Exhibit 10.30

     
[SEAL]
  STATE OF MISSOURI
 
  OFFICE OF ADMINISTRATION
 
  DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
 
  REQUEST FOR BEST AND FINAL OFFER (BAFO)
 
  FOR REQUEST FOR PROPOSAL (RFP)

     
BAFO REQUEST NO.: 002
  REQ NO.: NR 886 25756004320
RFP NO.: B3Z06118
  BUYER: Julie Kleffner
TITLE: Medicaid Managed Care – Central, Eastern, & Western Regions
  PHONE NO.: (573) 751-7656
ISSUE DATE: 03/28/06
  E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN BAFO RESPONSE NO LATER THAN 03/30/06 AT 5:00 PM CENTRAL TIME

     
MAILING INSTRUCTIONS:
  Print or type RFP Number and Return Due Date on the lower left hand corner of
the envelope or package. Sealed BAFOs should be in DPMM office (301 W High
Street, Room 630) by the return date and time.

             
 
  (U.S. Mail)       (Courier Service)
RETURN BAFO RESPONSE TO:
  DPMM   or   DPMM
 
  PO BOX 809       301 WEST HIGH STREET, RM 630 
 
  JEFFERSON CITY MO 65102-0809       JEFFERSON CITY MO 65101

CONTRACT PERIOD: July 1, 2006 through June 30, 2007
               (with two additional one-year renewal periods at the State’s sole
option)
DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
The offeror hereby declares understanding, agreement and certification of
compliance to provide the items and/or services, at the prices quoted, in
accordance with all terms and conditions, requirements, and specifications of
the original RFP as modified by any previously issued RFP amendments and by this
and any previously issued BAFO requests. The offeror agrees that the language of
the original RFP as modified by any previously issued RFP amendments and by this
and any previously issued BAFO requests shall govern in the event of a conflict
with his/his proposal. The offeror further agrees that upon receipt of an
authorized purchase order from the Division of Purchasing and Materials
Management or when a Notice of Award is signed and issued by an authorized
official of the State of Missouri, a binding contract shall exist between the
offeror and the State of Missouri.
SIGNATURE REQUIRED

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
   
Community CarePlus
  Alliance for Community Health
 
   
MAILING ADDRESS
  IRS FORM 1099 MAILING ADDRESS
 
   
10123 Corporate Square Drive
  10123 Corporate Square Drive
 
   
CITY, STATE, ZIP CODE
  CITY, STATE, ZIP CODE
 
   
St. Louis, MO 63132
  St. Louis, MO 63132
 
   
CONTACT PERSON
  jlinder@ccphealth.com
Jerry Linder or Marcia Albridge
  malbridge@ccphealth.com
 
   
PHONE NUMBER
  FAX NUMBER
 
   
314-432-9300
  314-994-9398

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
       
43-1743902
             ___X___ FEIN          ___ SSN   817919905 
 
        VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)        (NOTE: LLC IS NOT A
VALID TAX FILING TYPE.)
 
        __X_ Corporation           ___ Individual           ___ State/Local
Government           ___ Partnership           ___ Sole Proprietor          
___ Other              

     
AUTHORIZED SIGNATURE
  DATE
 
   
 
  3/29/06
 
   
PRINTED NAME
  TITLE
 
   
Jerry Linder
  CEO

 

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          RFP B3Z06118   BAF0#002   Page 2

Medicaid Managed Care – Central, Eastern, & Western Regions
Department of Social Services, Division of Medical Services
Contract Period: July 1, 2006 through June 30, 2007
               (with two additional one-year renewal periods at the State’s sole
option)
Offerors are hereby notified that paragraph 2.1.2 a. is hereby revised.

 

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

 

      [SEAL]   STATE OF MISSOURI   OFFICE OF ADMINISTRATION   DIVISION OF
PURCHASING AND MATERIALS MANAGEMENT (DPMM)   REQUEST FOR BEST AND FINAL OFFER
(BAFO)   FOR REQUEST FOR PROPOSAL (RFP)

     
BAFO REQUEST NO.: 001
  REQ NO.: NR 886 25756004320
RFP NO.: B3Z06118
  BUYER: Julie Kleffner
TITLE: Medicaid Managed Care — Central, Eastern, & Western Regions
  PHONE NO.: (573) 751-7656
ISSUE DATE: March 10, 2006
  E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN BAFO RESPONSE NO LATER THAN March 15, 2006 AT 5:00 PM CENTRAL TIME

     
MAILING INSTRUCTIONS:
  Print or type RFP Number and Return Due Date on the lower left hand corner of
the envelope or package. Sealed BAFOs should be in DPMM office (301 W High
Street, Room 630) by the return date and time.

             
 
  (U.S. Mail)       (Courier Service)
RETURN BAFO RESPONSE TO:
  DPMM   or   DPMM
 
  PO BOX 809
JEFFERSON CITY MO 65102-0809       301 WEST HIGH STREET, RM 630
JEFFERSON CITY MO 65101

CONTRACT PERIOD: July 1, 2006 through June 30, 2007
(with two additional one-year renewal periods at the State’s sole option)
DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
The offeror hereby declares understanding, agreement and certification of
compliance to provide the items and/or services, at the prices quoted, in
accordance with all terms and conditions, requirements, and specifications of
the original RFP as modified by any previously issued RFP amendments and by this
and any previously issued BAFO requests. The offeror agrees that the language of
the original RFP as modified by any previously issued RFP amendments and by this
and any previously issued BAFO requests shall govern in the event of a conflict
with his/his proposal. The offeror further agrees that upon receipt of an
authorized purchase order from the Division of Purchasing and Materials
Management or when a Notice of Award is signed and issued by an authorized
official of the State of Missouri, a binding contract shall exist between the
offeror and the State of Missouri.
SIGNATURE REQUIRED

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
   
MAILING ADDRESS
  IRS FORM 1099 MAILING ADDRESS
 
   
CITY, STATE, ZIP CODE
  CITY, STATE, ZIP CODE
 
   
CONTACT PERSON
  EMAIL ADDRESS
 
   
PHONE NUMBER
  FAX NUMBER

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
  ___ FEIN      ___ SSN    

     
VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)
  (NOTE: LLC IS NOT A VALID TAX FILING TYPE.) ___ Corporation       ___
Individual      ___ State/Local Government       ___ Partnership       ___ Sole
Proprietor     ___ Other ___  
AUTHORIZED SIGNATURE
  DATE
 
   
PRINTED NAME
  TITLE

 

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

 

RFP B3Z06118   BAFO #001   Page 2

Medicaid Managed Care — Central, Eastern, & Western Regions
Department of Social Services, Division of Medical Services
Contract Period: July 1, 2006 through June 30, 2007
(with two additional one-year renewal periods at the State’s sole option)
Offerors are hereby notified the following paragraphs have been revised:
2.14.4
2.14.4 b. 4)
2.31.1
2.31.3

 

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

 

      [SEAL]   STATE OF MISSOURI   OFFICE OF ADMINISTRATION   DIVISION OF
PURCHASING AND MATERIALS MANAGEMENT (DPMM)   REQUEST FOR PROPOSAL (RFP)

     
AMENDMENT NO.: 002
  REQ NO.: NR 886 25756004320
RFP NO.: B3Z06118
  BUYER: Julie Kleffner
TITLE: Medicaid Managed Care — Central, Eastern, & Western Regions
  PHONE NO.: (573) 751-7656
ISSUE DATE: 02/07/06
  E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN PROPOSAL NO LATER THAN: 02/15/06 AT 2:00 PM CENTRAL TIME

     
MAILING INSTRUCTIONS:
  Print or type RFP Number and Return Due Date on the lower left hand corner of
the envelope or package. Delivered Sealed Proposals must be in DPMM office (301
W High Street, Room 630) by the return date and time.

RETURN PROPOSAL AND AMENDMENT(S) TO:

             
 
  (U.S. Mail)       (Courier Service)
 
  DPMM   or   DPMM
 
  PO BOX 809
JEFFERSON CITY MO 65102-0809       301 WEST HIGH STREET, ROOM 630
JEFFERSON CITY MO 65101

CONTRACT PERIOD: July 1, 2006 through June 30, 2007
(with two additional one-year renewal periods at the State’s sole option)
DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
The offeror hereby declares understanding, agreement and certification of
compliance to provide the items and/or services, at the prices quoted, in
accordance with all terms and conditions, requirements, and specifications of
the original RFP as modified by this and any previously issued RFP amendments.
The offeror should, as a matter of clarity and assurance, also sign and return
all previously issued RFP amendment(s) and the original RFP document. The
offeror agrees that the language of the original RFP as modified by this and any
previously issued RFP amendments shall govern in the event of a conflict with
his/her proposal. The offeror further agrees that upon receipt of an authorized
purchase order from the Division of Purchasing and Materials Management or when
a Notice of Award is signed and issued by an authorized official of the State of
Missouri, a binding contract shall exist between the offeror and the State of
Missouri.
SIGNATURE REQUIRED

      LEGAL NAME OF ENTITY/INDIVIDUAL
 
   
MAILING ADDRESS
   
 
   
CITY, STATE, ZIP CODE
   
 
   
CONTACT PERSON
  EMAIL ADDRESS
 
   
PHONE NUMBER
  FAX NUMBER

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
  ___ FEIN      ___ SSN    

     
VENDOR TYPE (CHECK ONE)
    ___ Corporation       ___ Individual       ___ State/Local Government      
___ Partnership      ___ Sole Proprietor      ___ Other ___  
AUTHORIZED SIGNATURE
  DATE
 
   
PRINTED NAME
  TITLE

 

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

 

RFP B3Z06118   Amendment #002   Page 2

Medicaid Managed Care — Central, Eastern, and Western Regions
Department of Social Services, Division of Medical Services
CONTRACT PERIOD: July 1, 2006 through June 30, 2007
(with two additional one-year renewal periods at the State’s sole option)
Prospective offerors are hereby advised of the following:

1.   The return by date and time shall be February 15, 2006 at 2:00 PM Central
Time in lieu of February 10, 2006 at 2:00 PM Central Time.   2.   The following
have been revised:

1.3.1 b.
2.12.5 d.
2.14.4
Attachment 6 revised to amend Exhibit 1
Attachment 10 revised to clarify the Annual Audit instructions

 

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

 

     
[SEAL]
  STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
REQUEST FOR PROPOSAL (RFP)

     
AMENDMENT NO.: 001
  REQ NO.: NR 886 25756004320
RFP NO.: B3Z06118
  BUYER: Julie Kleffner
TITLE: Medicaid Managed Care – Central, Eastern, & Western Regions
  PHONE NO.: (573) 751-7656
ISSUE DATE: 01/31/06
  E-MAIL: Julie.Kleffner@oa.mo.gov

Amendment #002 changed the proposal receipt date from February 10, 2006 to
February 15, 2006
RETURN PROPOSAL NO LATER THAN: 02/10/06 AT 2:00 PM CENTRAL TIME

MAILING INSTRUCTIONS:   Print or type RFP Number and Return Due Date on the
lower left hand corner of the envelope or package. Delivered sealed proposals
must be in DPMM office (301 W High Street, Room 630) by the return date and
time.

