

c.                                       For the sterilization and hysterectomy
audit, submit documentation of the methodology used to pull the sample of
sterilization and hysterectomies and include the sampling proportions.

 

d.                                      In an Excel file, submit the following
information for all abortions, the sample of sterilizations, and the sample of
hysterectomies:

 

(1)                                  client name

(2)                                  Medicaid ID number

(3)                                  procedure code

(4)                                  date of service

(5)                                  history/physical (yes/no)

(6)                                  operative report (yes/no)

(7)                                  pathology report (yes/no)

(8)                                  consent form (yes/no)

(9)                                  medical necessity criteria - hysterectomies
only

 

e.                                       When information is submitted
electronically, the CONTRACTOR will use a secured electronic transmission
process.

 

f.                                         The DEPARTMENT will evaluate the
results of the CONTRACTOR’s audit and identify the cases that will require
medical record submission.

 

(1)                                  Medical record submission will be required
for all abortions and a random sample of hysterectomy and sterilization cases.

 

(2)                                 The DEPARTMENT will notify the CONTRACTOR in
writing of the cases that will require medical record submission and the time
line for the medical record submissions.

 

10.                                 Provider Network

 

The CONTRACTOR will submit a monthly file of its provider network that meets the
DEPARTMENT’s provider file specifications and data element requirements.

 

11.                                 Case Management Reports

 

The CONTRACTOR will submit quarterly case management reports due 30 days after
the end of each quarter being reported; i.e., data covering July through
September is due November 1. (See Utah’s Quality Assessment and Performance

 

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Improvement Plan, Attachment D).

 

12.                                 Development of New Reports

 

Any new reports/data requirements mandated by the DEPARTMENT will be mutually
developed by the DEPARTMENT and the CONTRACTOR.

 

D.                                    Data Certification

 

1.                                      Certifications

 

The CONTRACTOR will certify financial data that are submitted to the DEPARTMENT.

 

2.                                      Timing of Certification for Financial
Data and Reports

 

a.                                       When submitting paper copies of the
financial data or reports, the CONTRACTOR may submit the written certification
by using the DEPARTMENT-developed data and reports cover sheet which includes a
certification statement.

 

b.                                      If the CONTRACTOR does not use the cover
sheet, the CONTRACTOR will attach a cover letter that includes the data
certification statement.

 

c.                                       When submitting data and reports
electronically, the CONTRACTOR will include a certification statement with the
submission.

 

3.                                       Content of Certification

 

In the certification, the CONTRACTOR will attest to the completeness and
truthfulness of the data and documents based on best knowledge, information and
belief.

 

4.                                      Authority to Certify

 

The CONTRACTOR will ensure one of the following certifies data and documents:

 

a.                                       the CONTRACTOR’s chief executive
officer;

 

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b.                                      the CONTRACTOR’s chief financial
officer; or

 

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c.                                       an individual who has delegated
authority to sign for, and who reports directly to the chief executive officer
or chief financial officer.

 

Article XIV - Compliance/Monitoring

 

A.                                    Audits

 

1.                                      Right of DEPARTMENT and CMS to Audit

 

The DEPARTMENT and the Department of Health and Human Services, Centers for
Medicare and Medicaid Services may audit and inspect any financial records of
the CONTRACTOR or its subcontractors relating (a) to the ability of the
CONTRACTOR to bear the risk of potential financial losses, or (b) to evaluate
services performed or determinations of amounts payable under the Contract.

 

2.                                      Information to Determine Allowable Costs

 

The CONTRACTOR will make available to the DEPARTMENT all reasonable and related
financial, statistical, clinical or other information needed for the
determination of allowable costs to the Medicaid program for “related party/home
office” transactions as defined in CMS 15-1. These records are to be made
available in Utah or the CONTRACTOR will pay the increased cost (incremental
travel, per diem, etc.) of auditing at the out-of-state location. The cost to
the CONTRACTOR will include round-trip travel and two days per diem/lodging.
Additional travel costs of the site audit will be shared equally by the
CONTRACTOR and the DEPARTMENT.

 

3.                                      Management and Utilization Audits

 

(1)                                  The CONTRACTOR will allow the DEPARTMENT
and the Department of Health and Human Services, Centers for Medicare and
Medicaid Services, to perform audits for identification and collection of
management data, including Enrollee satisfaction data, quality of care data,
fraud-related data, abuse-related data, patient outcome data, and cost and
utilization data, which will include patient profiles, exception reports, etc.

 

(2)                                  The CONTRACTOR will provide all data
required by the DEPARTMENT or the independent quality review examiners in
performance of these audits.

 

(3)                                  Prior to beginning any audit, the
DEPARTMENT will give the CONTRACTOR reasonable notice of audit, and the
DEPARTMENT will be responsible for costs of its auditors or representatives.

 

B.                                    Quality Monitoring by the DEPARTMENT

 

1.                                       The DEPARTMENT will review, at least
annually, the impact and effectiveness of the CONTRACTOR’s quality assessment
and performance improvement program. The review will include:

 

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a.                                       The CONTRACTOR’s performance on the
standard measures on which it is required by the DEPARTMENT to report.

 

b.                                      The results of the CONTRACTOR’s
performance improvement projects.

 

c.                                       The results of the CONTRACTOR’s
evaluation of the impact and effectiveness of its quality assessment and
performance improvement program.

 

1.                                       The DEPARTMENT will review the
CONTRACTOR for compliance to standards defined in Utah’s Quality Assessment and
Performance Improvement Plan (Attachment D).

 

C.                                    External Quality Review

 

1.                                      In General

 

a.                                       Pursuant to 42 CFR Part 438 Subpart E
-  External Quality Review (EQR), the DEPARTMENT will provide for an annual
external quality review conducted by an External Quality Review Organization
(EQRO) of the quality, timeliness, and access to Covered Services. The
CONTRACTOR will support the annual external quality review.

 

b.                                      The DEPARTMENT will choose an agency to
perform an annual EQR pursuant to Federal law and will pay for such review.

 

(1)                                  The CONTRACTOR will maintain all clinical
and administrative records for use by the EQRO.

 

(2)                                  The CONTRACTOR agrees to support quality
assurance reviews, focused studies and other projects performed for the
DEPARTMENT by the EQRO.

 

(3)                                  The purpose of the reviews and studies is
to comply with Federal requirements for an annual EQR.

 

(4)                                  The external quality reviews are conducted
by the EQRO, with the advice, assistance, and cooperation of a planning team
composed of representatives from the CONTRACTOR, the EQRO and the DEPARTMENT
with final approval by the DEPARTMENT.

 

2.                                      Specific Requirements

 

a.                                      Liaison for Routine Communication

 

The CONTRACTOR will designate an individual to serve as liaison with the EQRO
for routine communication with the EQRO.

 

b.                                      Representative to Assist with Projects

 

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(1)                                  The CONTRACTOR will designate a minimum of
two representatives (unless one individual can service both functions) to serve
on the planning team for each EQRO project.

 

(2)                                  Representatives will include a quality
improvement representative and a data representative.

 

(3)                                  The planning team is a joint collaborative
forum between DEPARTMENT staff, the EQRO and the CONTRACTOR.

 

(4)                                  The role of the planning team is to
participate in the process and completion of EQRO projects.

 

c.                                       Copies and On-Site Access

 

(1)                                  The CONTRACTOR will be responsible for
obtaining copies of Enrollee information and facilitating on-site access to
Enrollee information as needed by the EQRO. Such information will be used to
plan and conduct projects and to investigate complaints and grievances.

 

(2)                                  Any associated copying costs are the
responsibility of the CONTRACTOR.

 

(3)                                  Enrollee information includes medical
records, administrative data such as, but not limited to, enrollment information
and claims, nurses’ notes, medical logs, etc. of the CONTRACTOR or its
providers.

 

d.                                      Format of Enrollee Files

 

The CONTRACTOR will provide Enrollee information in a mutually agreed upon
format compatible for the EQRO’s use, and in a timely fashion to allow the EQRO
to select cases for its review.

 

e.                                       Time-frame for Providing Data

 

(1)                                  The CONTRACTOR will provide data to the
EQRO within 15 working days of the written request from the EQRO and will
provide medical records within 30 working days of the written request from the
EQRO.

 

(2)                                  Requests for extensions of these time
frames will be reviewed and approved or disapproved by the DEPARTMENT on a
case-by-case basis.

 

f.                                         Work Space for On-Site Reviews

 

The CONTRACTOR will assure that the EQRO staff and consultants have

 

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adequate work space, access to a telephone and copy machines at the time of
review. The review will be performed during agreed-upon hours.

 

g.                                      Staff Assistance During On-Site Visits

 

The CONTRACTOR will assign appropriate person(s) to assist the EQRO personnel
conduct the reviews during on-site visits and to participate in an informal
discussion of screening observations at the end of each on-site visit, if
necessary.

 

D.                                    Corrective Action

 

1.                                      When Corrective Actions are Necessary

 

a.                                       The CONTRACTOR agrees to implement
corrective action as specified by the DEPARTMENT when quality assurance
monitoring including, but not limited to, site reviews, CONTRACTOR documentation
reviews, data analysis, medical audits, or complaints/grievances, determines the
need for such corrective action.

 

b.                                      In addition, if the DEPARTMENT
determines that the CONTRACTOR has not provided services in accordance with the
Contract or within expected professional standards, the DEPARTMENT will request
in writing that the CONTRACTOR correct deficiencies or identified problems by
developing a corrective action plan.

 

c.                                       If the corrective action is a result of
non-compliance with the DEPARTMENT’s Quality Assessment Improvement and
Performance Improvement Plan, the time frames below do not necessarily apply;
the time frames will be specified in a formal letter sent to the CONTRACTOR from
the DEPARTMENT if a corrective action is required.

 

2.                                      Initial Response by CONTRACTOR

 

a.                                       The CONTRACTOR has 20 working days from
the date the DEPARTMENT mails, through certified mail, its written request for
the CONTRACTOR to respond to the problems identified and will either:

 

(1)                                  submit a corrective action plan,

 

(2)                                  submit a letter summarizing the
CONTRACTOR’s disagreements with the DEPARTMENT’s findings, or

 

(3)                                  request, in writing, an extension of the
20-day time frame. The CONTRACTOR may only request an extension if it determines
it will conduct a medical records review or there are other extenuating
circumstances.

 

b.                                      If the CONTRACTOR fails to respond in
one of the above ways, the CONTRACTOR will be subject the following sanction:

 

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A $500 penalty for each working day, beginning on the first day after the 20-day
time period has expired, and continuing until the day a corrective action plan
is submitted to the DEPARTMENT.

 

3.                                      Submission of Corrective Action to
DEPARTMENT

 

a.                                       Acceptance of Corrective Action Plan

 

If the CONTRACTOR submits a corrective action plan to the DEPARTMENT within 20
working days (or other agreed upon time frame) and the DEPARTMENT accepts the
corrective action plan, the DEPARTMENT will send written notice to the
CONTRACTOR officially approving the corrective action plan.

 

b.                                      When Corrective Action Plan Requires
Revisions

 

(1)                                  If the CONTRACTOR submits a corrective
action plan, but the DEPARTMENT determines the corrective action plan requires
revisions, the CONTRACTOR will have 20 working days to submit a revised plan
from the date the DEPARTMENT mails, through certified mail, the request for a
revised plan. The DEPARTMENT’s letter will state the specific revisions to be
made in the corrective action plan.

 

(2)                                  If the CONTRACTOR is unable or unwilling to
submit to the DEPARTMENT within the established time frame, a revised corrective
action plan containing the DEPARTMENT’s requested revisions, the CONTRACTOR will
be subject to the following sanction:

 

A $500 penalty for each working day, beginning on the first day after the 20-day
time period has expired, and continuing until the day a corrective action plan
is submitted to the DEPARTMENT.

 

4.                                      Initial Appeal of DEPARTMENT’s Findings

 

a.                                       If the CONTRACTOR disagrees with the
DEPARTMENT’s findings and wishes to appeal those findings, the CONTRACTOR will
submit a detailed explanation of the disagreement in writing to the DEPARTMENT
within the established time frame. If the DEPARTMENT agrees with the CONTRACTOR,
the DEPARTMENT will provide written notification of its decision and will
withdraw the request for a corrective action plan.

 

b.                                      If the DEPARTMENT upholds its request
for a corrective plan, the CONTRACTOR has 20 days from the date the DEPARTMENT
mails, through certified mail, a letter upholding its request for a corrective
action plan.

 

c.                                       If the CONTRACTOR does not submit a
corrective action plan within that

 

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time frame, the CONTRACTOR will be subjected to the following sanction:

 

A $500 penalty for each working day, beginning on the first day after the 20-day
time period has expired, and continuing until the day a corrective action plan
is submitted.

 

5.                                      Formal Hearing

 

a.                                       If the DEPARTMENT upholds its decision
that a corrective action plan is required, the CONTRACTOR may file a request for
a formal hearing with the DEPARTMENT within 30 days from the date the DEPARTMENT
mails, through certified mail, a letter upholding its decision. If the $500
penalty has begun, it will discontinue once the DEPARTMENT receives the formal
hearing request from the CONTRACTOR.

 

b.                                      If the outcome of the formal hearing is
in favor of the CONTRACTOR, the DEPARTMENT will provide the CONTRACTOR with
written notification that a corrective action plan is no longer required. The
DEPARTMENT will reimburse the CONTRACTOR any penalties the CONTRACTOR has paid
to the DEPARTMENT that accrued beginning on day 21 from the date the DEPARTMENT
mails, through certified mail, the request for a corrective action plan and
ending on the day the request for a formal hearing is received by the
DEPARTMENT.