RETURN PROPOSAL AND AMENDMENT(S) TO:

             
 
  (U.S. Mail)       (Courier Service)
 
  DPMM   or   DPMM
 
  PO BOX 809       301 WEST HIGH STREET, ROOM 630
 
  JEFFERSON CITY MO 65102-0809       JEFFERSON CITY MO 65101

     
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007
 
       (with two additional one-year renewal periods at the State’s sole option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
The offeror hereby declares understanding, agreement and certification of
compliance to provide the items and/or services, at the prices quoted, in
accordance with all terms and conditions, requirements, and specifications of
the original RFP as modified by this and any previously issued RFP amendments.
The offeror should, as a matter of clarity and assurance, also sign and return
all previously issued RFP amendment(s) and the original RFP document. The
offeror agrees that the language of the original RFP as modified by this and any
previously issued RFP amendments shall govern in the event of a conflict with
his/her proposal. The offeror further agrees that upon receipt of an authorized
purchase order from the Division of Purchasing and Materials Management or when
a Notice of Award is signed and issued by an authorized official of the State of
Missouri, a binding contract shall exist between the offeror and the State of
Missouri.
SIGNATURE REQUIRED

     
LEGAL NAME OF ENTITY/INDIVIDUAL
   
 
   
MAILING ADDRESS
   
 
   
CITY, STATE, ZIP CODE
   
 
   
CONTACT PERSON
  EMAIL ADDRESS
 
   
PHONE NUMBER
  FAX NUMBER

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
  ___ FEIN       ___ SSN      
VENDOR TYPE (CHECK ONE)
        ___ Corporation       ___ Individual       ___ State/Local Government
      ___ Partnership       ___ Sole Proprietor       ___ Other ___

     
AUTHORIZED SIGNATURE
  DATE
 
   
PRINTED NAME
  TITLE

 

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

 

          B3Z06118   Amendment No. 001   Page 2

Medicaid Managed Care – Central, Eastern, and Western Regions
Department of Social Services, Division of Medical Services

     
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007
 
        (with two additional one-year renewal periods at the State’s sole
option)

Prospective offerors are hereby advised of the following:

1.   The following have been revised, inserted, deleted or renumbered:

1.3.1 c.
1.3.1 i.
1.3.1 l.
1.3.1 n.
1.3.1 o.
1.7.2 q.
2.5.5 b.
2.5.5 c.
2.6.2 t. 5)
2.6.2 v.
2.12.10
2.25.5
4.1.1

Attachment 3 – All references to Attachment 3 shall be deemed to mean revised
Attachment 3 Attachment 6 – All references to Attachment 6 shall be deemed to
mean revised Attachment 6

The State of Missouri anticipates that another amendment will be forthcoming at
a later date.

 

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

 

     
[SEAL]
  STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
REQUEST FOR PROPOSAL (RFP)

     
RFP NO.: B3Z06118
  REQ NO.: NR 886 25756004320
TITLE: Medicaid Managed Care – Central, Eastern, & Western Regions
  BUYER: Julie Kleffner
ISSUE DATE: 01/10/06
  PHONE NO.: (573) 751-7656
 
  E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN PROPOSAL NO LATER THAN: 02/10/06 AT 2:00 PM CENTRAL TIME

MAILING INSTRUCTIONS:   Print or type RFP Number and Return Due Date on the
lower left hand corner of the envelope or package. Delivered sealed proposals
must be in DPMM office (301 W High Street, Room 630) by the return date and
time.

             
 
  (U.S. Mail)       (Courier Service)
RETURN PROPOSAL TO:
  DPMM   or   DPMM
 
  PO BOX 809       301 WEST HIGH STREET, RM 630
 
  JEFFERSON CITY MO 65102-0809       JEFFERSON CITY MO 65101

     
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007
 
        (with two additional one-year renewal periods at the State’s sole
option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
The offeror hereby declares understanding, agreement and certification of
compliance to provide the items and/or services, at the prices quoted, in
accordance with all requirements and specifications contained herein and the
Terms and Conditions Request for Proposal (Revised 01/03/06). The offeror
further agrees that the language of this RFP shall govern in the event of a
conflict with his/her proposal. The offeror further agrees that upon receipt of
an authorized purchase order from the Division of Purchasing and Materials
Management or when a Notice of Award is signed and issued by an authorized
official of the State of Missouri, a binding contract shall exist between the
offeror and the State of Missouri.
SIGNATURE REQUIRED

     
LEGAL NAME OF ENTITY/INDIVIDUAL
   
 
   
MAILING ADDRESS
   
 
   
CITY, STATE, ZIP CODE
   
 
   
CONTACT PERSON
  EMAIL ADDRESS
 
   
PHONE NUMBER
  FAX NUMBER

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
  ___ FEIN       ___ SSN      
VENDOR TYPE (CHECK ONE)
        ___ Corporation       ___ Individual       ___ State/Local Government
      ___ Partnership       ___ Sole Proprietor       ___ Other ___

     
AUTHORIZED SIGNATURE
  DATE
 
   
PRINTED NAME
  TITLE

 

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      RFP B3Z06118   Page 2

1.   INTRODUCTION AND GENERAL INFORMATION   1.1   Introduction:   1.1.1   This
document constitutes a request for competitive, sealed proposals from the health
plan provider community for becoming providers in the Missouri managed care
program, hereinafter referred to as “MC+ managed care” in the following regions
of the State of Missouri:

  a.   Central Region: Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper,
Gasconade, Howard, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis,
Randolph, and Saline counties.     b.   Eastern Region: Franklin, Jefferson,
Lincoln, St. Charles, St. Francois, Ste. Genevieve, St. Louis, Warren, and
Washington counties and St. Louis City.     c.   Western Region: Cass, Clay,
Henry, Jackson, Johnson, Lafayette, Platte, Ray, and St. Clair counties.

1.1.2   Organization — This document, referred to as a Request for Proposal
(RFP), is divided into the following parts:

  1)   Introduction and General Information     2)   Performance Requirements  
  3)   General Contractual Requirements     4)   Proposal Submission Information
    5)   Pricing Pages: The Pricing Pages are a separate link that must be
downloaded from the Division of Purchasing and Materials Management’s Internet
web site at: https://www.moolb.mo.gov. It shall be the sole responsibility of
the offeror to obtain the Pricing Pages. If the pricing page(s) are not
downloaded and included with the response, the response could be determined to
be non-responsive and eliminated from consideration for award.     6)   Exhibits
A – B     7)   Terms and Conditions     8)   Attachments 1 – 14: The offeror is
advised that attachments exist to this document which provide additional
information and instruction. These attachments are separate links that must be
downloaded from the Division of Purchasing and Materials Management’s Internet
web site at: https://www.moolb.mo.gov. It shall be the sole responsibility of
the offeror to obtain each of the attachments. The offeror shall not be relieved
of any responsibility for performance under the contract due to the failure of
the offeror to obtain a copy of the attachments.

1.2   Pre-Proposal Conference and MC+ Managed Care Quality Assessment and
Improvement Advisory Groups Meeting:   1.2.1   A pre-proposal conference
regarding this Request for Proposal will be held on January 24, 2006, at
10:00 a.m. in the Interpretive Center of the James C. Kirkpatrick State
Information Center, 600 West Main Street, Jefferson City, Missouri.   1.2.2  
The MC+ Managed Care Quality Assessment and Improvement Advisory Groups
quarterly meeting is scheduled for January 25, 2006 at 10:30 a.m. in room 202 of
the Howerton Court Building, 615 Howerton Court, Jefferson City, Missouri.
During the meeting, portions of the RFP will be discussed; specifically section
2.28.2 Adjustments for Performance Based on HEDIS Performance Ratings and the
Quality Strategy, Attachment 6.   1.2.3   All potential offerors are encouraged
to attend this conference and the MC+ Managed Care Quality Assessment and
Improvement Advisory Groups quarterly meeting in order to ask questions and
provide comments on the RFP. Attendance is not required in order to submit a
response; however, offerors are encouraged to attend since information relating
to this RFP will be discussed in detail. The offeror should bring a copy of the
RFP to the pre-proposal conference since it will be used as the agenda for the
pre-

 

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

 

      RFP B3Z06118   Page 3

    proposal conference . The offeror should also bring a copy of the RFP to the
MC+ Managed Care Quality Assessment and Improvement Advisory Groups quarterly
meeting.   1.2.4   Offerors may submit questions regarding the RFP prior to the
Pre-Proposal Conference to allow time for the State of Missouri to prepare
answers. However, the offeror should restate each question for verbal response
during the Pre-Proposal Conference and/or MC+ Managed Care Quality Assessment
and Improvement Advisory Groups quarterly meeting. Only those questions/answers
which necessitate changes to the RFP will be included in an amendment, if any.  
1.2.5   Offerors are strongly encouraged to advise the Division of Purchasing
and Materials Management within five (5) working days of the scheduled
pre-proposal conference and/or MC+ Managed Care Quality Assessment and
Improvement Advisory Groups quarterly meeting of any special accommodations
needed for disabled personnel who will be attending the conference and/or
meeting so that these accommodations can be made.   1.3   Available
Documentation and Offeror’s Contact:

1.3.1   The offeror may request a copy of any of the following documents by
contacting Julie Kleffner at the Division of Purchasing and Materials
Management. Requests for copies may be sent to Ms. Kleffner via fax at
573-526-9817, or emailed to Julie.Kleffner@oa.mo.gov, or mailed to the Division
of Purchasing and Materials Management, P.O. Box 809, Jefferson City, MO 65102.

  a.   Overview — Division of Medical Services. Available via the Internet at
the Division of Medical Services’ website: www.dss.state.mo.us/dms (Look under
Missouri Medicaid Description and Missouri Medicaid History).

Paragraph 1.3.1 b. revised by Amendment #002

  b.   Quality Improvement System for Managed Care (QISMC)

Paragraph 1.3.1 c. revised by Amendment #001

  c.   Health Plan Record Layout Manual – available electronically at website
www.emomed.com (Look under Provider, Electronic Billing Layout, System Manuals,
Health Plan Layout Manual)     d.   Medicaid Fee-for-Service Pricing File
available electronically at the Division of Medical Service’ website:
http://www.dss.mo.gov/dms/providers/pages/cptagree.htm     e.   Division of
Medical Services MC+ Managed Care Policy Statements     f.   Missouri’s 1115
Waiver Amendment     g.   EPSDT Screening Codes and Reporting Methodology     h.
  Historical Enrollment Data

Paragraph 1.3.1 i(MRDD Waiver Services) deleted by Amendment #001 and all other
paragraphs renumbered accordingly

  i.   Description of Member Satisfaction Survey Data Reporting     j.  
Hospital Per Diem Rates     k.   Federal regulations regarding home health
agencies are available via the Internet at
http://www.gpoaccess.gov/cfr/retrieve.html (42 CFR 484, Subpart A, B, C and 42
CFR 441.15).

Paragraph 1.3.1 l. revised by Amendment #001

  l.   Guidelines for Addressing Fraud and Abuse in managed Care”, is available
via the internet at
http://new.cms.hhs.gov/FraudAbuseforProfs/02_MedicaidGuidance.asp     m.  
Jackson County Consent Decree and Operational Guide

 

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      RFP B3Z06118   Page 4

Paragraphs 1.3.1 n. and o. inserted by Amendment #001

  n.   Mercer presentation from the January 24, 2006 Pre-proposal Conference    
o.   Criteria for Post-Payment Review of Specialty Pediatric Hospital
Discharges.

1.3.2   All possible efforts have been made to ensure that the information
provided in these relevant documents is complete and current. However, the
offeror shall not assume that such information is indeed complete or current.  
1.4   Questions:   1.4.1   All questions regarding this Request for Proposal
and/or the competitive procurement process must be directed to Julie Kleffner at
the Division of Purchasing and Materials Management. Questions may be faxed to
Julie Kleffner at 573-526-9817, or emailed to Julie.Kleffner@oa.mo.gov, or
mailed to the Division of Purchasing and Materials Management, P.O. Box 809,
Jefferson City, MO 65102. All questions should be submitted three weeks prior to
the proposal receipt date specified on Page 1.   1.5   Description of Missouri
MC+ Managed Care Program:   1.5.1   Effective July 1, 2006, the State of
Missouri will continue a health care delivery program in Audrain, Boone,
Callaway, Camden, Cass, Chariton, Clay, Cole, Cooper, Franklin, Gasconade,
Henry, Howard, Jackson, Jefferson, Johnson, Lafayette, Lincoln, Miller,
Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis, Platte, Randolph, Ray,
Saline, St. Charles, St. Clair, St. Francois, Ste. Genevieve, St. Louis, Warren,
and Washington counties and St. Louis City to serve MC+ managed care eligibles
meeting specified eligibility criteria. The goal is to improve the accessibility
and quality of health care services for Missouri’s MC+ managed care and State
aid eligible populations, while controlling the program’s rate of cost increase.

  a.   The Missouri Department of Social Services, Division of Medical Services
intends to achieve this goal by enrolling MC+ managed care eligibles in
comprehensive, qualified health plans that contract with the State of Missouri
to provide a specified scope of benefits to each enrolled member in return for a
capitated payment made on a per member, per month basis.

1.5.2   The health care delivery program was designed through a collaborative
process that included feedback from providers, consumers, health plans,
communities, the State of Missouri government agencies, and the Centers for
Medicare and Medicaid Services (CMS) (formerly the Health Care Financing
Administration).   1.5.3   The Missouri Department of Social Services, Division
of Medical Services has identified eight (8) guiding principles for Missouri’s
Medicaid Program as follows:

  1)   All recipients must have a medical home.     2)   Attention to wellness
of the individual (i.e. education).     3)   Chronic care management.     4)  
Care management – (resources focused towards people receiving the services they
need, not necessarily because the service is available).     5)   Appropriate
setting at the right cost.     6)   Emphasis on the individual person.     7)  
Evidenced based guidelines for improved quality care and use of resources.    
8)   Encourage responsibility and investment on the part of the recipient to
ensure wellness.

 

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      RFP B3Z06118   Page 5

1.6   Program Management and Oversight:   1.6.1   In the State of Missouri, the
Department of Social Services, Division of Medical Services is officially
designated with administration of the medical assistance and federal Medicaid
(Title XIX and Title XXI) programs. In addition to Division of Medical Services’
oversight, CMS also monitors MC+ managed care activities through its Regional
Office in Kansas City, Missouri and its Center for Medicaid and State
Operations, Division of Integrated Health Systems in Baltimore, Maryland.   1.7
  Missouri MC+ Managed Care Program Eligibility Groups:   1.7.1   For purposes
of this Request for Proposal, the MC+ managed care population consists of
different eligibility groups which have been combined for the purpose of rate
setting. The qualifications for the program are based on a combination of
factors, including family composition, income level, insurance status, or
pregnancy status depending on the eligibility group in question. The eligibility
groups and their current estimated sizes are described below and summarized in
Attachment 1.

  a.   Eligibility of Parents/Caretakers, Children, Pregnant Women, and
Refugees: Individuals covered under MC+ managed care within this group are as
follows:

  1)   Parents/Caretakers and Children eligible under Medical Assistance for
Families, and Transitional Medical Assistance.     2)   Children eligible under
MC+ for Poverty Level Children.     3)   Women eligible under Medical Assistance
for Pregnant Women and 60 days post-partum.     4)   Individuals eligible under
Recipients of Refugee Medical Assistance.     5)   Individuals eligible under
the above groups and are MRDD Waiver participants.     6)   Those that are
eligible are defined by their MC+ Medical Eligibility (ME) Codes as Specified in
Attachment 1.

  b.   Eligibility of Other MC+ Children In the Care and Custody of the State
and Receiving Adoption Subsidy Assistance: All children in the care and custody
of the Department of Social Services; all children placed in a not-for-profit
residential group home by a juvenile court; all children receiving adoption
subsidy assistance; and all children receiving non-medical assistance (i.e.,
living expenses) that are in the legal custody of the Department of Social
Services shall remain the responsibility of the Department of Social Services.
Those that are eligible are defined by their MC+ Medical Eligibility code as
specified in Attachment 1.     c.   1115 Demonstration Waiver: Missouri
submitted an amendment to its pending 1115 demonstration waiver on August 26,
1997. The amendment is to Missouri’s 1115 demonstration waiver that was
submitted on June 30, 1994. The 1115 demonstration waiver as amended was
approved April 28, 1998. The waiver amendment continues Missouri’s commitment to
improving medical care to low income children and supports families moving from
welfare into jobs.

  1)   Uninsured Children Below 200 Percent Under Title XIX, Coordinated with
Title XXI Funding: Uninsured children with net family income up to 200 percent
of the federal poverty level (300 percent gross income) are covered under an MC+
expansion. The MC+ expansion will occur under a Title XIX 1115 waiver. Children
will include individuals birth through age 18. No new eligibles will be excluded
because of pre-existing illness or condition. “Uninsured Children” are persons
up to nineteen years of age who have not had access to employer-subsidized
health care insurance or other health care coverage for six (6) months prior to

 

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      RFP B3Z06118   Page 6

      application, are residents of the State of Missouri, and have parents or
guardians who meet the following requirements:

  •   Furnish to the Department of Social Services the uninsured child’s social
security number or numbers, if the uninsured child has more than one such
number;     •   Cooperate with the Department of Social Services in identifying
and providing information to assist the Division of Medical Services in pursuing
any third-party health insurance carrier who may be liable to pay for health
care;     •   Cooperate with the Department of Social Services, Family Support
Division in establishing paternity and in obtaining support payments, including
medical support;     •   Demonstrate, upon request, their child’s participation
in wellness programs including immunizations and a periodic physical
examination. (This shall not apply to any child whose parent or legal guardian
objects in writing to such wellness programs including immunizations and an
annual physical examination because of religious beliefs or medical
contraindications);     •   Demonstrate annually that their total net worth does
not exceed two hundred fifty thousand dollars in total value; and     •   There
will be protections against dropping or foregoing private coverage, including a
six (6) month waiting period and insurance availability screens through the
Division of Medical Services’ Health Insurance Premium Payment (HIPP) program.

  Ø   Any child identified as having special health care needs defined as a
condition which left untreated would result in the death or serious physical
injury of a child, that does not have access to affordable employer-subsidized
health care insurance will be exempt from the requirement to be without health
care coverage for six months in order to be eligible for services.     Ø   A
child shall not be subject to the 30-day waiting period as long as the child
meets all other qualifications for eligibility.

  d.   MC+ managed care eligibles in the above specified eligibility groups may
voluntarily disenroll from the MC+ Managed Care Program or choose not to enroll
in the MC+ Managed Care Program if they:

  1)   Are eligible for Supplemental Security Income (SSI) under Title XVI of
the Social Security Act;     2)   Are described in Section 501(a)(1)(D) of the
Social Security Act;     3)   Are described in Section 1902(e)(3) of the Social
Security Act;     4)   Are receiving foster care or adoption assistance under
part E of Title IV of the Social Security Act;     5)   Are in foster care or
otherwise in out-of-home placement; or     6)   Meet the SSI disability
definition as determined by the Department of Social Services.