 

c.                                       If the outcome of the formal hearing is
in favor of the DEPARTMENT, the CONTRACTOR will submit a corrective action plan,
as determined by the formal hearing decision, within 20 days of the date of the
hearing decision, otherwise the CONTRACTOR will be subject to the following
sanction:

 

A $500 penalty for each working day, beginning on the first day after the 20-day
time period has expired, and continuing until the day a corrective action plan
that complies with the formal hearing decision is submitted to the DEPARTMENT.
If the DEPARTMENT determines that the corrective action plan requires revisions,
the CONTRACTOR will again be subject to a $500 penalty for each working day
beginning on the first day after the DEPARTMENT verbally notifies the CONTRACTOR
that the corrective action plan requires revisions and continuing until the day
the DEPARTMENT receives the corrective action plan containing the DEPARTMENT’s
required revisions.

 

6.                                      CONTRACTOR Unwilling or Unable to
Implement Corrective Action Plan

 

a.                                       If the CONTRACTOR is unwilling or
unable to implement the corrective action plan to the satisfaction of the
DEPARTMENT, the CONTRACTOR will be subject to the following sanction:

 

A $500 penalty for each working day, beginning on the first day after the
DEPARTMENT verbally notifies the CONTRACTOR that the corrective action plan has
not been implemented, and continuing

 

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until the day the CONTRACTOR successfully demonstrates to the DEPARTMENT that it
has implemented the plan. Following the DEPARTMENT’s verbal notification, the
DEPARTMENT will mail, through certified mail, a letter stating the penalty has
been invoked.

 

b.                                      The CONTRACTOR will be apprized of its
right to request a formal hearing.

 

(1)                                  If the CONTRACTOR decides to formally
appeal the DEPARTMENT’s decision that the corrective action plan has not been
implemented, then the procedures detailed in number 2 above apply.

 

(2)                                  If the outcome of the formal hearing is in
favor of the DEPARTMENT, penalties will resume on the date of the formal hearing
decision and continue until the CONTRACTOR complies with the decision of the
formal hearing.

 

7.                                      Collection of Financial Penalties

 

The DEPARTMENT may deduct any financial penalties assessed by the DEPARTMENT
from the monthly payment to the CONTRACTOR.

 

Article XV - Termination of the Contract

 

A.                                    Automatic Termination

 

This Contract will automatically terminate June 30, 2006. The parties agree to
meet prior to the end date of this Contract to discuss terms and conditions that
may be incorporated into the next Contract period, unless terminated by either
party as provided herein.

 

B.                                    90-Day Termination Option

 

Either party may terminate the Contract without cause by giving the other party
written notice of termination at least 90 days prior to the termination date.

 

C.                                    Effect of Termination

 

1.                                      Coverage

 

Inasmuch as the CONTRACTOR is paid on a monthly basis, the CONTRACTOR will
continue providing the Covered Services required by this Contract until midnight
of the last day of the calendar month in which the termination becomes
effective. If an Enrollee is a patient in a hospital setting during the month in
which termination becomes effective, the CONTRACTOR is responsible for the
entire hospital stay including physician charges until discharge or thirty days
following termination, whichever occurs first.

 

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2.                                      Enrollee Not Liable for Debts of
CONTRACTOR or its Subcontractors

 

If the CONTRACTOR or one of its subcontractors becomes insolvent or bankrupt,
the Enrollees will not be liable for the debts of the CONTRACTOR or its
subcontractor. The CONTRACTOR will include this term in all of its subcontracts.

 

3.                                      Information for Claims Payment

 

The CONTRACTOR will promptly supply to the DEPARTMENT all information necessary
for the reimbursement of any Medicaid claims not paid by the CONTRACTOR.

 

4.                                      Changes in Enrollment Process

 

The CONTRACTOR will be advised of anticipated changes in policies and procedures
as they relate to the enrollment process and their comments will be solicited.
The CONTRACTOR agrees to be bound by such changes in policies and procedures
unless they are not agreeable to the CONTRACTOR, in which case the CONTRACTOR
may terminate the Contract in accordance with the Contract termination
provisions.

 

5.                                      Hearing Prior to Termination

 

Regarding the General Provisions, Article XVII (Default, Termination, & Payment
Adjustment), item 3, if the CONTRACTOR fails to meet the requirements of the
Contract, the DEPARTMENT will give the CONTRACTOR a hearing prior to
termination. Enrollees will be informed of the hearing and will be allowed to
disenroll from this Health Plan without cause.

 

6.                                      CMS Consent Required

 

If the Department of Health and Human Services, Centers for Medicare and
Medicaid (CMS) directs the DEPARTMENT to terminate this Contract, the DEPARTMENT
will not be permitted to renew this Contract without CMS consent.

 

D.                                    Assignment

 

Assignment of any or all rights or obligations under this Contract without the
prior written consent of the DEPARTMENT is prohibited. Sale of all or any part
of the rights or obligations under this Contract will be deemed an assignment.
Consent may be withheld in the DEPARTMENT’s sole and absolute discretion.

 

Article XVI - Miscellaneous

 

A.                                   Integration

 

This Contract contains the entire agreement between the parties with respect to
the subject matter of this Contract. There are no representations, warranties,
understandings, or agreements other than those expressly set forth herein.
Previous contracts between the

 

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parties hereto and conduct between the parties which precedes the implementation
of this Contract will not be used as a guide to the interpretation or
enforcement of this Contract or any provision hereof. If there is a conflict
between these Special Provisions (Attachment B) or the General Provisions
(Attachment A), then these Special Provisions will control.

 

B.                                     Enrollees May Not Enforce Contract

 

Although this Contract relates to the provision of benefits for Enrollees and
others, no Enrollee is entitled to enforce any provision of this Contract
against the CONTRACTOR nor will any

 

provision of this Contract be constructed to constitute a promise by the
CONTRACTOR to any Enrollee or Potential Enrollee.

 

C.                                     Interpretation of Laws and Regulations

 

The DEPARTMENT will be responsible for the interpretation of all Federal and
State laws and regulations governing or in any way affecting this Contract. When
interpretations are required, the CONTRACTOR will submit written requests to the
DEPARTMENT. The DEPARTMENT will retain full authority and responsibility for the
administration of the Medicaid program in accordance with the requirements of
Federal and State law.

 

D.                                    Adoption of Rules

 

Adoption of rules by the DEPARTMENT which govern the Medicaid program, will be
automatically incorporated into this Contract upon receipt by the CONTRACTOR of
written notice thereof.

 

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Attachment C

Molina Healthcare of Utah

January 1, 2006

 

Covered Services

Limitations & Exclusions

Co-payment & Co-insurance Requirements

 

Covered Services are the same under both the Traditional and Non-Traditional
Medicaid Plans unless otherwise indicated. Co-payments and co-insurances are
listed if required. Pregnant women and children under age 18 are exempt from all
co-payment and co-insurance requirements. Services related to family planning
are excluded from all co-payment and co-insurance requirements. Medicaid
Provider Manuals provide detailed information regarding covered services and are
available to the CONTRACTOR upon request.

 

A.                                   In General

 

The CONTRACTOR will provide the following benefits to Enrollees in accordance
with Medicaid benefits as defined in the Utah State Plan subject to the
exception or limitations as noted below. The DEPARTMENT reserves the right to
interpret what is in the State plan. Medicaid services can only be limited
through utilization criteria based on Medical Necessity. The CONTRACTOR will
provide at least the following benefits to Enrollees.

 

The CONTRACTOR is responsible to provide or arrange for all Medically Necessary
Covered Services on an emergency basis 24 hours each day, seven days a week. The
CONTRACTOR is responsible for payment for all covered Emergency Services
furnished by providers that do not have arrangements with the CONTRACTOR.

 

B.                                    Hospital Services

 

1.                                      Inpatient Hospital

 

Services furnished in a licensed, certified hospital are Covered Services.

 

Non-Traditional Medicaid Plan excludes the following revenue codes:

430 - 439 (Occupational Therapy)

380 - 382, and 391 (Whole Blood)

390 and 399 (Autologous or self blood storage for future use)

811 - 813 (Organ Donor charges)

 

CO-INSURANCE

Traditional Medicaid: $220.00 for non-emergency admissions. Limited to $220.00
per Enrollee per calender year.

Non-Traditional Medicaid: $220.00 for each non-emergency admission per Enrollee.
Counts toward total maximum co-payment and co-insurance of $500.00 per Enrollee
per calendar year.

 

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2.                                      Outpatient Hospital

 

Services provided to Enrollees at a licensed, certified hospital who are not
admitted to the hospital are Covered Services.

 

CO-PAYMENT

 

Traditional Medicaid: $2.00 co-payment per visit. Limited to one co-payment per
date of service per provider. The facility fees associated with services
provided in an outpatient hospital or free-standing ambulatory surgical centers
are subject to $2.00 co-payment per date of service per provider. Annual
calendar year maximum for any combination of physician, podiatry, outpatient
hospital, and surgical centers is $100.00 per Enrollee.

 

Non-Traditional Medicaid: $3.00 co-payment per visit. Limited to one co-payment
per date of service per provider. The facility fees associated with services
provided in an outpatient hospital or a free standing ambulatory surgical
centers are subject to $3.00 co-payment per date of service per provider. Counts
toward total maximum co-payment and co-insurance of $500.00 per Enrollee per
calendar year.

 

3.                                      Emergency Department Services

 

Emergency Services provided to Enrollees in designated hospital emergency
departments are Covered Services.

 

CO-PAYMENT

 

Traditional Medicaid: Co-payment is $6.00 for non-emergency use of the emergency
room.

 

Non-Traditional Medicaid: Co-payment is $6.00 for non-emergency use of the
emergency room. Counts toward total maximum co-payment and co-insurance of
$500.00 per Enrollee per calendar year.

 

C.                                     Physician Services

 

Services provided directly by licensed physicians or osteopaths, or by other
licensed professionals such as physician assistants, nurse practitioners, or
nurse midwives under the physician’s or osteopath’s supervision are covered
Services.

 

Non-Traditional Medicaid excludes office visits in conjunction with allergy
injections (CPT codes 95115 through 95134 and 95144 through 95199).

 

CO-PAYMENT

 

Traditional Medicaid: Co-pay is $3.00 per visit. Limited to one co-payment per
date of service per provider. Annual calendar year maximum is $100.00 per
Enrollee for any combination of physician, osteopath, podiatry, outpatient
hospital, freestanding

 

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emergency centers, and surgical centers. Co-payment required for preventive
services and immunizations.

 

Non-Traditional Medicaid: Co-payment is $3.00 per visit. Limited to one
co-payment per date of service per provider. No co-payment for preventive
services and immunizations. Counts toward total maximum co-payment and
co-insurance of $500.00 per Enrollee per calendar year.

 

D.                                    General Preventive Services

 

The CONTRACTOR must develop or adopt practice guidelines consistent with current
standards of care, as recommended by professional groups such as the American
Academy of Pediatric and the U.S. Task Force on Preventive Care.

 

A minimum of three screening programs for prevention or early intervention (e.g.
Pap Smear, diabetes, hypertension).

 

E.                                      Vision Care

 

Services provided by licensed ophthalmologists or licensed optometrists, and
opticians within their scope of practice are Covered Services. Services include,
but are not limited to, the following:

 

1.                                       Eye examinations and care to identify
and treat medical problems

2.                                       Eye refractions, examinations

3.                                       Laboratory work

4.                                       Lenses

5.                                       Eyeglass Frames

6.                                       Repair of Frames

7.                                       Repair or Replacement of Lenses

8.                                       Contact Lenses (when Medically
Necessary)

 

Traditional Medicaid Plan: Full coverage for all Non-Traditional clients.

 

Non-Traditional Medicaid Plan is limited to the following services and
limitations:Non-Traditional Medicaid clients have coverage for vision screening
in conjunction with determining refractions. Providers may bill using procedure
codes 92002, 92004, 92012, and 92014. There is a maximum Medicaid benefit of
$31.21 for screening services. Charges above the $31.21 are non-covered Medicaid
services and are considered the patient’s responsibility. Eye
refraction/examination is limited to one eye examination every 12 months.

 

Eyeglasses (lenses and frames) are not covered.

 

Services to identify and treat medical problems such as diabetic retinopathy,
glaucoma, cataracts, etc., may be billed by ophthalmologists and optometrists
using procedure codes

 

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92020, 92083, 92135, 95930, 99201-99205, 99211-99215, 65210, 65220, 65222,
67820, 68761, and 68801. Ophthalmologists may bill additional procedure codes
within their scope of service that are covered by Medicaid. These services are
paid based on the Medicaid fee schedule and are considered payment in full.

 

F.                                      Lab and Radiology Services

 

Professional and technical laboratory and X-ray services furnished by licensed
and certified providers are Covered Services. All laboratory testing sites,
including physician office labs, providing services under this Contract will
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.

 

G.                                    Physical and Occupational Therapy

 

1.                                      Physical Therapy

 

Treatment and services provided by a licensed physical therapist. Treatment and
services must be authorized by a physician and include services prescribed by a
physician or other licensed practitioner of the healing arts within the scope of
his or her practice under State law and provided to an Enrollee by or under the
direction of a qualified physical therapist. Necessary supplies and equipment
will be reviewed for medical necessity and follow the criteria of the R414.12
rule.

 

2.                                      Occupational Therapy

 

Treatment of services provided by a licensed occupational therapist. Treatment
and services must be authorized by a physician and include services prescribed
by a physician or other licensed practitioner of the healing arts within the
scope of his or her practice under State law and provided to an Enrollee by or
under the direction of a qualified occupational therapist. Necessary supplies
and equipment will be reviewed for medical necessity and follow the criteria of
the R414.12 rule.

 

Non-Traditional Medicaid:  Physical therapy and occupational therapy (in
combination) are limited to 10 visits per calendar year.

 

CO-PAYMENT

 

Non-Traditional Medicaid: $3.00 co-payment per visit. Limited to one co-payment
per date of service per provider. Counts toward total maximum co-payment and
co-insurance of $500.00 per Enrollee per calendar year.

 

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H.                                    Speech and Hearing Services

 

Services and appliances, including hearing aids and hearing aid batteries,
provided by a licensed medical professional to test and treat speech defects and
hearing loss are Covered Services.

 

Non-Traditional Medicaid Plan: Full coverage except hearing aids are limited to
congenital (birth defect) hearing losses only.

 

I.                                         Podiatry Services

 

Services provided by a licensed podiatrist are Covered Services.

 

Traditional Medicaid Plan: Full coverage is limited to children up to age 21 and
pregnant women. Limited podiatry benefits are covered for adults.

 

Non-Traditional Medicaid Plan:  Limited podiatry benefits are covered.

 

CO-PAYMENT

 

Traditional Medicaid:  Co-pay is $3.00 per visit. Limited to one co-payment per
date of service per provider. Annual calendar year maximum is $100.00 per
Enrollee for any combination of physician, podiatry, outpatient hospital,
freestanding emergency centers, and surgical centers. Co-payment required for
preventive services and immunizations.

 

Non-Traditional Medicaid: Co-payment is $3.00 per visit. Limited to one
co-payment per date of service per provider. Counts toward total maximum
co-payment and co-insurance of $500.00 per Enrollee per calendar year.

 

J.                                        End Stage Renal Disease - Dialysis

 

Treatment of end stage renal dialysis for kidney failure is a Covered Service.
Dialysis is to be rendered by a Medicare-certified Dialysis facility.

 

K.                                    Home Health Services

 

Home health services are defined as intermittent nursing care provided by
certified nursing professionals (registered nurses, licensed practical nurses,
and home health aides) in the client’s home when the client is homebound or
semi-homebound are Covered Services. Home health care must be rendered by a
Medicare-certified Home Health Agency. The CONTRACTOR agrees to comply with all
federal regulations regarding surety bonds. The CONTRACTOR agrees to contract
with only Medicare-certified Home Health Agencies who carry a surety bond if
federal regulations regarding this requirement are reinstated. The DEPARTMENT
agrees to notify the CONTRACTOR if such federal regulations are reinstated.

 

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Personal care services as defined in the DEPARTMENT’s Medicaid Personal Care
Provider Manual are included in this Contract. Personal care services may be
provided by a State licensed home health agency.

 

L.                                      Hospice Services

 

Services delivered to terminally ill patients (six months life expectancy) who
elect palliative versus aggressive care are Covered Services. Hospice care must
be rendered by a Medicare-certified hospice. When an Enrollee is receiving
hospice in a nursing facility, ICF/MR or freestanding hospice facility, the
CONTRACTOR is responsible for up to 30 days of hospice care.

 

M.                                  Private Duty Nursing

 

Services provided by licensed nurses for ventilator-dependent children and
technology-dependent adults in their home in lieu of hospitalization if
Medically Necessary, feasible, and safe to be provided in the patient’s home are
Covered Services. Requests for continuous care will be evaluated on a case by
case basis and must be approved by the CONTRACTOR.

 

Non-Traditional Medicaid Plan:  Private Duty Nursing is not a covered service.

 

N.                                    Medical Supplies and Medical Equipment

 

This Covered Service includes any necessary supplies and equipment used to
assist the Enrollee’s medical recovery, including both durable and non-durable
medical supplies and equipment, and prosthetic devices. The objective of the
medical supplies program is to provide supplies for maximum reduction of
physical disability and restore the Enrollee to his or her best functional
level. Medical supplies may include any necessary supplies and equipment
recommended by a physical or occupational therapist, but should be ordered by a
physician. Durable medical equipment (DME) includes, but is not limited to,
prosthetic devices and specialized wheelchairs. Durable medical equipment and
supplies must be provided by a DME supplier that has a surety bond. Necessary
supplies and equipment will be reviewed for medical necessity and follow the
criteria of the R414.12 of the Utah Administrative Code, with the exception of
criteria concerning long term care since long term care services are not covered
under the Contract.

 

Non-Traditional Medicaid Plan excludes blood pressure monitors, and replacement
of lost, damaged, or stolen durable medical equipment or prosthesis.

 

O.                                   Abortions and Sterilizations

 

These Covered Services are provided to the extent permitted by Federal and State
law and must meet the documentation requirement of 42 CFR 441, Subparts E and F.
These requirements must be met regardless of whether Medicaid is primary or
secondary payer.

 

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P.                                      Treatment for Substance Abuse and
Dependency

 

Treatment will cover medical detoxification for alcohol or substance abuse
conditions is a Covered Service. Medical services including hospital services
will be provided for the medical non-psychiatric aspects of the conditions of
alcohol/drug abuse.

 

Q.                                    Organ Transplants

 

The following transplantations are Covered Services for all Enrollees: kidney,
liver, cornea, bone marrow, stem cell, heart, intestine, lung, pancreas, small
bowel, combination heart/lung, combination intestine/liver, combination
kidney/pancreas, combination liver/kidney, multi visceral, and combination
liver/small bowel unless amended under the provisions of Attachment B, Article
IV (Benefits), Section C, Subsection 2 of this Contract.

 

Non-Traditional Medicaid Plan is limited to kidney, liver, cornea, bone marrow,
stem cell, heart, and lung transplantations.

 

R.                                    Other Outside Medical Services

 

The CONTRACTOR, at its discretion and without compromising quality of care, may
choose to provide services in Freestanding Emergency Centers, Surgical Centers
and Birthing Centers.

 

CO-PAYMENT

 

Traditional Medicaid: $2.00 co-payment per visit. Limited to one co-payment per
date of service per provider. Annual calendar year maximum is $100.00 per
Enrollee for any combination of physician, podiatry, outpatient hospital,
freestanding emergency centers, and surgical centers. (Co-payment does not apply
to birthing centers.)

 

Non-Traditional Medicaid: $3.00 co-payment per visit. Limited to one co-payment
per date of service per provider. Counts toward total maximum co-payment and
co-insurance of $500.00 per Enrollee per calendar year.

 

S.                                     Long Term Care

 

The CONTRACTOR may provide long term care for Enrollees in skilled nursing
facilities requiring such care as a continuum of a medical plan when the plan
includes a prognosis of recovery and discharge within thirty (30) days or less.
When the prognosis of an Enrollee indicates that long term care (over 30 days)
will be required, the CONTRACTOR will notify the DEPARTMENT and the skilled
nursing facility of the prognosis determination and will initiate disenrollment.
Skilled nursing care is to be rendered in a skilled nursing facility which meets
federal regulations of participation.

 

7

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T.                                     Services to CHEC Enrollees

 

1.                                      CHEC Services

 

The CONTRACTOR will provide to CHEC Enrollees preventive screening services and
other necessary medical care, diagnostic services, treatment, and other measures
necessary to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services, whether or not such services
are covered under the State Medicaid Plan. The CONTRACTOR is not responsible for
home and community-based services available through Utah’s Home and
Community-Based waiver programs.

 

The CONTRACTOR will provide the full early and periodic screening, diagnosis,
and treatment services to all eligible children and young adults up to age 21 in
accordance with the periodicity schedule as described in the Utah CHEC Provider
Manual. All children between six months and 72 months must be screened for blood
lead levels.

 

Non-Traditional Medicaid : CHEC services are not covered. Enrollees who are 19
or 20 years of age receive the adult scope of services.

 

2.                                      CHEC Policies and Procedures

 

The CONTRACTOR agrees to have written policies and procedures for conducting
tracking, follow-up, and outreach to ensure compliance with the CHEC periodicity
schedules. These policies and procedures will emphasize outreach and compliance
monitoring for children and young adults, taking into account the multi-lingual,
multi-cultural nature as well as other unique characteristics of the CHEC
Enrollees.

 

U.                                     Family Planning Services

 

These Covered Services includes disseminating information, counseling, and
treatments relating to family planning services. All services must be provided
by or authorized by a physician, certified nurse midwife, or nurse practitioner.
All services must be provided in concert with Utah law.

 

Birth control services include information and instructions related to the
following:

 

1.                                       Birth control pills;

2.                                       Norplant (removal only);

3.                                       Depo Provera;

4.                                       IUDs;

5.                                       Barrier methods including diaphragms,
male and female condoms, and cervical caps;

 

8

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6.                                       Vasectomy or tubal ligations;

7.                                       Nuvaring; and

8.                                       Office calls, examinations or
counseling related to contraceptive devices.

 

Non-Traditional Medicaid:  Norplant is not a covered service.

 

V.                                    High-Risk Prenatal Services

 

1.                                      In General - Ensure Services are
Appropriate and Coordinated

 

The CONTRACTOR must ensure that high risk pregnant Enrollees receive an
appropriate level of quality perinatal care that is coordinated, comprehensive,
preventive, and continuous either by direct service or referral to an
appropriate provider or facility. In the determination of the provider and
facility to which a high risk prenatal Enrollee will be referred, care must be
taken to ensure that the provider and facility both have the appropriate
training, expertise and capability to deliver the care needed by the Enrollee
and her fetus/infant. Although many complications in perinatal health cannot be
anticipated, most can be identified early in pregnancy. Ideally, preconceptional
counseling and planned pregnancy are the best ways to assure successful
pregnancy outcome, but this is often not possible. Provision of routine
preconceptional counseling must be made available to those women who have
conditions identified as impacting pregnancy outcome, i.e., diabetes mellitus,
medications which may result in fetal anomalies or poor pregnancy outcome, or
previous severe anomalous fetus/infant, among others.

 

2.                                      Risk Assessment

 

a.                                       General

 

Enrollees who are pregnant should be risk assessed at their first prenatal
visit, preferably in the first trimester, and later in pregnancy as low,
moderate or high risk for medical and psychosocial conditions which may
contribute to poor birth outcomes. Women found to not be moderate or high risk
should be evaluated for change in risk status throughout their pregnancy.

 

b.                                       Assessment tools

 

The CONTRACTOR must have a mechanism to assure that prenatal care providers
conduct risk assessments on all pregnant Enrollees on entry into prenatal care
and, as needed, on an ongoing basis to re-assess risk status throughout
pregnancy. Assessment tools used by prenatal care providers should be consistent
with standards of practice and linked to the CONTRACTOR’s care coordination/case
management programs for those Enrollees who have a moderate or high risk status.
All prenatal health care

 

9

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providers should be able to identify the full range of medical and psychosocial
risk factors and either provide appropriate care or initiate referrals to the
appropriate level of care/consultation throughout pregnancy.

 

The CONTRACTOR’s healthy pregnancy programs must also include assessment of risk
for all pregnant Enrollees as soon as a pregnancy is identified and as needed,
on an ongoing basis. The CONTRACTOR shall refer to and coordinate care with the
prenatal care providers concerning the treatment plan and risk factors. The
CONTRACTOR’s risk assessments shall be overseen by the CONTRACTOR’s Medical
Director.

 

Assessment tools used by prenatal care providers and the CONTRACTOR should
include a means of identifying prenatal risk factors based on medical and
psychosocial conditions that may contribute to poor birth outcomes and that will
assist the CONTRACTOR and prenatal care providers in determining the level and
intensity of care coordination/case management required to ensure the
appropriate level of perinatal care.

 

The DEPARTMENT recommends “Guidelines for Perinatal Care by American Academy of
Pediatrics, and American College of Obstetricians and Gynecologists” as a
resource for evaluating and classification of risk, the level of care and
consultation recommended based on risk status, and the level of care
coordination required. The DEPARTMENT recommends that Enrollees be identified
with a status of no risk, low risk, moderate risk, or high risk and that at a
minimum, Enrollees who are classified as moderate or high risk should receive
care coordination/case management services.

 

c.                                       Recommended Prenatal Screening

 

(1)                                 Hepatitis B surface antigen

 

The DEPARTMENT recommends routine prenatal screening of every woman for
hepatitis B surface antigen (HBsAg) early in prenatal care to identify all those
at high risk for transmitting the virus to their newborns and later in pregnancy
for women who tested negative for HbsAg during early pregnancy but who are at
high risk based on:

 

(a)                                  evidence of clinical hepatitis during
pregnancy;

(b)                                 injection drug use;

(c)                                  occurrence during pregnancy or a history of
STDs; or

(d)                                 judgement of the health care provider.

 

When a woman is found to be HBsAg-positive, the CONTRACTOR will provide HBIG and
HB vaccine at birth. Initial treatments should be given during the first 12
hours of life. The CONTRACTOR will comply with all other requirements as
specified in Utah Law R386-702-9.

 

10

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(2)                                 Sexually Transmitted Diseases (STDs)

 

The DEPARTMENT recommends prenatal screening including sexually transmitted
diseases such as gonorrhea, chlamydia, and standard serological testing for
syphilis as required by Utah Law 26-6-20. Testing for STDs should be repeated in
the 3rd trimester for Enrollees at high risk for exposure.

 

(3)                                 HIV testing

 

The DEPARTMENT also recommends testing of all pregnant Enrollees for HIV and
testing and treatment at labor and delivery for women who have not received
testing during pregnancy. The CONTRACTOR should encourage providers to develop
policies that are consistent with the American College of Obstetricians and
Gynecologists, including but not limited to:

 

(a)                                  universal testing with an opt-out approach
(testing of all pregnant women and not just those who appear to be at high risk
for HIV;

(b)                                 flexibility in the consent process; and

(c)                                  prevention and referral through education
during prenatal care.

 

Prenatal care providers should have a mechanism to document in medical records
when pregnant Enrollees are offered HIV tests and when tests are refused.
Pregnant Enrollees who refuse HIV testing earlier in pregnancy should be offered
HIV testing again later in pregnancy. Pregnant Enrollees who test positive
should receive treatment throughout their pregnancy and labor and delivery to
reduce the risk of HIV transmission to their newborns.

 

3.                                      Prenatal Initiative Program

 

Prenatal services provided directly or through agreements with appropriate
providers include those services covered under Medicaid’s Prenatal Initiative
Program which includes the following enhanced services for pregnant women:

 

a.                                       perinatal care coordination

b.                                      prenatal and postnatal home visits

c.                                       group prenatal and postnatal education

d.                                      nutritional assessment and counseling

e.                                       prenatal and postnatal psychosocial
counseling

 

Psychosocial counseling is a service designed to benefit the pregnant client by
helping her cope with the stress that may accompany her pregnancy. Enabling her
to manage this stress improves the likelihood that she will have a healthy
pregnancy. This counseling is intended to be short term and directly related to
the pregnancy. However, pregnant women who are also suffering from a serious
emotional or mental illness should be referred to an appropriate mental health
care

 

11

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provider.