1.7.2   Not Covered Under the MC+ Managed Care Program: The following
individuals are not covered under the MC+ Managed Care Program and receive their
services through the Medicaid/MC+ fee-for-service program:

 

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      RFP B3Z06118   Page 7

  a.   Permanently and Totally Disabled individuals eligible under ME Codes 04
(Permanently and Totally Disabled), 13 (Medical Assistance-PTD), 16 (Nursing
Care-PTD), and 11 (Medical Assistance (MA) Spenddown and Non-Spenddown, Old Age
Assistance (OAA)).     b.   Individuals eligible under ME Code 14 (Nursing
Care-OAA) residing in a nursing home and receiving cash to apply toward their
nursing home costs or a vendor payment directly to a nursing home for their care
through the Medicaid program.     c.   Individuals eligible under ME Codes 23
and 41 (MA ICF-MR Poverty) residing in a State Mental Institution or an
Intermediate Care Facility for the Mentally Retarded (ICF/MR).     d.  
Individuals eligible under ME Codes 28, 49, and 67 (Children placed in foster
homes or residential care by the Department of Mental Health).     e.   Pregnant
women eligible under ME Code 58 and 59, the Presumptive Eligibility Program for
ambulatory prenatal care only.     f.   Individuals eligible under ME Codes 2,
3, 12, and 15 (Aid to the Blind and Blind Pension).     g.   AIDS Waiver
participants (individuals twenty-one (21) years of age and over).     h.   Any
individual eligible and receiving either or both Medicare Part A and Part B
benefits.     i.   Individuals eligible under ME Codes 33 and 34 (MO Children
with Developmental Disabilities Waiver).     j.   Individuals eligible under ME
Code 55 (Qualified Medicare Beneficiary – QMB).     k.   Children eligible under
ME Code 65, placed in residential care by their parents, if eligible for
MC+/Medicaid on the date of placement.     l.   Uninsured women losing their MC+
eligibility 60 days after the birth of their child would be eligible under ME
Code 80 for women’s health services for one year plus 60 days, regardless of
income level. This population will obtain their services through the MC+
fee-for-service program.     m.   Individuals with ME code 81 (Temporary
Assignment Category).     n.   Women eligible under ME codes 83 and 84 (Breast
and Cervical Cancer Treatment).     o.   Individuals eligible under ME code 87
(Presumptive Eligibility for Children).     p.   Individuals eligible under ME
code 88 (Voluntary Placement).

Paragraph 1.7.2 q. inserted by Amendment #001

  q.   Individuals eligible under ME code 82 (MoRx)

1.7.3   Where economically cost effective, the Division of Medical Services will
use the Division of Medical Services’ HIPP program to obtain available coverage
through available commercial insurance. Those services included in the
comprehensive benefit packages described herein, but not included in the
commercial insurance service package, may be obtained through MC+ managed care
or fee-for-service as appropriate.

 

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      RFP B3Z06118   Page 8

1.8   Information:   1.8.1   Although an attempt has been made to provide
accurate and up-to-date information, the State of Missouri does not warrant or
represent that the background information provided herein reflects all
relationships or existing conditions related to this Request for Proposal.  
1.8.2   The State of Missouri has previously contracted for these services
through C302226001 through C302226004 for the Eastern and Central Regions and
through C303182001 through C303182004 for the Western Region. These contracts
expire on June 30, 2006. A copy of the contracts can be viewed and printed from
the Division of Purchasing and Materials Management’s Public Record Search and
Retrieval System located on the Internet at: http://www.oa.mo.gov/purch. In
addition, all proposal and evaluation documentation leading to the award of the
expiring contracts may also be viewed and printed from the Division of
Purchasing and Materials Management’s Public Record Search and Retrieval System.
Please reference the Bid number B3Z02226 and B3Z03182 or any of the contract
numbers when searching for these documents.

 

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RFP B3Z06118   Page 9

2. CONTRACTUAL REQUIREMENTS

2.1.1   The contractor (hereinafter referred to as the “health plan”) shall
provide a managed care medical service delivery system for the Department of
Social Services, Division of Medical Services (hereinafter referred to as the
“state agency”), located in the State of Missouri pursuant to the requirements
contained herein.   2.1.2   Prior to performing services in each of the
counties, the health plan shall:

Paragraph 2.1.2 a. revised by BAFO #002

  a.   Have and maintain a certificate of authority from the Department of
Insurance to establish and operate a health maintenance organization in all the
counties specified herein by no later than April 14, 2006 so the state agency
can proceed with open enrollment with only health plans that are appropriately
licensed. In the event the health plan is awarded a contract and fails to
achieve appropriate licensure by April 14, 2006, the contract shall be cancelled
in its entirety;     b.   Understand that federal approval is required prior to
commitment of the federal financing share of funds under the contract;     c.  
Participate in readiness reviews. If the health plan is new to the MC+ managed
care program, the state agency shall conduct on-site readiness reviews of the
health plan in order to document the status of the health plan with respect to
meeting the program requirements outlined herein. If the health plan has an
established relationship with the state agency, the state agency shall conduct
off-site reviews of the health plan in order to document the status of the
health plan with respect to meeting any new program requirements; and     d.  
Submit to the state agency all policies and procedures that require prior
approval listed in Attachment 12. The health plan must submit all modifications,
additions, or deletions to such policies and procedures to the state agency at
least thirty (30) days prior to implementation. The health plan must operate in
accordance with such policies and procedures. The health plan must incorporate
and implement any revisions identified by the state agency to the health plan’s
policies and procedures within the time frame specified by the state agency. All
other policies and procedures required herein shall be submitted to the state
agency on request.

2.1.3   The health plan awarded a contract for the Eastern region shall provide
services to individuals determined eligible by the state agency for the Missouri
MC+ Managed Care Program in all of the following ten areas in the State of
Missouri:

  a.   Franklin County     b.   Jefferson County     c.   Lincoln County     d.
  St. Charles County     e.   St. Francois County     f.   Ste. Genevieve County
    g.   St. Louis County     h.   Warren County     i.   Washington County    
j.   St. Louis City

2.1.4   The health plan awarded a contract for the Central region shall provide
services to individuals determined eligible by the state agency for the Missouri
MC+ Managed Care Program in all of the following eighteen areas in the State of
Missouri:

  a.   Audrain County     b.   Boone County     c.   Callaway County     d.  
Camden County

 

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RFP B3Z06118   Page 10

  e.   Chariton County     f.   Cole County     g.   Cooper County     h.  
Gasconade County     i.   Howard County     j.   Miller County     k.   Moniteau
County     l.   Monroe County     m.   Montgomery County     n.   Morgan County
    o.   Osage County     p.   Pettis County     q.   Randolph County     r.  
Saline County

2.1.5   The health plan awarded a contract for the Western region shall provide
services to individuals determined eligible by the state agency for the Missouri
MC+ Managed Care Program in all of the following nine areas in the State of
Missouri:

  a.   Cass County     b.   Clay County     c.   Henry County     d.   Jackson
County     e.   Johnson County     f.   Lafayette County     g.   Platte County
    h.   Ray County     i.   St. Clair County

2.2 Health Plan Administration:

2.2.1   The health plan shall have in place sufficient administrative staff and
organizational structure to comply with all requirements described herein. The
health plan must be staffed by qualified persons in numbers appropriate to the
health plan’s size of enrollment. At a minimum, the health plan must provide the
following staff to perform the responsibilities listed. Unless otherwise
specified, the health plan may combine or split the listed responsibilities
among the health plan’s staff as long as the health plan demonstrates that the
responsibilities are being met. Similarly, the health plan may contract with a
third party (subcontractor) to perform one or more of these responsibilities.

  a.   A full time Medicaid Plan Administrator with clear authority over the
general administration and implementation of the requirements set forth herein.
    b.   Clerical and support staff to ensure appropriate functioning of the
health plan’s operation.     c.   A Medical Director who shall be a
Missouri-licensed physician. The Medical Director shall be actively involved in
all major clinical and quality program components of the health plan. The
Medical Director shall devote sufficient time to the health plan to ensure
timely medical decisions, including after hours consultation as needed. The
Medical Director shall be responsible for the sufficiency and supervision of the
health plan provider network. The Medical Director shall ensure compliance with
State and local reporting laws on communicable diseases, child abuse, neglect,
etc.     d.   A Dental Consultant who shall be a Missouri-licensed dentist. The
Dental Consultant shall devote sufficient time to the health plan to ensure
timely dental decisions and claim review.

 

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RFP B3Z06118   Page 11

  e.   A full-time Chief Financial Officer to oversee the budget and accounting
systems implemented by the health plan.     f.   A Quality Assessment and
Improvement and Utilization Management Coordinator who shall be a
Missouri-licensed registered nurse, nurse practitioner, or physician.     g.   A
Special Programs Coordinator who shall be a Missouri-licensed social worker,
registered nurse including advanced practice nurse, physician, or physician’s
assistant; or have a Master’s degree in health services, public health, or
health care administration. In addition, the Special Programs Coordinator should
be familiar with the variety of services available through the Missouri human
services agencies that interface with health care. The duties of the Special
Programs Coordinator shall include care coordination with all stakeholders and
providers involved in the care of members. These stakeholders and providers may
include, but not be limited to, the state agency, the Department of Health and
Senior Services, local public health agencies, the Department of Mental Health,
the Department of Elementary and Secondary Education, the Family Support
Division, Children’s Division, hospitals, the judicial system, schools, and
Community Mental Health Centers. The Special Programs Coordinator shall provide
timely and comprehensive facilitation of the identification of medically
necessary services and implementation of such when included in a member’s
Individualized Education Program/Individual Family Service Plan. The Special
Programs Coordinator is the point of contact for members, their representatives,
providers, the state agencies, and local public health agencies.     h.   A
Mental Health Coordinator shall be a qualified mental health professional as
specified herein and possess, at a minimum, a master’s degree.     i.   Prior
authorization staff shall be available to authorize services twenty-four
(24) hours per day, seven (7) days per week. This staff shall be directly
supervised by a Missouri-licensed registered nurse, physician, or physician’s
assistant. Prior approval functions for mental health services shall be
performed by a qualified mental health professional.     j.   Inpatient
certification review staff shall conduct inpatient initial, concurrent, and
retrospective reviews. The review staff shall consist of registered nurses,
physicians, physician’s assistants, or licensed practical nurses experienced in
inpatient reviews and under the direct supervision of a registered nurse,
physician, or physician’s assistant.     k.   Member services staff shall
coordinate communications with members and act as member advocates. The health
plan shall provide sufficient member services staff to enable members to receive
prompt resolution to their problems or inquiries.     l.   Provider services
staff shall coordinate communications between the health plan and providers. The
health plan shall provide sufficient provider services staff to enable providers
to receive prompt resolution to their problems or inquiries.     m.   A
Complaint, Grievance, and Appeal Coordinator shall manage and adjudicate member
and provider complaints, grievances, and appeals in a timely manner.     n.  
Claims Administrator/Management Information System (MIS) Director.     o.  
Compliance Officer.

2.2.2   The health plan shall inform the state agency in writing within seven
(7) calendar days of staffing changes in the following key positions. The health
plan shall fill vacancies in any of these key positions with permanent qualified
replacements within ninety (90) calendar days of the departure of the former
staff member.

 

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RFP B3Z06118   Page 12

  a.   Medicaid Plan Administrator     b.   Medical Director     c.   Quality
Assessment and Improvement and Utilization Management Coordinator     d.  
Special Programs Coordinator     e.   Mental Health Coordinator     f.   Chief
Financial Officer

2.2.3   The health plan shall ensure that all staff have appropriate training,
education, experience, liability coverage, and orientation to fulfill the
requirements of the positions and have met all appropriate licensure
requirements.   2.2.4   The health plan may not knowingly employ as a director,
officer, partner, or person with beneficial ownership of more than 5 percent of
the health plan’s equity, a person 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 pursuant to Executive Order No. 12549 or under guidelines
implementing such order; or is an affiliate (as defined in such Act) of such a
person. In addition, the health plan may not have an employment, consulting, or
other agreement with such a person described above for the provision of items
and services that are significant and material to the health plan’s obligations
required herein.   2.2.5   The health plan shall require each physician
providing services to members to have a unique identifier in accordance with the
system established under section 1173(b) of the Health Insurance Portability and
Accountability Act of 1996.   2.2.6   Non-Discrimination in Hiring and Provision
of Services: The health plan shall ensure that all federal and state laws, as
amended, and policies of non-discrimination in hiring and the provision of
services are strictly enforced. The health plan shall comply with Title VI of
the Civil Rights Act of 1964, as amended; the Rehabilitation Act of 1973, as
amended; Title IX of the Education Amendments of 1972, as amended; the Age
Discrimination Act of 1975, as amended; and the American Disabilities Act of
1990, as amended.

  a.   The health plan shall incorporate in its policies, administration, and
delivery of services the values of:

  1)   Honoring member’s beliefs;     2)   Being sensitive to cultural
diversity; and     3)   Fostering in staff and providers attitudes and
interpersonal communication styles which respect the member’s cultural
backgrounds.

  b.   The health plan shall have specific policy statements on minority
inclusion and non-discrimination and procedures to communicate the policy
statements and procedures to subcontractors.     c.   The health plan shall not
discriminate in regard to the participation, reimbursement, or indemnification
of any provider who is acting within the scope of his or her license or
certification under applicable State law, solely on the basis of that license or
certification. If a health plan declines to include individual or groups of
providers in its network, it must give the affected providers written notice of
the reason for its decision. The health plan’s provider selection policies and
procedures cannot discriminate against particular providers that serve high risk
populations or specialize in conditions that require costly treatment. This
section may not be construed to:

 

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RFP B3Z06118   Page 13

  1)   Require the health plan to contract with providers beyond the number
necessary to meet the needs of its members;     2)   Preclude the health plan
from using different reimbursement amounts for different specialties or for
different practitioners in the same specialty; or     3)   Preclude the health
plan from establishing measures that are designed to maintain quality of
services, control costs, and are consistent with its responsibilities to
members.

2.3 Health Plan Provider Networks:

2.3.1   The health plan shall establish and maintain health plan provider
networks in geographically accessible locations, in accordance with the travel
distance standards specified herein, comprised of hospitals, physicians,
advanced practice nurses, mental health providers, substance abuse providers,
pharmacies, dentists, emergent and non-emergent transportation services, etc.,
with sufficient capacity to make available all services in accordance with the
service accessibility standards specified herein. In order to maintain
geographically accessible locations, the health plan should look to providers in
contiguous and other counties for full development of the network.   2.3.2  
Primary Care Provider Responsibilities: The health plan shall have written
policies and procedures for linking every member to a primary care provider. The
primary care provider must serve as the member’s initial and most important
contact. As such, primary care provider responsibilities must include at a
minimum:

  a.   Maintaining continuity of each member’s health care.     b.   Making
referrals for specialty care and other medically necessary services to both
in-network and out-of-network providers.     c.   Maintaining a comprehensive
current medical record for the member, including documentation of all services
provided to the member by the primary care provider, as well as any specialty or
referral services, diagnostic reports, physical and mental health screens, etc.
    d.   Although primary care providers are responsible for the above
activities, the health plan must monitor the primary care providers’ actions for
compliance with health plan and MC+ Managed Care Program policies.     e.  
Primary care providers may have formalized relationships with other primary care
providers to see their members for after hours care, during certain days, for
certain services, or other reasons to extend their practice. However, the
primary care provider shall be ultimately responsible for the above listed
activities.

2.3.3   Eligible Specialties: The health plan shall limit its primary care
providers to licensed residents specializing in family and general practice,
pediatrics, obstetrics and gynecology (OB/GYN), and internal medicine;
registered nurses who are advanced practice nurses with specialties in family
practice, pediatric practice, and OB/GYN practice; and licensed physicians in
the following specialties: family and general practitioners, pediatricians,
OB/GYN, and internists.

  a.   To the maximum extent possible, the health plan should include all of
these specialties in its health plan provider network.

2.3.4   Primary Care Provider Teams and Primary Care Clinics: The
responsibilities of a primary care provider team and a primary care clinic shall
be the same as the responsibilities listed herein for primary care providers.

 

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RFP B3Z06118   Page 14

  a.   If the health plan provider network includes institutions with teaching
programs, primary care provider teams, comprised of residents and a supervising
faculty physician, may serve as a primary care provider. In addition, the health
plan should establish primary care provider teams that include advanced practice
nurses or physician assistants as recognized by the Board of Healing Arts who,
at the member’s discretion, may serve as the point of first contact for the
member. In both instances, the health plan shall organize its primary care
provider teams so as to ensure continuity of care to members and identify a
“lead physician” within the team for each member. The “lead physician” must be
an attending physician and not a resident.     b.   The health plan may also
elect to make available clinics to serve as primary care providers. The primary
care clinic must provide the range of services required of all primary care
providers. A centralized medical record shall be maintained on each member
enrolled with the primary care clinic.

2.3.5   The health plan shall offer its members freedom of choice in selecting a
primary care provider. The number of members assigned to a primary care provider
shall be decreased by the health plan if necessary to maintain the appointment
availability standards. To the degree possible, these shifts should occur
prospectively (before care has been initiated) and the health plan should take
steps to minimize the need for such shifts.   2.3.6   The health plan shall
include a mix of mental health and substance abuse providers with experience in
treating children, adolescents, and adults in the health plan provider network
to ensure a broad range of treatment options are available.

  a.   To the maximum extent possible, the health plan should include Community
Mental Health Centers (CMHC) in the health plan provider network. A listing of
CMHC is provided in Attachment 5.     b.   The mental health provider network
may include licensed psychiatrists, licensed psychologists, licensed psychiatric
advance practice nurses, provisional licensed professional counselors, licensed
professional counselors, provisional licensed clinical social workers, licensed
clinical social workers, licensed clinical nurse specialists, licensed home
health, licensed psychiatric nurse, and state certified mental health or
substance abuse program. To be considered adequate, the mental health provider
network must, at a minimum, include Qualified Mental Health Professionals
(QMHP), Qualified Substance Abuse Professionals (QSAP), licensed psychiatrists,
licensed psychologists, licensed psychiatric nurses, licensed professional
counselors, licensed clinical social workers, and licensed clinical nurse
specialists.

  1)   A QMHP shall be one of the following and provide services within their
defined scope of practice:

  •   A physician, licensed under Missouri state law to practice medicine or
osteopathy who has either specialized training in mental health services or one
(1) year of experience, under supervision, in treating problems related to
mental illness;     •   A psychiatrist, a physician licensed under Missouri
state law, who has successfully completed a training program in psychiatry
approved by the American Medical Association, the American Osteopathic
Association, or other training program identified as equivalent by the state
agency;     •   A psychologist licensed under Missouri state law to practice
psychology with specialized training in mental health services;     •   A
professional counselor licensed under Missouri state law to practice counseling
who has specialized training in mental health services;

 

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RFP B3Z06118   Page 15

  •   A licensed clinical social worker or a clinical social worker with a
Master’s Degree in social work from an accredited program who has specialized
training in mental health services;     •   A psychiatric nurse, a registered
professional nurse, licensed under Missouri state law who has at least two
(2) years of experience in a psychiatric setting or a Master’s Degree in
psychiatric nursing; or     •   An individual possessing a Master’s Degree or
Doctorate Degree in counseling and guidance, rehabilitation counseling,
vocational counseling, psychology, pastoral counseling, family therapy, social
work, or a related field, who has successfully completed a practicum or has one
(1) year of experience under the supervision of a mental health professional.

  2)   A QSAP shall be one of the following and provide services within their
defined scope of practice:

  •   A counselor, psychologist, clinical social worker, or physician licensed
in Missouri who has at least one (1) year of full-time experience in the
treatment or rehabilitation of substance abuse;     •   A graduate of an
accredited college or university with a Master’s Degree in social work,
counseling, psychology, psychiatric nursing, or closely related field who has at
least two (2) years of full-time experience in the treatment or rehabilitation
of substance abuse;     •   A graduate of an accredited college or university
with a Bachelor’s Degree in social work, counseling, psychology, or closely
related field who has at least three (3) years of full-time experience in the
treatment or rehabilitation of substance abuse; or     •   An alcohol, drug, or
substance abuse counselor certified by the Missouri Substance Abuse Counselors
Certification Board, Inc.