 

W.                                Services for Children with Special Needs

 

1.                                      In General

 

In addition to primary care, children with chronic illnesses and disabilities
need specialized care provided by trained experienced professionals. Since early
diagnosis and intervention will prevent costly complications later on, the
specialized care must be provided in a timely manner. The specialized care must
comprehensively address all areas of need to be most effective and must be
coordinated with primary care and other services to be most efficient. The
children’s families must be involved in the planning and delivery of the care
for it to be acceptable and successful.

 

2.                                      Services Requiring Timely Access

 

All children with special health care needs must have timely access to the
following services:

 

a.                                       Comprehensive evaluation for the
condition.

b.                                      Pediatric subspecialty consultation and
care appropriate to the condition.

c.                                       Rehabilitative services provided by
professionals with pediatric training in areas such as physical therapy,
occupational therapy and speech therapy.

d.                                      Durable medical equipment appropriate
for the condition.

e.                                       Care coordination for linkage to early
intervention, special education and family support services and for tracking
progress.

 

In addition, children with the conditions marked by * below must have timely
access to coordinated multispecialty clinics, when Medically Necessary, for
their disorder.

 

12

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3.                                      Definition of Children with Special
Health Care Needs

 

The definition of children with special health needs includes, but is not
limited to, the following conditions:

 

a.

 

Nervous System Defects such as

 

 

Spina Bifida*

 

 

Sacral Agenesis*

 

 

Hydrocephalus

 

 

 

b.

 

Craniofacial Defects such as

 

 

Cleft Lip and Palate*

 

 

Treacher - Collins Syndrome

 

 

 

c.

 

Complex Skeletal Defects such as

 

 

Arthrogryposis*

 

 

Osteogenesis Imperfecta*

 

 

Phocomelia*

 

 

 

d.

 

Inborn Metabolic Disorders such as

 

 

Phenylketonuria*

 

 

Galactosemia*

 

 

 

e.

 

Neuromotor Disabilities such as

 

 

Cerebral palsy*

 

 

Muscular Dystrophy*

 

 

Complex Seizure Disorders

 

 

 

f.

 

Congenital Heart Defects

 

 

 

g.

 

Genetic Disorders such as

 

 

Chromosome Disorders

 

 

Genetic Disorders

 

 

 

h.

 

Chronic Illnesses such as

 

 

Cystic Fibrosis

 

 

Hemophilia

 

 

Rheumatoid Arthritis

 

 

Bronchopulmonary Dysplasia

 

 

Cancer

 

 

Diabetes

 

 

Nephritis

 

 

Immune Disorders

 

13

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i.                                          Developmental Disabilities with
multiple or global delays in development such as Down Syndrome or other
conditions associated with mental retardation.

 

The CONTRACTOR agrees to cover all Medically Necessary services for children
with special health care needs such as the ones listed above. The CONTRACTOR
further agrees to cooperate with the DEPARTMENT’s quality assurance monitoring
for this population by providing requested information.

 

X.                                    Medical and Surgical Services of a Dentist

 

1.                                      Who May Provide Services

 

Under Utah law, medical and surgical services of a dentist may be provided by
either a physician or a doctor of dental medicine or dental surgery.

 

2.                                      Universe of Covered Services

 

Medical and surgical services that under Utah law may be provided by a physician
or a doctor of dental medicine or dental surgery, are covered under the
Contract.

 

3.                                       Services Specifically Covered

 

The CONTRACTOR is responsible for palliative care and pain relief for severe
mouth or tooth pain in an emergency room. If the emergency room physician
determines that it is not an emergency and the client requires services at a
lesser level, the provider should refer the client to a dentist for treatment.
If the dental-related problem is serious enough for the client to be admitted to
the hospital, the CONTRACTOR is responsible for coverage of the inpatient
hospital stay. The CONTRACTOR is responsible for authorized/approved medical
services provided by oral surgeons consistent with injury, accident, or disease
(excluding dental decay and periodontal disease) including, but not limited to,
removal of tumors in the mouth, setting and wiring a fractured jaw. Also covered
are injuries to sound natural teeth and associated bone and tissue resulting
from accidents including services by dentists performed in facilities other than
the emergency room or hospital.

 

4.                                       Dental Services Not Covered

 

The CONTRACTOR is not responsible for routine dental services such as fillings,
extractions, treatment of abscess or infection, orthodontics, and pain relief
when provided by a dentist in the office or in an outpatient setting such as a
surgical center or scheduled same day surgery in a hospital including the
surgical facilities charges.

 

Y.                                     Diabetes Education

 

The CONTRACTOR shall provide diabetes self-management education from a Utah
certified or American Diabetes Association recognized program when an Enrollee:

 

14

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1.                                       has recently been diagnosed with
diabetes, or

 

2.                                       is determined by the health care
professional to have experienced a significant change in symptoms, progression
of the disease or health condition that warrants changes in the Enrollee’s
self-management plan, or

 

3.                                       is determined by the health care
professional to require re-education or refresher training.

 

Z.                                     HIV Prevention

 

The CONTRACTOR shall have in place the following:

 

1.                                      General Program

 

The CONTRACTOR must have educational methods for promoting HIV prevention to
Enrollees. HIV prevention information, both primary (targeted to uninfected
Enrollees), as well as secondary (targeted to those Enrollees with HIV) should
must be culturally and linguistically appropriate. All Enrollees should be
informed of the availability of both in-plan HIV counseling and testing
services, as well as those available from Utah State-operated programs.

 

2.                                      Focused Program for Women

 

Special attention should be paid identifying HIV+ women and engaging them in
routine care in order to promote treatment including, but not limited to,
antiretroviral therapy during pregnancy.

 

15

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SUMMARY OF CO-PAYMENT AND

CO-INSURANCE REQUIREMENTS

 

Pregnant women and children under age 18 are exempt from all co-payment and
co-insurance requirements. Services related to family planning are excluded from
all co-payment and co-insurance requirements.

 

Traditional Medicaid Plan

 

•                                          Inpatient hospital: Each Enrollee
must pay a $220.00 co-insurance for non-emergency inpatient hospital admissions.
The maximum co-payment per Enrollee per calendar year is $220.00 for
non-emergency inpatient hospital admissions.

 

•                                          Emergency Department: Each enrollee
must pay a $6.00 co-payment for non-emergency use of the emergency room.

 

•                                          Physician, osteopath, podiatrist,
outpatient hospital, freestanding emergency centers, and surgical centers: Each
Enrollee must pay a $3.00 co-payment per provider per day. The maximum
co-payment per Enrollee per calendar year is $100.00 for any combination of the
services provided by the above providers.

 

•                                          Prescription Drugs: Each Enrollee
must pay a co-payment of $3.00 per prescription. The maximum co-payment is
$15.00 per Enrollee per month.*

 

There is no overall out-of-pocket maximum for the above services.

 

Non-Traditional Medicaid Plan

 

•                                          Inpatient hospital:  Each Enrollee
must pay a $220.00 co-insurance for each non-emergency inpatient hospital
admissions.

 

•                                          Emergency Department: Each enrollee
must pay a $6.00 co-payment for non-emergency use of the emergency room.

 

•                                          Physician, osteopath, podiatrist,
physical therapist, occupational therapist, chiropractor*, freestanding
emergency centers, surgical centers: Each Enrollee must pay a $3.00 co-payment
per provider per day.

 

•                                          Prescription Drugs: Each Enrollee
must pay a co-payment of $2.00 per prescription.*

 

The out-of-pocket maximum for each Enrollee is $500.00 for any combination of
the above co-payments and co-insurance.

 

--------------------------------------------------------------------------------

*Pharmacy services and chiropractic services are not the responsibility of the
CONTRACTOR.

 

16

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Utah’s Quality Assessment and Performance Improvement Plan

(Utah “QAPIP”)

 

For Contracted Medicaid Health Plans

 

Attachment D: Program Description

 

[g100171ki09i001.jpg]

 

State of Utah

Department of Health

Division of Health Care Financing

Bureau of Managed Health Care

 

August 13, 2003

 

 

[g100171ki09i002.gif]

 

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Table of Contents

 

 

 

Page

 

 

 

 

 

I. Utah Quality Assessment and Performance Improvement Plan (UQAPIP), Executive
Summary

 

3

 

 

 

 

 

II. Utah Quality Assessment and Performance Improvement Plan (UQAPIP), Program
Description

 

4

 

 

 

 

 

A. Overview

 

4

 

B. Purpose

 

4

 

C. Objectives

 

4

 

D. Quality Assessment and Performance Improvement (QAPI) Strategy

 

5

 

 

 

 

 

 1. Health Plan Compliance Reviews

 

5

 

a. CMS Reporting

 

7

 

b. Documentation Requirements and Time Lines

 

7

 

c. Deeming

 

7

 

d. Corrective Actions and Sanctions

 

8

 

 

 

 

 

 2. Internal Surveillance and Tracking (analysis of internal MMCS and Data
Warehouse data)

 

8

 

 

 

 

 

 3. External Quality Reviews (EQR’s)

 

8

 

 

 

 

 

a. Mandatory EQR activities include

 

8

 

b. Optional activities include

 

9

 

 

 

 

 

 4. ANNUAL PROGRAM EVALUATION PAGE

 

9

 

 

 

 

 

III. TABLE OF APPENDICES

 

10

 

 

 

 

 

IV. REFERENCES

 

11

 

 

2

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I. Utah Quality Assessment and Performance Improvement Monitoring Plan (QAPIP)
Executive Summary:

 

The Utah Department of Health (DOH), Division of Health Care Financing (DHCF),
Bureau of Managed Health Care (BMHC) by authority of 42 CFR, Part 438, Subparts
C, D, E, F, H (438.602, 438.608, 438.610), and Subpart I (438.700) has oversight
responsibility of contracted Medicaid health plans to ensure the delivery of
quality health care and compliance with state and federal regulations.

 

The BMHC oversight methodology consists of activities to collect and analyze
data from on-site reviews, required reports, and other internal and external
data sources. This information is used to determine compliance with state
Medicaid requirements; federal regulations pertaining to managed care entities;
to identify opportunities for improvement and areas of non-compliance. When BMHC
identifies non-compliance and areas where improvement is needed, BMHC makes
recommendations and requires corrective action plans (CAP’s). Health plans are
required to submit CAP’s according to specified timeframes; BMHC reviews what is
submitted and either accepts or requests a revised CAP. Health plans can request
extensions to the required CAP timeframes or appeal the BMHC’s findings. Once
the health plan submits an acceptable action plan, the BMHC provides adequate
opportunity for the plan to implement corrections and improvements. Follow up
activities are conducted thereafter to assess progress toward compliance and
address areas for continuous improvement.

 

The BMHC uses information from quality monitoring activities to assess the
effectiveness of its monitoring program, implement improvements to its oversight
processes, update health plan compliance requirements and develop work plans for
subsequent years. The BMHC reports to Centers for Medicare and Medicaid Services
(CMS) as required concerning results of quality monitoring activities and
program evaluations.

 

3

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II. Utah Quality Assessment and Performance Improvement Monitoring Plan (QAPIP)
Program Description

 

A. Overview:

 

The Utah Department of Health (DOH), Division of Health Care Financing (DHCF),
Bureau of Managed Health Care (BMHC) by authority of 42 CFR, Part 438, Subparts
C, D, E, F, H (438.602, 438.608, 438.610), and Subpart I (438.700) has oversight
responsibility of contracted Medicaid health plans to ensure the delivery of
quality health care and compliance with state and federal regulations.

 

The UTAH QAPIP encompasses oversight of regulations pertaining to Managed Care
Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs) and Primary Care
Case Management (PCCM) entities.

 

B. Purpose:

 

The purpose of the Utah Quality Assessment and Performance Improvement Plan is
to ensure that the Medicaid health plans provide quality health care to Medicaid
enrollees, to provide a mechanism to ensure continuous improvement in the care
and services provided and assess compliance to state and federal regulations
required for managed care entities.

 

C. Objectives:

 

•                  To establish a monitoring plan that uses experts outside of
the BMHC to promote interagency cooperation and support other state DOH
programs.

•                  To establish a monitoring plan which includes deeming
provisions, in order to minimize duplication and redundancy of comparable
monitoring content for organizations that have received accreditation by a
nationally recognized accreditation body.

•                  To assess the quality, availability and access to,
coordination of, and appropriateness of care and services provided to Medicaid
enrollees (including those with special health care needs) under MCO, PIHP and
PCCM contracts.

•                  To assure care and services are provided in a culturally
competent manner, which respects the rights of enrollees, including those with
disabilities.

•                  To assess compliance through regular monitoring in a way that
promotes collaboration and continuous quality improvement.

•                  To ensure adherence to contract requirements, state and
federal regulations applicable to the types of health plans contracted with
Medicaid.

•                  To assure appropriate adherence to privacy and
confidentiality rules in the provision of care and services.

•                  To assure the organizations structure, operations and
information systems support adherence to the Utah QAPIP, program oversight needs
and meet federal and state regulations.

•                  To assure that data and documentation necessary for quality
oversight is accurate and complete.

 

4

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D. Quality Assessment and Performance Improvement (QAPI) Strategy:

 

The BMHC’s methods of oversight of contracted Medicaid health plans involve an
integrated approach using information derived from the following four
activities. These include:

 

1. Health Plan Compliance Reviews

2.              Internal Surveillance and Tracking (analysis of internal data)

3.              External Quality Review (EQR)

4.              Annual Program Review

 

1. Health Plan Compliance Reviews

 

The BMHC conducts periodic reviews of contracted MCOs, PIHPs and PCCMs to
monitor contract compliance and compliance to state and federal regulations
applicable to these types of health plan entities. Reviews are done using the
Utah Quality Assessment and Performance Improvement Plan (QAPIP), which is a
comprehensive set of compliance Standards based on quality improvement, contract
monitoring, and regulatory oversight needs. Most of the compliance Standards in
the QAPIP is applicable to MCO and PIHP health plan entities. Oversight of PCCM
contracts and compliance with state and federal regulations is also accomplished
through the UTAH QAPIP; although, much fewer of the compliance Standards are
applicable to PCCM entities.