2.3.7   Mental Health and Substance Abuse In-Network Self Referrals: The health
plan shall have written policies and procedures that permit members to seek
in-network mental health services and substance abuse services without a
referral or authorization from the primary care provider. The policies and
procedures shall permit members to contact an in-network mental health and
substance abuse provider directly and shall provide for the authorization of at
least four (4) visits annually without prior authorization requirements. Health
plan mental health and substance abuse providers shall complete a health status
screen, at the initial point of contact and as part of the re-assessment process
for members in treatment. Members with physical health conditions as indicated
by the screen shall be referred to their primary care provider for evaluation
and treatment of the physical health condition.   2.3.8   Physician Specialists:
Because of the large number of physician specialties that exist, the health plan
is not required to maintain specific member-to-specialist provider ratios.
However, the health plan must provide adequate access to physician specialists
for primary care provider referrals and employ or contract with physician
specialists in sufficient numbers to ensure specialty services can be made
available in a timely manner. The health plan shall have protocols for
coordinating care between primary care providers and specialists which include
the expected response time for consults between primary care providers and
specialists.   2.3.9   Any Willing Pharmacy Provider: Any pharmacy, licensed
without restriction under chapter 338, Revised Statutes of the State of Missouri
(RSMo), as amended, and participating as an approved provider in the Missouri
Medicaid program, which is qualified under the terms of the health plan and
willing to accept the health plan’s operating terms including, but not limited
to, its schedule of fees, covered expenses, and quality standards, shall be
allowed to participate in the health plan. Nothing shall prevent a

 

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RFP B3Z06118   Page 16

    health plan from instituting reasonable credentialing criteria, requiring
fee discounts, or establishing any other reasonable measure designed to maintain
quality or control costs.   2.3.10   Federally Qualified Health Centers and
Rural Health Clinics: The health plan shall include Federally Qualified Health
Centers (FQHCs) and Rural Health Clinics (RHCs) in the health plan provider
network, unless the health plan can demonstrate that it has both adequate
capacity and an appropriate range of services to provide care for the expected
enrollment in the region without contracting with FQHCs or RHCs. (A description
of FQHC/RHC services is included in Attachment 2. A listing of FQHCs and RHCs
are provided in Attachment 5.) If the health plan is competing against an FQHC
or RHC owned health plan, the health plan shall not be required to comply with
the previous requirement, although the health plan still must provide the
FQHC/RHC services that are within the covered benefits of the MC+ managed care
program. The health plan shall have protocols for coordinating care between the
primary care provider and the FQHC and RHC provider and indicate the expected
response time for consults between the FQHC and RHC and the primary care
provider.   2.3.11   Family Planning and Sexually Transmitted Disease
(STD) Treatment Providers: The health plan should include Title X and sexually
transmitted disease treatment providers in the health plan provider network to
serve members covered under the comprehensive and extended family planning,
women’s reproductive health, and sexually transmitted diseases benefit packages.
The health plan shall allow for full freedom of choice for the provisions of
these services. A listing of Family Planning and STD treatment providers is
provided in Attachment 5.   2.3.12   Local Public Health Agencies: The health
plan should include local public health agencies in the health plan provider
network for the public health services described herein or for other services.
(A listing of local public health agencies is provided in Attachment 5.)
However, in order to ensure care coordination of members seeking services at a
local public health agency, the health plan should establish an agreement with
local public health agencies describing, at a minimum, care coordination,
medical record management, and billing procedures. Requirements for
reimbursement for certain services are specified in the Performance Requirements
segment regarding public health programs and mandated health plan
reimbursements. Attachment 4 lists a number of conditions for which the health
plan shall report to or cooperate with local public health agencies. In
addition, the health plan may wish to contract with local public health
agencies, as defined above, to provide other health plan covered services.

  a.   All statutorily mandated disease or condition reporting requirements
remain, regardless of the site of the service. The health plan shall provide a
list of their contracted laboratories to the Missouri Department of Health and
Senior Services by July 1 each year.

2.3.13   Network Changes: The health plan shall notify the state agency within
five (5) business days of first awareness/notification of change to the
composition of the health plan provider network or the health care service
subcontractors’ provider network that materially affect the health plan’s
ability to make available all covered services in a timely manner. The health
plan shall have procedures to address changes in the health plan provider
network that negatively affect the ability of members to access services,
including access to a culturally diverse provider network. Material changes in
network composition that negatively affect member access to services may be
grounds for contract cancellation or State determined sanctions.   2.3.14  
Mainstreaming: The state agency considers mainstreaming of MC+ managed care
members into the broader health delivery system to be important. The health plan
therefore must ensure that all of the in-network providers accept members for
treatment. The health plan also must accept responsibility for ensuring that
in-network providers do not intentionally segregate members in any way from
other persons receiving services.

  a.   To ensure mainstreaming of members, the health plan shall take
affirmative action so that members are provided covered services without regard
to race, color, creed, sex, religion, age, national origin, ancestry, marital
status, sexual preference, health status, income status, program membership, or

 

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RFP B3Z06118   Page 17

      physical or mental disability, except where medically indicated. Examples
of prohibited practices include, but are not limited to, the following:

  1)   Denying or not providing to a member any covered service or availability
of a facility.     2)   Providing to a member any covered service which is
different, or is provided in a different manner, or at a different time from
that provided to other members, other public or private patients, or the public
at large.     3)   Subjecting a member to segregation or separate treatment in
any manner related to the receipt of any covered service.

  b.   If the health plan knowingly executes a subcontract with a provider with
the intent of allowing or permitting the subcontractor to implement barriers to
care (i.e., the terms of the subcontract are more restrictive than the
contract), the State shall consider the health plan to have breached the
provisions and requirements of the contract. In addition, if the health plan
becomes aware of any of its existing subcontractors’ failure to comply with this
section and does not take action to correct this within thirty (30) calendar
days, the State shall consider the health plan to have breached the provisions
and requirements of the contract.

2.3.15   The health plan shall comply with any applicable federal requirements
with respect to home health agencies, as amended.   2.3.16   School Based Dental
Services: The state agency has reimbursed dental providers for the provision of
preventive dental services provided to children in a school setting. These
preventive services have included dental exams, prophylaxis, and sealants. The
state agency is committed to the continuation of such programs for members
enrolled with a health plan. The health plan shall contract and reimburse any
licensed dental providers who provide such services in a school setting. The
dental providers must be qualified under the terms of the health plan and
willing to accept the health plan’s operating terms, including but not limited
to, its fee schedule, covered expenses, and quality standards, to be allowed to
participate in the health plan provider network. Nothing shall prevent a health
plan from instituting reasonable credentialing criteria for school-based dental
services or establishing other reasonable measures designed to maintain quality
of care or control costs.   2.3.17   Tertiary Care: Tertiary care is defined as
health services provided by highly-specialized providers, such as medical
sub-specialists. These services frequently require complex technological and
support facilities. The health plan shall provide tertiary care services
including trauma centers, burn centers, level III (high risk) nurseries,
rehabilitation facilities, and medical sub-specialists available twenty-four
(24) hours per day in the region. If the health plan does not have a full range
of tertiary care services, the health plan must have a process for providing
such services including transfer protocols and arrangements with out-of-network
providers.   2.3.18   Specialty Pediatric Hospitals: The health plan shall
include specialty pediatric hospitals as defined in 13 CSR 70-15.010 (2) (P), as
amended, in the health plan provider network.   2.4   Payments to Providers:    
  The state agency believes that one of the advantages of a managed care system
is that it permits the health plan and providers to enter into creative payment
arrangements intended to encourage and reward effective utilization management
and quality of care. The state agency therefore shall give the health plan and
providers as much freedom as possible to negotiate mutually acceptable payment
rates and payment time frames. All subcontracts shall contain the time frames
for paying in-network providers for covered services. However, regardless of the
specific arrangements the health plan makes with providers, the health plan
shall make timely payments to both in-network and out-of-network providers,
subject to the conditions described below. All disputes between the health plan
and in-network and out-of-network

 

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RFP B3Z06118   Page 18

    providers shall be solely between such providers and the health plan. In the
case of any disputes regarding payment for covered services between the health
plan and providers, the member shall not be charged for any of the disputed
costs. This agreement shall only be overcome by written evidence of an agreement
between the provider and the member indicating that the member accepts the
status and liabilities of a private pay patient. The health plan shall make it
clear to members that all covered services are available to the member at no
cost subject to any applicable co-pays. The private pay agreement shall only be
for services not included in the comprehensive benefit package.   2.4.1  
Retroactive Eligibility Period: Except for newborns, the health plan shall not
be responsible for any payments owed to providers for services rendered prior to
a member’s enrollment even if they fell within the established period of
retroactive eligibility.   2.4.2   Claims Processing Requirements: The claim
processing requirements are set forth by RSMo 376.383 and RSMo 376.384, as
amended.   2.4.3   Clean Claims: Clean claim means a claim that can be processed
without obtaining additional information from the provider of the service or
from a third party.   2.4.4   Inappropriate Payment Denials: If the health plan
has a pattern of inappropriately denying or delaying payments for services, the
health plan may be subject to suspension of new enrollments, withholding in full
or in part of capitation payments, contract cancellation, or refusal to contract
in a future time period. This applies not only to cases where the state agency
has ordered payment after appeal but to cases where no appeal has been made
(i.e., the state agency is knowledgeable about the documented abuse from other
sources).   2.4.5   Copayment Requirements and Member Participation in Pharmacy
Professional Dispensing Fee:

  a.   Copayment requirements do not apply to MC+ Managed Care members.     b.  
Member Participation in Pharmacy Professional Dispensing Fee

  1)   Unlike traditional copayment requirements, the current Missouri Medicaid
Recipient Pharmacy fee requirement is considered a portion of the professional
dispensing fee and is not deducted from the reimbursement to providers.
Therefore, the member portion of the pharmacy dispensing fee is required to be
collected, according to current Medicaid policy, for pharmacy services provided
by the health plan. The provider must charge and collect dispensing fees as
specified in accordance with section 208.152 RSMo, as amended. Providers shall
not deny or reduce services to members solely on the basis of the member’s
inability to pay the fee when charged. A member’s inability to pay a required
amount as due and charged when a service is delivered, shall in no way
extinguish the member’s liability to pay the amount due. Fee responsibility and
amounts collectible shall be as follows:

              Member Participation in Pharmacy Ingredient Cost for Each Item of
Service   Professional Dispensing Fee
$10.00 or Less:
    $0.50  
$10.01 to $25.00:
    $1.00  
$25.01 or More:
    $2.00  

  2)   Under current pharmacy dispensing fee policy, all Missouri eligible
recipients are subject to the fee requirement when provided covered pharmacy
services, with the exception of the following:

  •   Beneficiaries under age 19.

 

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RFP B3Z06118   Page 19

  •   Services related to Early Periodic Screening, Diagnosis and Treatment
(EPSDT): Those drugs which are prescribed and identified as relating to an EPSDT
program screening or referral services must be confirmed as such to the
dispensing provider through one of the following methods:

  Ø   The prescribing provider identifies on the prescription that it relates to
an EPSDT examination and treatment; or     Ø   The prescribing provider verbally
states that the prescription relates to an EPSDT examination and treatment in
cases of telephone prescribing. This verbal assertion must be included in the
dispensing provider’s reduction into writing of the prescription.

  •   Institutionalized members residing in a skilled nursing facility,
psychiatric hospital, residential care facility, or adult boarding home.     •  
Foster Care children.     •   All Medicare/Medicaid crossover claims as primary
coverage as afforded by the Medicare program.     •   Those services
specifically identified as related to Family Planning services.     •  
Emergency services.     •   Services provided to pregnant women which are
directly related to the pregnancy or a complication of the pregnancy.

  3)   Participation in the health plan provider network shall be limited to
providers who accept, as payment in full, the amounts paid by the health plan
plus any fee amount required of the member and collected by the provider.

2.4.6   Pharmacy Dispensing Fee: The health plan shall pay a pharmacy dispensing
fee of $4.09 to each qualifying pharmacy for the first 1,000 prescriptions
filled in any calendar quarter. The reimbursement of a pharmacy dispensing fee
shall be available only to corporations, partnerships, or individual
proprietorships with less than 25 employees who operate pharmacies or pharmacy
franchises and to public health entities owned and operated by a state, county,
or local government agency and where the entity is a hospital which qualifies as
a first-tier 10% add-on disproportionate share hospital in accordance with 13
CSR 70-15.010. The health plan shall identify its pharmacies that qualify. The
health plan shall supply the state agency with a list of those pharmacies
identified to qualify for a pharmacy dispensing fee reimbursement upon request.
  2.4.7   Federally Qualified Health Centers (FQHCs) and Rural Health Clinics
(RHCs): If the health plan includes subcontracted FQHCs or RHCs in the health
plan provider network, the FQHC or RHC is entitled to reimbursement of
reasonable costs from the state agency and any differential payment paid by the
state agency.

  a.   The health plan shall reimburse the FQHC/RHC at the same reimbursement
level as other providers for the same services. The state agency shall perform
reconciliation between the health plan reimbursement and the FQHC/RHC’s
reasonable costs for the covered services provided under the contract. The
FQHC/RHC must fully comply with the state agency’s payment and billing systems,
and provide the state agency with all cost reporting information required by the
state agency to verify reasonable costs and apply applicable reasonable cost
reimbursement principles. The health plan shall submit a list of its contracted
FQHCs and RHCs to the state agency annually at the start of each contract
period.

 

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RFP B3Z06118   Page 20

  b.   If the health plan contracts with FQHCs or RHCs, the health plan shall
fulfill the following:

  1)   Billing for Services Provided by an FQHC or RHC: The FQHC/RHC must bill
using a valid FQHC/RHC’s Medicaid Provider Number. The health plan shall include
this Medicaid Provider Number on FQHC/RHC claims as follows:

  •   FQHC Medical and Dental Claims: The health plan shall submit the FQHC’s
Missouri Medicaid Provider Number on the NSF layout, record ‘FAO’, within field
number 23. This field is referenced as the Rendering Provider Number.     •  
FQHC Home Health Claims: The health plan shall submit the FQHC’s Missouri
Medicaid Provider Number on the UB92 layout, record ‘80’, within field number
11. This field is referenced as the Other Provider.     •   FQHC Pharmacy
Claims: The health plan shall submit the FQHC’s Missouri Medicaid Provider
Number on the NCPDP 3C layout, field number 411. This field is referenced as the
Prescriber ID.     •   RHC Claims: The health plan shall submit the RHC’s
Missouri Medicaid Provider Number on the UB92 layout, record 80’, within field
number 11. This field is referenced as the Other Provider.

  2)   The FQHC/RHC must bill its usual and customary amount for all payor
classes. The health plan shall include the billed amount when the health plan
submits the encounter claims to the state agency.     3)   Reporting
Requirements for Services Provided by an FQHC or RHC

  •   The health plan shall submit Schedule M-1 included with Attachment 7
documenting the accepted charges, denied charges, and payments for each
contracted RHC/FQHC. The health plan shall submit Schedule M-1 thirty (30)
calendar days after the month end for services provided by the contracted
FQHC/RHC. Attachment 7 also provides the instructions for completing Schedule
M-1.     •   The health plan shall submit Schedule M-2 included with Attachment
7 documenting the accepted charges, denied charges, and payments for each
contracted RHC/FQHC for the FQHC’s/RHC’s entire fiscal year. The health plan
shall submit Schedule M-2 within 14 business days of request by the state agency
for MC+ managed care services provided by contracted FQHC/RHC during the
reporting period requested. Attachment 7 also provides the instructions for
completing Schedule M-2.     •   Health plan records applicable to a FQHC/RHC
are subject to audit by the state agency or its contracted agent.

2.4.8 Payment for Emergency Services and Post-stabilization Care Services:

  a.   The health plan shall cover and pay for emergency services regardless of
whether the provider that furnishes the services has a contract with the health
plan.

  1)   The state agency encourages the health plan and providers to reach
agreement on payment for services.     2)   The health plan shall pay
out-of-network providers for emergency services at the current Missouri Medicaid
program rates in effect at the time of service unless the health plan and
provider have negotiated a mutually acceptable rate.

 

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RFP B3Z06118   Page 21

  b.   The health plan may not deny payment for treatment obtained under either
of the following circumstances:

  1)   A member 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 specified herein.     2)   A
representative of the health plan instructs the member to seek emergency
services.

  c.   The health plan shall not limit what constitutes an emergency medical
condition as defined herein on the basis of lists of diagnoses or symptoms.    
d.   The health plan shall not refuse to cover emergency services based on the
emergency room provider, hospital, or fiscal agent not notifying the member’s
primary care provider or the health plan of the member’s screening and treatment
within ten (10) calendar days of presentation for emergency services.     e.   A
member 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.     f.   The attending emergency physician, or the
provider actually treating the member, is responsible for determining when the
member is sufficiently stabilized for transfer or discharge, and that
determination is binding on the health plan.     g.   The health plan must be
financially responsible for post-stabilization care services obtained within or
outside the health plan that are pre-approved by a health plan provider or other
health plan representative.     h.   The health plan must be financially
responsible for post-stabilization care services obtained within or outside the
health plan that are not pre-approved by a health plan provider or other health
plan organization representative, but administered to maintain the enrollee’s
stabilized condition within thirty (30) minutes of a request to the health plan
for pre-approval of further post-stabilization care services.     i.   The
health plan must be financially responsible for post-stabilization care services
obtained within or outside the health plan that are not pre-approved by a health
plan provider or other health plan representative, but administered to maintain,
improve, or resolve the enrollee’s stabilized condition if:

  1)   The health plan does not respond to a request for pre-approval within
thirty (30) minutes;     2)   The health plan cannot be contacted; or     3)  
The health plan representative and the treating physician cannot reach an
agreement concerning the member’s care and a health plan physician is not
available for consultation. In this situation, the health plan must give the
treating physician the opportunity to consult with a health plan physician and
the treating physician may continue with care of the patient until a health plan
physician is reached or one of the criteria in subparagraph l below is met.

  j.   The health plan must limit charges to members for post-stabilization care
services to an amount no greater than what the health plan would charge the
member if he or she had obtained the services through the health plan.     k.  
The health plan shall negotiate mutually acceptable payment rates with
out-of-network providers for post-stabilization services for which the health
plan has financial responsibility.

 

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RFP B3Z06118   Page 22

  l.   The health plan’s financial responsibility for post-stabilization care
services it has not pre-approved ends when:

  1)   A health plan physician with privileges at the treating hospital assumes
responsibility for the member’s care;     2)   A health plan physician assumes
responsibility for the member’s care through transfer;     3)   A health plan
representative and the treating physician reach an agreement concerning the
enrollee’s care; or     4)   The member is transferred.

2.4.9   The health plan shall maintain the fee schedule for dental services
located in Attachment 14 at no lower than the Medicaid fee-for-service fee
schedule in effect at the time of service.   2.4.10     Specialty Pediatric
Hospitals. The health plan shall reimburse specialty pediatric hospitals as
defined in 13 CSR 70-15.010 (2) (P) at no lower than the Medicaid
fee-for-service fee schedule in effect at the time of service unless otherwise
negotiated with the provider.   2.4.11   A health plan shall pay for services
furnished outside their service area to the same extent that it would pay for
services furnished within their service area if the services are furnished to a
member and any of the following conditions are met:

  a.   Medical services are needed because of a medical emergency;     b.  
Medical services are needed and the member’s health would be endangered if he
were required to travel to member’s residence:     c.   The health plan
determines, on the basis of medical advice, that the needed medical services, or
necessary supplementary resources, are more readily available outside the
service area. These services are subject to the health plan’s prior
authorization and concurrent review process.

2.5   Eligibility Determinations:       The Missouri Department of Social
Services, the Family Support Division performs eligibility determinations.
Trained staff are stationed full-time at field offices located throughout the
State and on a periodic basis at health care provider sites that serve large
numbers of MC+ members.   2.5.1   Health Plan Lock-In: All members will have a
twelve (12) month lock-in to provide a solid continuum of care. Once a member
chooses a health plan or is assigned to a health plan, the member will have
ninety (90) calendar days from the effective date of coverage with the health
plan in which to change health plans for any reason. This applies to the
member’s initial enrollment and to any subsequent enrollment periods where the
member changed health plans. All transfers between health plans that members
request during the first ninety (90) calendar days following initial enrollment
shall be granted without review by the state agency. Both the 90-day and the
12-month enrollment period begin on the same day. Children in COA 4 shall be
allowed automatic and unlimited changes in health plan choice as often as
circumstances necessitate.   2.5.2       Open Enrollment: The state agency may
conduct an open enrollment for the contract period. The state agency may at its
sole option adjust enrollment during the transition between contract periods.

  a.   Annual Open Enrollment: The state agency shall give members an annual
open enrollment period prior to their 12-month enrollment anniversary date with
the health plan. The state agency shall provide an open enrollment notice to
members at least sixty (60) calendar days before each annual enrollment
opportunity.