 

The BMHC’s conducts periodic comprehensive quality monitoring reviews (CQMRs)
using the UTAH QAPIP compliance Standards. Frequency of CQMRs is determined by
the level of compliance demonstrated during the on-reviews, internal
surveillance and monitoring (number 2, described below), the amount of
structural or operational changes made following reviews or based on other
oversight needs. For all MCO or PIHP entities CQMR’s will occur at least every
threes years and more frequently when necessary. Annually, follow-up reviews
will be done to assess progress toward recommended improvements and CAPs. The
BMHC may also conduct a focused review of a particular area(s); these are
Follow-up/ Focused Quality Monitoring Review’s (FQMR’s).

 

CQMRs consist of review of all UTAH QAPIP pertaining to the type of entity being
reviewed and all applicable data sources for each area. The UTAH QAPIP
delineates compliance areas that require detailed program narratives, any
mandatory data sources needed to assess compliance, authority for particular
areas of compliance, applicability of deeming status for entities who have
received national accreditation, and DOH staff resources that may be used to
assess each compliance area. Documentation requirements for annual monitoring
will be tailored to the level of compliance from the most recent CQMR, analysis
from internal surveillance, and other monitoring needed relating to quality,
access to care and appropriateness of care and services, etc.

 

CQMRs for MCOs or PIHPs will occur “on-site” at the organization’s local
office(s). On-site reviews will consist of reviewing documentation, interviewing
staff and conducting an exit conferencing, which outlines the organization’s
strengths and weaknesses. The BMHC may use on-site review, in-person meetings or
teleconferencing to conduct

 

5

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FQMRs. For PCCMs, an assessment of compliance to applicable regulations may be
conducted less formally (telephone conference following review of applicable
documentation) and therefore not require an on-site review. The BMHC’s Quality
Monitoring Unit staff and other DOH consultants will participate in review
activities. The BMHC uses consultants from the Division of Community and Family
Health Services, the Office of Health Care Statistics and other DHCF staff to
conduct reviews.

 

Following each review, the BMHC will compile a report addressing the level of
compliance to applicable Utah QAPIP Standards for the type of entity being
reviewed. This report will detail findings, recommendations for improvements and
general comments. Written corrective action plans (CAPs) for any areas of
non-compliance will be required as necessary. The BMHC will conduct follow-up
reviews annually that will assess the plan’s progress toward CAPs, other
recommended improvements and monitoring related to reviews and any reports
required by the contract relating to quality, access to care and appropriateness
of care and services since the last review. Depending on the level of
compliance, BMHC may elect to repeat CQMR as often as necessary or conduct a
partial/focused review annually until the required level of compliance is
achieved. Quarterly progress reports (verbal or written) may be required
depending on the level of non-compliance determined from CQMR or FQMRs.

 

The BMHC will regularly monitor areas requiring annual oversight (see compliance
Standards for “crosswalk” of annual monitoring areas). Attestation statements
may be permitted to satisfy part(s) of the QAPIP compliance areas after a
sufficient level of performance is demonstrated through CQMR’s. Attestation
statements are permitted only for areas that have not changed or have changed
minimally since the last review. The BMHC will determine if the attestations are
acceptable on a case-by-case basis. These will permit the health plan to not
have to provide full program narratives for areas that have not changed since
the last review or have changed minimally. The BMHC will determine if
attestations are acceptable on a case-by-case basis.

 

Annually, Medicaid MCOs and PIHPs are required to produce a Work Plan (WP) each
new calendar year detailing all quality assessment and performance improvement
(QAPI) activities; including activities related to recommended improvements from
reviews/CAPs, the organization’s clinical and non clinical performance
improvement projects/studies, specific program activities, projects related to
priority population groups, federal or state requirements, etc. Additionally, on
completion of each calendar year the health plans are required to conduct a
comprehensive program evaluation, called a Work Plan Evaluation (WPE), to
determine the effectiveness of interventions in each area of the WP. The WPE is
expected to be part of the process used to develop the WP for each new year and
update the organizations overall Quality Improvement Program Description (QIPD),
if necessary.

 

The BMHC on an ongoing basis will provide input on WP, WPE and annually updated
QIPD’s as part of annual monitoring activities or reviews for MCOs and PIHPs.
PCCMs are not required to submit these documents since they are outside the
scope of their regulations; however, may be required to submit other annual
reports related to applicable regulations or compliance areas.

 

6

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a. Center for Medicare and Medicaid Services (CMS) Reporting:

 

In accordance with 42 CFR, part 438, 438.202, the BMHC will submit to CMS any
required repots relating to BMHC’s UAPIP/quality improvement (QI) strategy,
reports on the implementation and effectiveness of the QAPIP/QI strategy and of
updates whenever substantial changes to the UAPIP/QI strategy are made.
Additionally, CMS may require the BMHC to submit reports of findings from
compliance reviews and EQR’s.

 

b. Documentation Requirements and Timelines:

 

Each health plan will be required to submit documentation that specifically
addresses all compliance Standards in the QAPIP prior to a CQMR and FQMR. This
documentation is required to be organized and categorized in accordance with the
sequencing of each domain and Standard within the Utah QAPIP. Process narratives
(a description of the compliance area and how compliance is achieved) are
mandatory for specific areas in which exhibits alone are insufficient to
determine how the plan operates in the given area (see “crosswalk” section of
compliance Standards).

 

Prior to an audit, the health plan may be required to submit pre-review
documentation as early as 60 days before a CQMR or FQMR. All documentation is
required to be available during the entire time of an on-site review.
Organization’s being reviewed are required to provide suitable, private
workspace; i.e., private conference room with a phone, for the number of staff
participating and make appropriate plan staff available to assist in finding
necessary information during documentation review sessions or for answering
questions. Prior to a CQMR or FQMR an agenda will be developed including time
frames for reviewing documentation, interviews, post interview team consultation
and an exit conference.

 

Following a CQMR or FQMR the BMHC will complete a compliance report within 60
calendar days of the date of the exit conference. The health plans, if
necessary, will be required to submit a written plan of correction within 45
calendar days of the receipt of the compliance report or submit an appeal of the
BMHC’s findings. If an extension is required the organization may request, in
writing, an extension to the due date for the CAP and the timeframes will be
adjusted as appropriate. The BMHC will provide written approval as to the
acceptance of the CAP within 30 calendar days of BMHC’s receipt of the CAP.
Within 30 calendar days of the receipt of the CAP the BMHC will provide written
approval or request revisions, if not accepted.

 

c. Deeming:

 

The BMHC has incorporated deeming provisions in the UTAH QAPIP for areas
applicable to MCOs and PIHPs. Accreditation by a nationally recognized
accreditation agency that is also recognized by the State will be accepted to
fulfill some compliance requirements. Examples of nationally recognized
accreditation agencies include National Committee for Quality Assurance (NCQA),
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and
Utilization Review and Accreditation Commission (URAC), also known as American
Accreditation HealthCare Commission. The organization must provide written
verification of accreditation in areas where deeming may be applicable. The BMHC
will determine areas applicable for deeming based on comparability and level of
accreditation achieved.

 

7

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d. Corrective Actions and Sanctions:

 

Corrective actions may be required to be submitted relating to quality
monitoring activities if the BMHC determines the contracted Medicaid
organization has not provided services in accordance with the contract or within
expected professional standards. The BMHC will request in writing that the
health plan correct deficiencies or identified problems through a corrective
action plan (CAP). The contracted Medicaid health plan agrees with all
applicable procedures and time frames set forth in the contract regarding
compliance with CAP’s. However, CAP’s which are the result of non compliance
findings with the Utah QAPIP, following reviews, longer time frames are granted
for submitting initial CAP’s and subsequent requests for revision to CAP’s,
until final acceptance. Additionally, longer time frames may be granted prior to
implementing sanctions. Areas of non compliance related to contract requirements
or the UQAMP, which are deemed more critical or urgent, may be subject to time
frames associated with requests for CAP’s as set forth in the contract. The BMHC
will follow do-process procedures as outlined in the contract with regard to
requests for CAP’s, requests for extensions of CAP’s, allowing opportunity to
appeal findings, considering explanations of disagreement and in issuing hearing
rights.

 

2.                  Internal Surveillance and Tracking (analysis of internal
MMCS and Data Warehouse data)

 

Additionally, as a mechanism of quality oversight the BMHC will monitor and
analyze other available internal data. These include internal MMCS data;
information available through the state’s Data Warehouse or reported encounter
data. When possible and appropriate this information will be integrated into
compliance reviews in order to address areas where further study or improvement
may be needed or when additional information is needed.

 

3.                  External Quality Reviews (EQR’s):

 

The BMHC uses an External Quality Review Organization (EQRO) to conduct an
annual, external assessment of outcomes related to quality, access to and
timeliness of care for services covered in MCO and PIHPs contracts (42 CFR Part
438, Subpart E, 438.320). External review includes mandatory and optional
activities.

 

Mandatory EQR activities include using information from the following
activities:

 

1.               Validation of performance improvement projects as noted in
438.240(b)(1), validation of performance measures required by the state in
accordance with 438.240(b)(2), and

2.               To conduct a review within the previous 3 year period to
determine MCO’s or PIHP’s compliance with standards related to access to care,
structure and operations, and quality measurement [(438.204(g)].

 

8

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Optional activities include using information derived from the previous 12
months from the following activities:

 

1.               Validation of encounter data reported by an MCO or PIHP,

2.               Administration or validation of consumer or provider surveys of
quality of care,

3.               Calculation of performance measures in addition to those
reported by an MCO or PIHP and validation

4.               Conducting performance improvement projects in addition to
those conducted by an MCO or PIHP.

 

The BMHC assures that EQROs meet the qualifications to perform external quality
reviews (EQRs) as set forth in 42 CFR, Part 438, Subpart E, 438.354 (competence
and independence). The state, its agent or the EQRO may perform the mandatory
and optional EQR-related activities [42 CFR, Part 438, Subpart E, 438.358(a)].

 

The BMHC will assure that the date collection methods and tools used by the EQRO
are consistent with the Medicaid managed care provisions of the Balanced Budget
Act (BBA) and the compliance requirements outlined in the Utah QAPIP, which were
developed to assess compliance in accordance with the BBA.

 

The EQRO will submit reports in accordance with requirements in 438.364. The
BMHC will make available upon request information obtained from the technical
report supplied by the EQRO to interested parties, such as participating health
care providers, enrollees and potential enrollees of the MCO or PIHP, recipient
advocacy groups and general public. This information will be supplied in
alternative formats for persons with sensory impairments, when requested.

 

The EQRO contract may be amended as necessary in order to accommodate review
activities. Study subjects will be determined collaboratively by DHCF, BMHC,
EQRO and health plan staff.

 

4. ANNUAL PROGRAM EVALUATION

 

Annually, the BMHC will develop a Work Plan, which outlines the planned review
activity (CQMR or follow up reviews), EQR activity and activities related to
available systems data (MMCS/DW, grievance/appeals, hearings, exemptions,
reporting, etc.,). At the end of each calendar a Work Plan Evaluation will be
completed. The Work Plan Evaluation will be used to develop the Work Plan for
each new year and schedule monitoring reviews. At least every 3 years the BMHC
will perform a more comprehensive evaluation, which will be used to make program
improvements. The BMHC will submit to CMS any required reports relating to the
states quality improvement program.

 

9

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III. TABLE OF APPENDICES

 

Tab Heading

 

Content

 

 

 

Utah’s QAPIP

 

Utah’s Quality Assessment and Performance Improvement Monitoring Plan (Program
Description Document)

 

 

 

Table of Appendices

 

Listing of all appendices to Attachment G, Utah’s QAPIP

 

 

 

Appendix A
Flow Chart

 

Utah QAPIP Flow Chart

 

 

 

Appendix B
Crosswalk

 

(B1) Utah’s QAPIP Compliance Standards Crosswalk (DRAFT)
(B2) Federal Register

 

 

 

Appendix C
Definitions

 

Definitions

 

 

 

Appendix D
Scoring

 

Weighting and Scoring (to be developed)

 

 

 

Appendix E
Attestation

 

Attestation Template (to be developed)

 

 

 

Appendix F
Data Collection

 

Review Data Collection Tools

 

 

 

Appendix G
WP Format

 

Work Plan Format (required)

 

 

 

Appendix H
WPE Format

 

Work Plan Format (required)

 

 

 

Appendix I
PI Topics

 

(I1) Example Clinical and Non-Clinical Areas for Study
(I2) Example Performance Improvement (PI) Project Description

 

 

 

Appendix J
CM Report

 

Example Case Management Report

 

 

 

Appendix K
ACOG Record

 

Example Risk Assessment Information: ACOG Antepartum Record© (by permission of
Donna Weber, ACOG Marketing,  Inventory and Distribution Manager, July 1, 2003)

 

 

 

Appendix L

 

Example CHEC Audit Report

 

 

 

Appendix M

 

(M1) Example Grievance, Appeal, Action and Notice of Action Requirements
(M2) Example Grievance Tracking
(M3) Flow Charts for Grievances, Appeals, Actions, Notices of Action,
Continuation of Benefits and State Fair          Hearing Procedures

 

 

 

Appendix N

 

Example Newsletter Topic Tracking Grid

 

 

 

Appendix O

 

Priority Matrix

 

 

 

Appendix P

 

Member Handbook Checklist (DRAFT)

 

10

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IV. References

 

1.

 

Federal Register, Volume 67, No. 115, Friday, June 14, 2002, 42 CFR, Part 438,
Managed Care.

2.

 

Utah Quality Assessment and Performance Improvement Plan (QAPIP) (Attachment G
of contracts).

3.

 

Quality Improvement System for Managed Care (QISMC), www.cms.hhs.gov/cop/2d.asp

4.

 

Case Management Society of America (CMSA) Standards of Practice, (2003).

5.

 

Aspen Publications, Inc. 1185 Avenue of the Americas, New York, NY 10036
(medical case management, forms, checklists, & guidelines), (1997),
www.aspenpublishers.com

6.

 

United States Department of Human Services, National Standards for Culturally
and Linguistically Appropriate Standards (CLAS),
Http://www.omhrc.gov/omh/programs/2pgprograms/finalreport.pdf

7.

 

Siefker, Garrett, Van Genderen, Weis: Guidelines for Practicing Case Managers;
Fundamentals of Case Management (1998).

8.

 

Powell, Suzanne K., A Practical Guide to Success in Managed Care, Case
Management (2000).

9.

 

Case Management Inc.,10530 Paces Ave. Suite 1511Matthews, NC 28105-2714Tel.
704.847.1195 management@casemanagement.com

10.

 

Melamed, Dennis, Brittin, Alexander, URAC, The HIPAA Handbook: What You
Organization Should Know About The Federal Privacy Standards (2001).

11.

 

Melamed, Dennis, Brittin, Alexander, URAC, The HIPAA Handbook: What You
Organization Should Know About The Federal Electronic Transaction Standards
(2002).

12.

 

Melamed, Dennis, Brittin, Alexander, URAC, The HIPAA Handbook: What You
Organization Should Know About The Federal Security Standards (2002).

13.

 

National Association for Healthcare Quality, Guide to Quality Management, Eighth
Edition (1998).

14.

 

American Accreditation Healthcare Commission/URAC, Health Plan Standards,
Version 3.2 (2003).

15.

 

American Accreditation Healthcare Commission/URAC, Health Network Standards &
Interpretive Guide, version 3.2 (2003).

16.

 

National Committee for Quality Assurance (NCQA), Standards and Guidelines for
the Accreditation of MCOs (2003).

17.

 

National Committee for Quality Assurance (NCQA), Data Collection Tools (2003).

18.

 

Joint Commission on Accreditation of Healthcare Organizations, 2003-2004
Comprehensive Accreditation Manual for Health Care Networks (2003)

19.

 

The Team Handbook, How to Use Teams to Improve Quality, Peter R. Scholtes,
(1988).

20.

 

United Health Care, The Language of Managed Health Care, the Managed Health Care
Resource (1994).

21.

 

Houghton Mifflin Company, Webster’s II, New College Dictionary, (1995).

22.

 

AMSO.com, American Medical Specialty Organization, Inc. Definition of Terms,
2003.

23.

 

The Managed Care Group, Managed Care Resources, Inc., MCR Canada, Managed Care
Options, LLC, Managed Care Terms and Definitions,
http://www.managedcaregroup.com/mcrdef.htm (2003).

24.

 

Center for Health Services Research and Policy, The George Washington
University2021 K Street, W, Suite 800Washington, DC 20006,
http://www.gwu.edu/~chsrp .

25.

 

The U.S. Department of Health and Human Services, 200 Independence Avenue, S. W.
Washington, D.C. 20201, http://www.hhs.gov/ContactUs.html.

26.

 

http://www.nlm.nih.gov/, U.S. National Library of Medicine, 8600 Rockville Pike,
Bethesda, MD 20894.

27.

 

http://www.access.gpo.gov/aboutgpo/index., Keepinfg America Informed, United
States Government Printing Office.

28.

 

http://www.chcs.org/contact/contact.html, Center For Health Care Strategies.

 

11

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Attachment E

Healthy U

 

MEDICAL SERVICES REVENUE AND COST DEFINITIONS FOR TABLE 2

 

REVENUES (Report all revenues received or receivable at the end-of-period date
on the form)

 

1.                                       Premiums

 

Report premium payments received or receivable from the DEPARTMENT.

 

2.                                       Delivery Fees

 

Report the delivery fee received or receivable from the DEPARTMENT.

 

3.                                       Reinsurance

 

Report the reinsurance payments received or receivable from a reinsurance
carrier other than the DEPARTMENT.

 

4.                                       Stop Loss

 

Report stop loss payments received or receivable from the DEPARTMENT.

 

5.                                       TPL Collections - Medicare

 

Report all third party collections received from Medicare.

 

6.                                       TPL Collections - Other

 

Report all third party collections received other than Medicare collections.
(Report TPL savings because of cost avoidance as a memo amount on line 48).

 

7.                                       Other (specify)

 

8.                                       Other (specify)

 

For lines seven and eight:  Report all other revenue not included in lines one
through six. (There may not be any amount to report; however, this line can be
used to report revenue from total Utah operations that do not fit lines one
through six.)

 

9.                                       TOTAL REVENUES

 

Total lines one through eight.

 

NOTE: Duplicate premiums are not considered a cost or revenue as they are
collected by the CONTRACTOR and paid to the DEPARTMENT. Therefore, the payment
to the DEPARTMENT would reduce or offset the revenue recorded when the duplicate
premium was received. However, line 49 has been established for reporting
duplicate premiums as a memo amount.

 

4

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MEDICAL COSTS:  Report all costs accrued as of the ending date on the form. In
the first data column (column 3), report all costs for Utah operations per the
general ledger. In the 15 Medicaid data columns (columns 4 through 18), report
only costs for Medicaid Enrollees.

 

10.                                 Inpatient Hospital Services

 

Costs incurred in providing inpatient hospital services to Enrollees confined to
a hospital.

 

11.                                 Outpatient Hospital Services

 

Costs incurred in providing outpatient hospital services to Enrollees, not
including services provided in the emergency department.

 

12.                                 Emergency Department Services

 

Costs incurred in providing outpatient hospital emergency room services to
Enrollees.

 

13.                                 Primary Care Physician Services (Including
EPSDT Services, Prenatal Care, and Family Planning Services)

 

All costs incurred for Enrollees as a result of providing primary care
physician, osteopath, physician assistant, nurse practitioner, and nurse midwife
services, including payroll expenses, any capitation and/or contract payments,
fee-for-service payments, fringe benefits, travel and office supplies.

 

14.                                 Specialty Care Physician Services (Including
EPSDT Services, Prenatal Care, and Family Planning Services)

 

All costs incurred as a result of providing specialty care physician, osteopath,
physician assistant, nurse practitioner, and nurse midwife services to
Enrollees, including payroll expenses, any capitation and/or contract payments,
fee-for-service payments, fringe benefits, travel and office supplies.

 

15.                                 Adult Screening Services

 

Expenses associated with providing screening services to Enrollees.

 

16.                                 Vision Care - Optometric Services

 

Included are payroll costs, any capitation and/or contract payments, and
fee-for-service payments for services and procedures performed by an optometrist
and other non-payroll expenses directly related to providing optometric services
for Enrollees.

 

17.                                 Vision Care - Optical Services

 

Included are payroll costs, any capitation and/or contract payments and
fee-for-service payments for services and procedures performed by an optician
and other supportive staff, cost of eyeglass frames and lenses and other
non-payroll expenses directly related to providing optical services for
Enrollees.

 

18.                                 Laboratory (Pathology) Services

 

Costs incurred as a result of providing pathological tests or services to
Enrollees including payroll expenses, any capitation and/or contract payments,
fee-for-service payments and other expenses directly related to in-house
laboratory services. Excluded are costs associated with a hospital visit.

 

5

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19.                                 Radiology Services

 

Cost incurred in providing x-ray services to Enrollees, including x-ray payroll
expenses, any capitation and/or contract payments, fee-for-service payments, and
occupancy overhead costs. Excluded are costs associated with a hospital visit.

 

20.                                 Physical and Occupational Therapy

 

Included are payroll costs, any capitation and/or contract payments,
fee-for-service costs, and other non-payroll expenditures directly related to
providing physical and occupational therapy services.

 

21.                                 Speech and Hearing Services

 

Payroll costs, any capitation and/or contract payments, fee-for-service
payments, and non-payroll costs directly related to providing speech and hearing
services for Enrollees.

 

22.                                 Podiatry Services

 

Salary expenses or outside claims, capitation and/or contract payments,
fee-for-service payments, and non-payroll costs directly related to providing
services rendered by a podiatrist to Enrollees.

 

23.                                 End Stage Renal Disease (ESRD) Services -
Dialysis

 

Costs incurred in providing renal dialysis (ESRD) services to Enrollees.

 

24.                                 Home Health Services

 

Included are payroll costs, any capitation and/or contract payments,
fee-for-service payments, and other non-payroll expenses directly related to
providing home health services for Enrollees.

 

25.                                 Hospice Services

 

Expenses related to hospice care for Enrollees including home care, general
inpatient care for Enrollees suffering terminal illness and inpatient respite
care for caregivers of Enrollees suffering terminal illness.

 

26.                                 Private Duty Nursing

 

Expenses associated with private duty nursing for Enrollees.

 

27.                                 Medical Supplies and Medical Equipment

 

This cost center contains fee-for-service cost for outside acquisition of
medical requisites, special appliances as prescribed by the CONTRACTOR to
Enrollees.

 

28.                                 Abortions

 

Medical and hospital costs incurred in providing abortions for Enrollees.

 

29.                                 Sterilizations

 

Medical and hospital costs incurred in providing sterilizations for Enrollees.

 

6

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30.                                 Detoxification

 

Medical and hospital costs incurred in providing treatment for substance abuse
and dependency (detoxification) for Enrollees.

 

31.                                 Organ Transplants

 

Medical and hospital costs incurred in providing transplants for Enrollees.

 

32.                                 Other Outside Medical Services

 

The costs for specialized testing and outpatient surgical centers for Enrollees
ordered by the CONTRACTOR.

 

33.                                 Long Term Care

 

Costs incurred in providing long-term care for Enrollees required under
Attachment C.

 

34.                                 Transportation Services

 

Costs incurred in providing ambulance (ground and air) services for Enrollees.

 

35.                                 Accrued Costs

 

Costs Incurred for services rendered to Enrollees but not yet billed.

 

36/37                    Other

 

Report costs not otherwise reported.

 

38.                                 TOTAL MEDICAL COSTS

 

Total lines10 through 37.

 

ADMINISTRATIVE COSTS

 

Report payroll costs, any capitation and/or contract payments, non-payroll costs
and occupancy overhead costs for accounting services, claims processing
services, health plan services, data processing services, purchasing, personnel,
Medicaid marketing and regional administration.

 

Report the administration cost under four categories - advertising, home office
indirect cost allocation, utilization and all other administrative costs. If
there are no advertising costs or indirect home office cost allocations, report
a zero amount in the applicable lines.

 

39.                                 Administration - Advertising

 

40.                                 Home Office Indirect Cost Allocations

 

41.                                 Utilization

 

Payroll cost and any capitation and/or contract payments for utilization staff
and other non-payroll costs directly associated with controlling and monitoring
outside physician referral and hospital admission and discharges of Enrollees.

 

7

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42.                                 Administration - Other

 

43.                                 TOTAL ADMINISTRATIVE COSTS

 

Total lines 39 through 42.

 

44.                                 TOTAL COSTS (Medical and Administrative)

 

Total lines 38 and 43.

 

45.                                 NET INCOME (Gain or Loss)

 

Line 9 minus line 44.

 

46.                                 ENROLLEE MONTHS

 

Total Enrollee months for period of time being reported.

 

47.                                 MEDICAL COSTS PER ENROLLEE MONTH

 

Line 38 divided by line 46.

 

48.                                 ADMINISTRATIVE COSTS PER ENROLLEE MONTH

 

Line 43 divided by line 46.

 

49.                                 TOTAL COSTS PER ENROLLEE MONTH

 

Line 44 divided by line 46.

 

OTHER DATA

 

50.                                 TPL Savings - Cost Avoidance

 

51.                                 Duplicate Premiums

 

Include all premiums received for Enrollees from all sources other than
Medicaid.

 

52.                                 Number of Deliveries

 

Total number of Enrollee deliveries when the delivery occurred at 24 weeks or
later.

 

53.                                 Family Planning Services

 

Include costs associated with family planning services as defined in Attachment
C (Covered Services, Section V, Family Planning Services).

 

54.                                 Reinsurance Premiums Received

 

Include the reinsurance premiums received or receivable that are not counted as
revenue.

 

8

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55.                                 Reinsurance Premiums Paid

 

Include reinsurance premiums paid to a reinsurance carrier other than the
DEPARTMENT.

 

56.                                 Administrative Revenue Retained by the
CONTRACTOR

 

Include the administrative revenue retained by the CONTRACTOR from the
reinsurance premiums received or receivable.

 

9

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MEDICAL SERVICES UTILIZATION DEFINITIONS FOR TABLE 3

 

MEDICAL SERVICES

 

1.                                       Hospital Services - General Days

 

Record total number of inpatient hospital days associated with inpatient medical
care.

 

2.                                       Hospital Services - Discharges

 

Record total number of inpatient hospital discharges.

 

3.                                       Hospital Services - Outpatient Visits

 

Record total number of outpatient visits.

 

4.                                       Emergency Department Visits

 

Record total number of emergency room visits.

 

5.                                       Primary Care Physician Services

 

Number of services and procedures defined by CPT-4 codes provided by primary
care physicians or licensed physician extenders or assistants under direct
supervision of a physician inclusive of all services except radiology,
laboratory and injections/ immunizations which should be reported in their
appropriate section. The reporting of data under this category includes both
outpatient and inpatient services.

 

6.                                       Specialty Care Physician Services

 

Number of ser services and procedures defined by CPT-4 codes provided by
specialty care physicians or licensed physician extenders or assistants under
direct supervision of a physician inclusive of all services except radiology,
laboratory and injections/ immunizations which should be reported in their
appropriate section. The reporting of data under this category includes both
outpatient and inpatient services.

 

7.                                       Adult Screening Services

 

Number of adult screenings performed.

 

8.                                       Vision Care - Optometric Services

 

Number of optometric services and procedures performed by an optometrist.

 

11

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9.                                       Vision Care - Optical Services

 

Number of eye glasses and contact lenses dispensed.

 

10.                                 Laboratory (Pathology) Procedures

 

Number of procedures defined by CPT-4 Codes under the Pathology and Laboratory
section. Excluded are services performed in conjunction with a hospital
outpatient or emergency department visit.

 

11.                                 Radiology Procedures

 

Number of procedures defined by CPT-4 Codes under the Radiology section.
Excluded are services performed in conjunction with a hospital outpatient or
emergency department visit.

 

12.                                 Physical and Occupational Therapy Services

 

Physical therapy refers to physical and occupational therapy services and
procedures performed by a physician or physical therapist.

 

13.                                 Speech and Hearing Services

 

Number of services and procedures.

 

14.                                 Podiatry Services

 

Number of services and procedures.

 

15.                                 End Stage Renal Disease (ESRD) Services -
Dialysis

 

Number of ESRD procedures provided upon referral.

 

16.                                 Home Health Services

 

Number of home health visits, such as skilled nursing, home health aide, and
personal care aide visits.

 

17.                                 Hospice Days

 

Number of days hospice care is provided, including respite care.

 

18.                                 Private Duty Nursing Services

 

Hours of skilled care delivered.

 

12

--------------------------------------------------------------------------------

 

19.                                 Medical Supplies and Medical Equipment

 

Durable medical equipment such as wheelchairs, hearing aids, etc., and
nondurable supplies such as oxygen etc.

 

20.                                 Abortion Procedures

 

Number of procedures performed.

 

21.                                 Sterilization Procedures

 

Number of procedures performed.

 

22.                                 Detoxification Days

 

Days of inpatient detoxification.

 

23.                                 Organ Transplants

 

Number of transplants.

 

24.                                 Other Outside Medical Services

 

Specialized testing and outpatient surgical services ordered by IHC.

 

25.                                 Long Term Care Facility Days

 

Total days associated with long-term care.

 

26.                                 Transportation Trips

 

Number of ambulance trips.

 

27.                                 Other (specify)

 

13

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Attachment F

Molina Healthcare of Utah

January 1, 2006

 

MOLINA

Attachment F:  Payment Methodology

 

This Contract is classified as non-risk. Under a non-risk contract, the
DEPARTMENT’s total payments to Molina for medical services provided under this
Contract net of third party payments may not exceed the Payment Limit. The
Payment Limit is the total amount Medicaid would have paid for the same services
on a fee-for-service (FFS) basis net of third party payments. In calculating
payments, the DEPARTMENT will use its reimbursement schedule for each claim and
subtract any third party payment reported on each claim to determine the amount
the DEPARTMENT pays on each claim.

 

Molina may reimburse individual providers at rates different from the Medicaid
fee schedule. However, the DEPARTMENT’s aggregate payments to Molina for medical
services provided to its Enrollees must not exceed what Medicaid would have paid
in aggregate for the same services on  a FFS basis.

 

Based on direction from the Centers for Medicare and Medicaid Services (CMS),
the 9% add-on amount that the DEPARTMENT reimburses Molina that includes
administration, case management services, profit earned, etc., and any incentive
payments (CHEC screenings and immunizations) will not be included when
determining the total payments the DEPARTMENT paid Molina when ascertaining
compliance with the Payment Limit for a non-risk contract. The amount for
administration, case management services, and profit that the DEPARTMENT
reimburses Molina will be included when calculating the savings sharing
payments. If CMS requires in writing that this method of calculating the Payment
Limit be revised, this Contract will be amended in accordance with, and only to
the extent necessary to comply with, the specific requirements of CMS.

 

For Molina clients enrolled in Molina’s Medicare product, Molina will reimburse
its providers at no less than the Medicare fee schedule.

 

A.                                   Molina Cost Plus 9% Payment Provisions
Based on Molina’s Encounter Records

 

1.                                       Molina will submit encounter records to
the DEPARTMENT following the Electronic Data Interchange (EDI) standards defined
in the Encounter Records 837 Institutional Companion Guide and Encounter Records
837 Professional Companion Guide. Molina will not submit any encounter record in
the same month in which the service to which the encounter record relates was
provided. In the event Molina inadvertently does so, the DEPARTMENT will not pay
for any encounter record in the same month in which the service was provided.

 

2.                                       The DEPARTMENT will process Molina’s
encounter records and reimburse Molina for encounter records that pass the
Medicaid Managed Care System (MMCS) encounter records’ edits within 30 calendar
days

 

1

--------------------------------------------------------------------------------

 

after the DEPARTMENT has received the encounter records. However, it is the
intent of the DEPARTMENT to pay Molina within 15 calendar days after the
DEPARTMENT has received the encounter records. The  DEPARTMENT will reimburse
Molina the amount Molina paid its providers as reflected in each encounter
record’s “paid amount” field, net of third party payments, for those encounters
that pass the MMCS edits. In addition, the DEPARTMENT will pay to Molina an
additional amount equal to 9% of the total amount of paid encounter records, net
of third party payments. The 9% does not apply to the Medicaid payment on
encounters for Molina’s Medicaid enrollees who are also enrolled in Molina’s
Medicare plan.

 

3.                                       The 9% is based on the reasonable
expenses of managed care plans organizations for all administrative functions,
case management services, profit earned, etc. necessary to operate as an
efficient and effective Medicaid managed care plan and including federal managed
care requirements as described in 42 CFR Part 438–Managed Care. The DEPARTMENT
will verify Molina’s costs incurred for administration, case management
services, profit earned, etc. using the quarterly reports submitted by Molina as
defined in Section F., Quarterly Report of Costs Incurred for Administration,
Case Management Services, Etc., of this

 

Attachment F.

 

4.                                       Rejected encounter records that are
corrected and resubmitted and that clear the MMCS edits will be paid to Molina
in the next regular payment cycle.

 

B.                                    Savings Sharing Provision for FY2005 and
FY2006

 

1.                                       Summary of Savings Sharing Methodology

 

For State fiscal years 2005 and 2006, the DEPARTMENT will calculate the amount
due to Molina, if any, under this Savings Sharing Provision, utilizing both a
“risk-adjuster” methodology and a “fee-for-service methodology.”  The DEPARTMENT
will first apply the risk-adjuster methodology. The DEPARTMENT will next apply
the “fee-for-service” methodology to determine the Payment Limit. Molina will be
entitled to the greater of the two savings amounts from the two calculation
methods as a savings incentive payment. Under no circumstances will the
DEPARTMENT pay Molina for both savings sharing calculations and in no event
shall the savings sharing payment exceed 95% of the Payment Limit.

 

a.                                       If one or both of the PMPM urban and
rural member calculations show that Molina’s risk adjusted aggregate PMPM cost
for FY2005

 

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and/or FY2006 are less than that of the IHC Access enrollees and/or FFS rural
enrollees respectively, then the DEPARTMENT will pay to Molina either
ninety-five percent (95%) of the aggregate savings amount up to 95% of the
Payment Limit or 75% of the savings calculated in Section B.2.c., whichever is
greater.

 

b.                                      If the PMPM urban and rural calculation
show that Molina’s risk adjusted aggregate PMPM costs for State FY2005 or FY2006
are greater than that of IHC Access urban enrollees or FFS rural for the same
period, then the DEPARTMENT will pay Molina either nothing or 75% of the savings
calculated in Section B.2.c (subject to Section B.1.a. above regarding the
greater of 95% of the Payment Limit and 75% of the risk adjusted amount).

 

2.                                      Risk-Adjuster Methodology

 

The same calculations described below for Molina’s urban enrollees will be used
for Molina’s rural enrollees. The same calculations described below for IHC
Access urban enrollees will be used for fee-for-service rural clients except
where noted.

 

The DEPARTMENT will calculate Molina’s risk adjusted, aggregate per member per
month (PMPM) cost for State fiscal years 2005 and 2006 for Molina’s urban
 members and compare the PMPM cost against IHC Access urban enrollees for the
same time periods. The PMPM amount paid to Molina’s urban enrollees  is the cost
of claims plus a 9% add-on fee for administration, case management services,
profit earned, etc. The PMPM amount the DEPARTMENT would have paid for IHC’s
urban enrollees is the Medicaid fee schedule plus a 2% administration fee plus
the IHC network access and continuum care case management fees.

 

The PMPM amount paid to Molina’s rural enrollees is the cost of claims plus a 9%
add-on fee for administration, case management services, profit earned, etc. The
PMPM amount the DEPARTMENT would have paid is the Medicaid fee schedule for
rural fee-for-service Medicaid clients plus a 2% administration fee.

 

In performing the PMPM calculation, the DEPARTMENT will share with Molina,
subject to appropriate confidentiality agreements, all data, methodologies, and
assumptions used in the PMPM calculations, and shall afford Molina a reasonable
opportunity to review and comment regarding such data, methodologies,
assumptions and report, and to confer with and ask questions of the actuary who
performed the calculations and prepared the report.

 

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The DEPARTMENT will use an independent actuary to measure cost effectiveness for
determining any savings sharing as follows:

 

a.                                       The actuary will select a comparable
fee-for-service Medicaid population to compare with the Molina’s managed care
population. IHC Access (IHC) urban enrollees will be the comparable plan for
Molina’s urban enrollees. Fee-for-service rural clients will be the comparable
population for Molina’s rural enrollees.

 

b.                                      The actuary will compare expenditures
for Molina urban enrollees with IHC Access urban enrollees by dates of service
and eligibility for the same year as the Contract year.

 

c.                                       The items to be compared are as
follows:

 

(1)                                  Claims Expenditures Without Third Party
Payment

 

These expenditures represent the total dollars that the DEPARTMENT paid to
health plans. For Molina the expenditures are the amount pursuant to Section A.
less expenditures the DEPARTMENT paid to Molina for Enrollees who are “dual
eligible” (have both Medicare and Medicaid). For IHC, the expenditures include
those claims the DEPARTMENT paid for IHC enrollees under Medicaid’s fee-for
service system less 1) expenditures the DEPARTMENT paid for IHC dual eligibles,
and 2) any amounts the DEPARTMENT paid for IHC enrollees with dates of service
during any period when an IHC enrollees was retroactively eligible for Medicaid.
The actuary will summarize the total dollar amounts by rate cell for Molina and
IHC.

 

(2)                                  Claims Expenditures With Third Party
Payment

 

These expenditures represent the total dollars which would have been allowed
under the Medicaid fee schedule to health plans and the dollar figure used to
calculate the per member per month expenditure. For Molina, the expenditures are
the amount pursuant to Section A. less expenditures the DEPARTMENT paid to
Molina for Enrollees who are “dual eligible” (have both Medicare and Medicaid).
For IHC, the expenditures include those claims the Department paid for IHC
enrollees under Medicaid’s fee-for service system less 1) expenditures the
DEPARTMENT paid for IHC dual eligibles, and 2) any amounts the

 

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DEPARTMENT paid for IHC enrollees with dates of service during any period when
an IHC enrollee was retroactively eligible for Medicaid. The actuary will
summarize the total dollar amounts by rate cell for Molina and IHC.

 

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(3)                                  Eligibles

 

For Molina and IHC, the actuary determines the total number of eligibles by rate
cell (excluding retroactive eligibles and dual eligibles) for each month of the
Contract year for Molina and for IHC. Total member months by rate cell are
calculated for Molina and for IHC by adding all months by rate cell.

 

(4)                                  Raw Per Member Per Month (PMPM) Calculation

 

The actuary calculates a  raw PMPM rate by dividing the “claims expenditures
with third party payment” by the number of member months. This is done for each
rate cell as well as total expenditures and total member months. The calculation
includes an eligibility group mix factor that normalizes the raw calculation for
eligibility group mix.

 

(5)                                  Risk Adjuster

 

The actuary calculates a risk adjuster from the diagnosis data used in the
expenditure totals. These diagnosis data are applied to a risk adjuster
methodology that is accepted and used nationally. The resulting risk adjuster
shows the relative complexity of each health plan’s cases to each other. The
risk adjuster excludes lab and x-ray and uses a population-normalized risk
adjustment factor. The resulting numbers are a separate risk adjuster by rate
cell for each of the plans compared. The composite risk adjustment scores are
calculated using all plans enrollment distribution and PMPM costs relativity.

 

(6)                                  Per Member Per Month calculation (risk and
eligibility mix adjusted)

 

This calculation is made by dividing the raw PMPM calculation by the risk
adjuster.

 

(7)                                  Administrative Cost /Adjustment

 

This adjustment is a PMPM amount by rate cell to account for administrative
costs. Molina’s adjustment is the 9% for administration, case management
services, and profit that is an  add-on to the cost of claims expenditure
(“Claims Expenditures Without Third Party Payment”) that Molina

 

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receives as part of its contract. IHC’s adjustment is the administrative add-on
includes the network access and continuum care case management fees; plus the 2%
administration fee. The rural fee-for-service’s adjustment is the 2%
administration fee.

 

(8)                                  Other Adjustments

 

These rate cell amounts are the amount added or subtracted to account for items
outside claims processing such as Synagis or other special drugs.

 

(9)                                  Total Adjustments

 

Administrative Cost and Other Adjustments added together and then calculated on
a PMPM adjustment value.

 

(10)                            Combined PMPM Risk Adjusted Claims Expenditure
and Adjustment

 

This final number adds the “PMPM Calculation (Risk and Eligibility Mix
Adjusted)” and the “Total Adjustments” PMPM to give a final comparison number.

 

d.                                      If Molina’s “Combined Urban PMPM Risk
Adjusted Claims Expenditure and Adjustment” pursuant to Section B.2.c.(10)
amount is greater than IHC’s “Combined Urban PMPM Risk Adjusted Claims
Expenditure and Adjustment” pursuant to Section B.2.c.(10), then a cost savings
has not occurred and Molina is not eligible for a savings sharing payment for
urban claims under this risk-adjuster methodology.

 

If Molina’s “Combined Rural PMPM Risk Adjusted Claims Expenditure and
Adjustment” pursuant to Section B.2.c.(10) amount is greater than the
fee-for-service “Combined Rural PMPM Risk Adjusted Claims Expenditure and
Adjustment” pursuant to Section B.2.c.(10), then a cost savings has not occurred
and Molina is not eligible for a savings sharing payment for rural claims under
this risk-adjuster methodology.

 

e.                                       If Molina’s “Combined Urban PMPM Risk
Adjusted Claims Expenditure and Adjustment” amount is less than IHC’s “Combined
Urban PMPM Risk Adjusted Claims Expenditure and Adjustment” pursuant to Section
B.2.c.(10), then a cost savings has occurred and Molina is eligible for a
savings sharing payment for urban

 

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claims under this risk-adjuster methodology .

 

8

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If Molina’s “Combined Rural PMPM Risk Adjusted Claims Expenditure and
Adjustment” amount is less than the fee-for-service rural “Combined Rural PMPM
Risk Adjusted Claims Expenditure and Adjustment” pursuant to Section B.2.c.(10),
then a cost savings has occurred and Molina is eligible for a savings sharing
payment under this risk-adjuster methodology.

 

3.                                      Payment Limit Methodology

 

a.                                       Determination of Covered Encounters

 

All encounter records not rejected in the process under Section A. above will go
through a final cleansing by running said encounters through the DEPARTMENT’s
fee-for-service process. Encounters for which the DEPARTMENT paid the CONTRACTOR
under Section A. but that are not covered encounters based on the criteria in
B.3.b. will be excluded from the Payment Limit calculation.

 

The DEPARTMENT will provide documentary support for its calculation to Molina
and afford Molina a reasonable opportunity to review and comment.

 

b.                                      Covered Services Criteria

 

For purposes of this Attachment F, a covered encounter record is an encounter
record that is covered under this Contract, not rejected by the rejection edits
in the DEPARTMENT’s Encounter Records Companion Guides and:

 

(1)                                  the procedure codes are either covered by
Medicaid as indicated on Medicaid’s Reference File, or

 

(2)                                  the Enrollee who received the service was a
CHEC eligible, or

 

(3)                                  the DEPARTMENT approves the payment for
services described in Attachment B (Special Provisions), under Article VI
(Authorization of Services and Notices of Action), A.2. (Process for the
CONTRACTOR to Request Payment Authorization of Services); or

 

(4)                                  the services provided are in lieu of
services covered in the Utah Medicaid State Plan because they are cost-effective
and of equal or higher quality.

 

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c.                                       Determination of Payments Subject to
the Payment Limit

 

For purposes of determining whether the DEPARTMENT paid Molina more or less than
the Payment Limit, the total amount the DEPARTMENT paid Molina is calculated as
follows:

 

(1)                                  the total amount as determined in Section
A. (net of third party payments) excluding the 9% add-on fee that includes
administration, case management services, profit earned, etc; plus

 

(2)                                  other covered services not submitted as
encounter records (such as Synagis) using the DEPARTMENT’s Medicaid fee
schedule.

 

d.                                       Determination of Payment Limit

 

The DEPARTMENT will determine the Payment Limit by pricing, net of third party
payments, and totaling all covered encounter records under B.3.b. plus other
covered services not submitted as encounter records (such as Synagis) using the
DEPARTMENT’s Medicaid fee schedule.

 

For services that do not have a reimbursement amount in the DEPARTMENT’s
Reference File or the Reference File indicates that the service is manually
priced, the amount the CONTRACTOR paid its provider will be the amount used in
determining the Payment Limit.

 

The DEPARTMENT will provide documentary support for its calculation to Molina
and afford Molina a reasonable opportunity to review and comment.

 

e.                                       Reconciliation

 

The DEPARTMENT will then compare the difference between the amounts resulting
from the calculations as provided in Section B.3.c. and Section B.3.d.

 

(1)                                  If the amount the DEPARTMENT paid to Molina
under Section B.3.c. is less than the amount the

 

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DEPARTMENT would have paid on a fee-for-service basis under B.3.d., the
DEPARTMENT will pay to Molina as an incentive payment either 75% of the
resulting amount as savings sharing or 95% of the savings under the risk
adjuster methodology, whichever is greater.

 

(2)                                  If the amount the DEPARTMENT paid Molina
under Section B.3.c. is more than the amount the DEPARTMENT would have paid on a
fee-for-service basis under B.3.d., the DEPARTMENT will recoup the difference
from Molina so that all payments to Molina equal the Payment Limit.

 

3.                                      Examples of Savings Sharing Calculations

 

a.                                       The risk-adjuster methodology shows
aggregate savings of $3 million. Molina would be entitled to receive 95% of that
amount ($2.85 million), but only up to 95% of the Payment Limit. Application of
the Payment Limit methodology shows that on a fee-for-service basis, costs would
have been only $2 million more than the amount the DEPARTMENT paid to Molina.
Molina is entitled to the greater of 95% of the savings under the risk adjustor
methodology ($2.85 million), but only up to 95% of the Payment Limit ($1.9
million), or 75% of the difference between the Payment Limit and the amount the
DEPARTMENT paid Molina ($1.5 million). Therefore, Molina would be entitled to
receive $1.9 million.

 

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b.                                      The risk-adjuster methodology shows
aggregate savings of $3 million. Molina would be entitled to receive 95% of that
amount ($2.85 million) but only up to 95% of the Payment Limit. Application of
the Payment Limit methodology shows that on a fee-for-service basis, costs would
have been $4 million more than the amount the DEPARTMENT paid to Molina. Molina
is entitled to the greater of 95% of the savings under the risk adjuster
methodology ($2.85 million), but only up to 95% of the Payment Limit ($3.8
million) or 75% of the difference between the Payment Limit and the amount the
DEPARTMENT paid Molina ($3 million). Therefore Molina would be entitled to
receive $3 million.

 

c.                                       The risk-adjuster methodology shows no
savings. Application of the Payment Limit methodology shows the amount the
DEPARTMENT paid to Molina is $4 million less than the Payment Limit. The total
amount the DEPARTMENT will pay Molina is 75% of $4 million or $3 million.

 

C.                                    Payment Limit for the Contract Period from
July 1, 2002 through June 30, 2004

 

Because it was not previously feasible to process encounter records through the
MMCS edits for State fiscal years 2003 and 2004 to confirm compliance with the
Payment Limit, the CONTRACTOR will submit encounters for these years. The
encounter records will follow the Electronic Data Interchange (EDI) standards
defined in the Encounter Records 837 Institutional Companion Guide and Encounter
Records 837 Professional Companion Guide.

 

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1.                                      Validation of Compliance with Payment
Limit

 

As soon as practicable, and using in all relevant respects the methodology
described in Section B.3 above regarding the calculation of the Payment Limit
and the comparison of the amounts paid to Molina with the Payment Limit, the
DEPARTMENT will process Molina’s encounter records for each fiscal year 2003 and
fiscal year 2004. Each year will be processed and analyzed separately. Such
claims processing is being done solely for the purpose of confirming compliance
with the Payment Limit and no action will be taken by either party with respect
to any previously paid or unpaid claim or particular group of claims.

 

2.                                      Reconciliation

 

a.                                       If the amount the DEPARTMENT paid to
Molina for fiscal year 2003 or fiscal year 2004 is more than the amount of the
Payment Limit for each year, the DEPARTMENT will recoup the difference from
Molina. For purposes of such comparison for fiscal year 2004, the $1.5 million
savings sharing payment made to Molina by the DEPARTMENT will be included in the
calculation of the amounts paid to Molina for such year.

 

b.                                      If the amount the DEPARTMENT paid to
Molina for fiscal year 2003 or fiscal year 2004 is less than the amount of the
Payment Limit for each year, the DEPARTMENT will pay Molina nothing. For
purposes of such comparison for fiscal year 2004, the $1.5 million savings
sharing payment made to Molina by the DEPARTMENT will be included in the
calculation of the amounts paid to Molina for such year.

 

D.                                    CHEC Screening Incentive Clause

 

1.                                       CHEC Screening Goal

 

Molina will ensure that Medicaid children have access to appropriate well-child
visits. Molina will follow the Utah EPSDT (CHEC) guidelines for the periodicity
schedule for well-child protocol. The Centers for Medicare and Medicaid Services
(CMS), mandates that all states have 80% of all children screened. The
DEPARTMENT and Molina will work toward that goal.

 

2.                                      Calculation of CHEC Incentive Payment

 

The DEPARTMENT will calculate Molina’s annual participation rate based on
information supplied by Molina under the CMS-416 EPSDT (CHEC) reporting
requirements. Based

 

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on the CMS-416 data, Molina’s well-child participation rate was 64% for Federal
Fiscal Year (FFY) 2004 (October 1, 2003 through  September 30, 2004). The
incentive payment for the Contract year ending June 30, 2005 will be based on
Molina’s FFY 2005 (October 1, 2004 through September 30, 2005) CMS-416
participation rate. The DEPARTMENT will pay Molina $10,000 if a rate of 80% or
higher is attained during FFY 2005.

 

The participation rate will be calculated no later than April 15, 2006; Molina
will be notified of the incentive payment, if applicable, no later than April
30, 2006.

 

3.                                      MOLINA’s Use of Incentive Payment

 

The CONTRACTOR agrees to use this incentive payment to rewardMolina’s employees
responsible for improving the EPSDT (CHEC)   participation rate.

 

E.                                      Immunization Incentive Clause

 

The CONTRACTOR will ensure that Enrollees have access to recommended
immunizations. Molina will follow the Advisory Committee on Immunization
Practices’ recommendations for immunizations for children.

 

1.                                       Immunizations for two-year-olds

 

The National Immunization Survey reported that in 2003 Utah had a statewide
immunization level of 78.8% for two-year-olds. Molina’s 2003 HEDIS rate was
62.1% for the Combination 1 immunization measure for two-year olds. Based on
Molina’s 2004 HEDIS result for the Combination 1 immunization measure, the
DEPARTMENT will pay Molina $300 for each full percentage point above 62.1%.

 

The CONTRACTOR agrees to use this incentive payment to reward Molina’s employees
responsible for improving the HEDIS immunization rate for two-year olds.

 

2.                                       Immunizations for adolescents

 

The DEPARTMENT realizes it is important that adolescents are vaccinated
according to the schedule recommended by the Advisory Committee on Immunization
Practices and other professional groups. Molina’s 2003 HEDIS rate was 22.5% for
the Combination 1 immunization measure for adolescents. Based on Molina’s 2004
HEDIS measure for adolescent immunizations, the DEPARTMENT will pay Molina $300
for each full percentage point above 22.5.8% up to 72.5%.

 

The CONTRACTOR agrees to use this incentive payment to reward Molina’s employees
responsible for improving the HEDIS immunization rate for adolescents.

 

3.                                       Immunizations for adults

 

The DEPARTMENT will provide an incentive to Molina using an influenza measure
developed by the DEPARTMENT and the Office of Health Care Statistics. The
measurement is the percentage of Enrollees age 50 and older who receive an
influenza immunization during the previous year’s flu season (September 1 of the
previous year through May 31 of the measurement year). The baseline year is
September 1, 2002 through August 31, 2003. Based on Molina’s percentage for the
flu season ending in 2005, the DEPARTMENT will pay Molina $300 for each full
percentage point above Molina’s percentage in the baseline year up to 50
percentage points above the baseline year.

 

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The CONTRACTOR agrees to use this incentive payment to reward Molina’s employees
responsible for improving the influenza immunization rate for adults.

 

F.                                      Quarterly Report of Costs Incurred for
Administration, Case Management Services,  Etc.

 

1.                                       On a quarterly basis, the DEPARTMENT is
required to report costs incurred for administration, case management services,
etc., from non-risk managed care contracts with Federal Financial Participation
(FFP). This reporting is required 30 days after the quarters ending March 31,
June 30, September 30, and December 31. In order to meet this requirement,
Molina must submit the cost data to the DEPARTMENT by the 25th of each month
following each quarter’s end.

 

2.                                       The CONTRACTOR will report to the
DEPARTMENT its costs incurred for administration,  case management services, 
profit earned, etc. in an Excel spreadsheet. Molina will develop a cost
reporting plan that documents methods used for reporting including direct
assignment and/or allocation process. The purpose of the plan methods is to
facilitate any reviews that the DEPARTMENT conducts.

 

The CONTRACTOR will itemize its costs incurred into at least the following cost
categories:

 

a.

 

Family Planning

b.

 

Claims Processing

c.

 

Provider Enrollment

d.

 

Prior Authorization

e.

 

Case Management Services/Care Coordination

f.

 

Disease Management Programs

g.

 

Perinatal Care Programs

h.

 

Educational Newsletters and other Outreach

i.

 

Provider Credentialing and Re-credentialing

j.

 

HEDIS Reporting

k.

 

Encounter Data Submitted to the DEPARTMENT

l.

 

Grievance and Appeals Processes

m.

 

Work related to the DEPARTMENT’s External Quality Review Organization

n.

 

Quality Improvement Programs

o.

 

Quality Committees

p.

 

Performance Improvement Projects

q.

 

Health Needs Assessments

r.

 

Utilization Management other than prior authorization

s.

 

Other General Administrative Costs (in detail)

t.

 

Profit from Operations Before Taxes

u.

 

Taxes from Operations

 

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For each of the cost categories that have a personnel component, Molina will
break out the costs by skilled Medical Professional; i.e, doctors, registered
nurses, pharmacists, social workers, etc.

 

G.                                    Other Payment-Related References

 

Attachment A, Article III, #4, #5, and #6 - (unauthorized changes to contract)

Attachment B, Article XI - Other Requirements (Fraud & Abuse)

Article XII - Payments (Third Party Liability)

Article XIII - Records and Reporting Requirements (Accuracy of Data)

Article XIV - Compliance/Monitoring (Right to Audit)

Article XV - Termination of Contract

 

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