2.5.3       Enrollment Counseling: The state agency shall make available
helpline operators to all program MC+ managed care eligibles to provide
assistance in selecting and enrolling into a health plan through the operation
of a toll-free telephone line. Helpline operators also shall be available by
telephone to assist

 

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RFP B3Z06118   Page 23

    MC+ managed care eligibles who would like to change health plans (e.g.,
during open enrollment). MC+ managed care eligibles shall be offered the
assistance of a helpline operator when needed. The helpline operator
responsibilities shall include the following:

  a.   Educating the family about managed care in general, including the
requirement to enroll in a health plan, the way services typically are accessed
under managed care, the role of the primary care provider, the health plan
member’s right to choose a primary care provider subject to the capacity of the
provider, the responsibilities of the health plan member, and the member’s
rights to file grievances and appeals and to request a State Fair Hearing.    
b.   Educating the family about benefits available through the health plan, both
in-network and out-of-network.     c.   Informing the family of available health
plans and outlining criteria that might be important when making a choice (e.g.,
presence or absence of the family’s existing provider in the health plan
provider network).     d.   Identifying any sources of Third Party Liability
that were not identified by the FSD eligibility technician.     e.  
Administering a health plan screen when possible, as designated by the state
agency, that collects baseline health status data to be used as part of the
health plan program evaluation. Any baseline health status data shall be made
available to the health plan. (See Attachment 8 for the most current version.)  
  f.   Explaining options for obtaining services outside the health plan
network.     g.   Providing a listing of the health plan primary care providers
generated from the provider demographic electronic file submitted by the health
plan to the state agency.

2.5.4   Voluntary Selection of Health Plan: Missouri MC+ managed care eligibles
shall be given fifteen (15) calendar days from the time of their eligibility for
managed care to select a health plan. All members of a family shall be
encouraged to select the same health plan. If a family does not select a health
plan within the fifteen (15) day window, the state agency shall automatically
assign the family to a health plan.

2.5.5   Automatic Assignment Into Health Plans:

  a.   The state agency shall employ an algorithm to assign to the health plan,
on a prorated basis, any MC+ managed care eligibles who do not make a voluntary
selection of a health plan during open enrollment. The algorithm shall be based
on the following:

  1)   If the MC+ managed care eligible’s case head is enrolled with a health
plan, the MC+ managed care eligible shall be assigned to that health plan. If
not, the next step in the algorithm shall be followed.     2)   If the MC+
managed care eligible is included in a case where another member is enrolled
with a health plan, the MC+ managed care eligible shall be assigned to that
health plan. If not, the MC+ managed care eligible shall be assigned randomly.

Paragraph 2.5.5 b. revised by Amendment #001

  b.   Eastern/Western Regions: The random auto assignment shall be based on the
total evaluation determined by the State of Missouri (see Proposal Submission
Information section).

Paragraph 2.5.5 c. inserted by Amendment #001

  c.   Central Region: The random auto assignment shall be based on the
inclusion of health plan signed contracts with acute care safety net hospitals,
as defined in 13 CSR 70-15.010 of the Code of State

 

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RFP B3Z06118   Page 24

      Regulations, as amended. (A listing of safety net hospitals is provided in
Attachment 5.) The acute care safety net hospital must be located in the Central
region counties.

  1)   The health plan including such acute care safety net hospitals in its
network shall equally divide seventy percent (70%) of the random auto
assignments, while the remaining health plans shall equally share the remaining
thirty percent (30%) of the algorithm assignments.     2)   In the event all
health plans have such acute care safety net hospitals in their networks, all
contracted health plans shall equally share one hundred percent (100%) of the
random auto assignments.

2.5.6   Automatic Re-Assignment Following Resumption of Eligibility: Members who
are disenrolled from a health plan due to loss of eligibility, shall
automatically be re-enrolled, or assigned, into the same health plan and to the
same primary care provider should they regain eligibility within sixty
(60) calendar days. The member will have ninety (90) calendar days from the
effective date of coverage with the health plan in which to change health plans
for any reason. If more than sixty (60) calendar days have elapsed, the member
shall be permitted to select a health plan and primary care provider through the
enrollment process.

2.6   Member Enrollment and Disenrollment:   2.6.1   MC+ Managed Care Marketing
Guidelines: The health plan may educate and conduct marketing campaigns for MC+
managed care members, subject to the restrictions and definitions outlined
herein. Education activities are efforts directed to current members to provide
knowledge or skills. Marketing campaigns are efforts directed to an audience of
members and potential health plan members to retain or increase health plan
membership. The health plan and subcontractors shall not influence member
enrollment.

  a.   Marketing Guidelines: The health plan shall:

  1)   Submit its proposed marketing plan, all marketing materials, and member
education materials to the state agency for written approval prior to use. The
state agency shall only consider the marketing plan and materials submitted by
the health plan, (not subcontractors). The health plan should submit all
materials in mock camera-ready form. When submitting marketing and education
materials for approval, the health plan shall indicate how and when the material
will be used, the time frames for the use, and the media to be used for
distribution if approved. All written materials must be at a 6th grade reading
level or less. The state agency shall approve, disapprove, or require
modifications of education and marketing materials. The state agency shall
review and respond as soon as possible, but within thirty (30) calendar days of
receipt by the state agency. Marketing and education materials are deemed
approved if a response from the state agency is not returned within thirty
(30) calendar days following receipt of the materials by the state agency. The
health plan shall engage in only those marketing activities which are prior
approved in writing.     2)   The health plan’s marketing material shall include
a listing of their in-network providers identified by specialty and location, as
appropriate for the document submitted for approval.     3)   The health plan’s
marketing and education materials shall include the member’s rights and
responsibilities to assistance in obtaining all covered services.     4)  
Correct problems and errors with the marketing plan and/or materials as
identified by the state agency. The health plan shall submit to the state agency
a written corrected marketing plan or revised material within ten (10) business
days following receipt date of the written notice from the state agency.

 

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RFP B3Z06118   Page 25

  5)   Not display or distribute any marketing materials in any manner at Family
Support Division (FSD) offices, or health plan provider sites, unless the health
plan has received prior written permission to do so from the state agency. Only
approved member handbooks and provider network listing may be distributed to
local FSD offices. The health plan shall supply current materials and remove
their out-dated materials in public areas at the FSD offices.     6)   Review
all education and marketing materials at least once a year. The health plan
shall provide the state agency with copies of materials and documentation
verifying the health plan reviewed their education and marketing material.    
7)   Submit to the state agency, for prior written approval, all materials used
by in-network providers to advise members of the health plans with which they
have contracts. The health plan shall provide the following listing of what
constitutes approved material to in-network providers.

  •   A list of all health plans with which they have contracts;     •   A
letter to previous fee-for-service recipients who may be eligible for MC+
managed care, informing them of all health plan(s) with which the provider has
contracted;     •   A display of all contracted health plan logos in an equal
fashion;     •   A listing of all contracted health plan phone numbers;     •  
Access to all contracted health plan directories and member handbooks as a
member resource but not for distribution; and     •   Displaying enrollment
helpline phone number.

      The in-network provider shall provide equal representation of all
contracted health plans and shall not favor one health plan over another in
displayed information.     8)   Show the date the state agency approved the
material in the lower right-hand corner of all materials.     9)   Use mandatory
education, marketing, and member notice language provided by the state agency.
The state agency shall provide such language as it deems necessary. Any
publicity given to the MC+ Managed Care Program or the MC+ managed care
benefits, including but not limited to: notices, pamphlets, press releases,
research, reports, signs, and public notices prepared by or for the health plan
shall be released only with prior written approval by the state agency.     10)
  Not use the state agency’s or the Department of Social Services’ name, logo,
or other identifying marks on any of the materials produced or issued without
the prior written approval of the state agency.     11)   Not use any report,
graph, chart, picture, or other document produced and included in whole or in
part under the MC+ managed care contract which is subject to copyright or the
subject of any application for copyright by or on behalf of the health plan.    
12)   Develop MC+ managed care marketing plans and materials that are accurate
and shall not mislead, confuse, defraud, or deceive MC+ managed care eligibles,
or otherwise violate Federal or State consumer protection laws or regulations.
MC+ managed care benefits must be listed according to the current MC+ managed
care contracts. The health plan may not verbally or in writing identify or
portray covered benefits as enhanced, additional, or free.     13)   Not
practice door-to-door, face-to-face, telephonic, or other “cold call” marketing.
The offerings of cash, prizes, other items for material gain, or other insurance
products as an award for enrollment are prohibited. However, the health plan may
offer additional health benefits to their members. If the health plan offers
additional health benefits, the health plan must notify

 

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RFP B3Z06118   Page 26

      the state agency of these benefits no later than ten (10) calendar days
prior to their offering and must notify the state agency no less than thirty
(30) calendar days prior to discontinuing such benefits.

  •   Cold Call Marketing means any unsolicited personal contact by the health
plan with a potential member for the purpose of marketing as defined in this
paragraph.

  14)   Provide notice to the state agency or have prior written approval from
the state agency in certain situations to sponsor or participate in community
activities, programs, or events.

  •   Community activities are defined for the purpose of this document as: An
activity where people come together to learn about or question health care
benefits, responsibilities, and procedures. These community activities require
no notice to the state agency, except when held at provider sites. At community
activities, the health plan shall only use materials approved by the state
agency and must adhere to the ban on engaging in enrollment activities required
herein.     •   Community activities at provider sites require a seven
(7) calendar day notice to the state agency prior to sponsoring or participating
in an activity. Provider sites may include, but are not limited to pharmacies in
discount or grocery stores if the pharmacies are in an MC+ managed care network,
local public health agency, provider clinics, hospitals etc.     •   The health
plan may offer the availability of gifts no greater than $10 in value, and only
if such gifts are offered during any community activity (i.e. health fair). The
nominal items must be offered to all individuals attending the community
activity. The gifts must be directly and obviously health related or limited to
printed materials, T-shirts, pens or pencils, caps, mugs, key chains, etc. All
items must have prior written approval by the state agency and written proof of
cost per unit must be provided by the health plan to the state agency prior to
approval. Once an item is approved, it does not have to be re-approved for
additional community activities. Advertising the availability of such gifts
through mailings, TV or radio, posters, and other promotions or publicity is
prohibited.

  15)   Not offer raffles or conduct lotteries. Door prizes may be offered
within the parameters and limits specified for participation in community
activities, programs, or events.     16)   Request state agency prepared
mandatory MC+ managed care materials from the state agency. The health plan and
its subcontractors should make the general public aware of the MC+ program by
providing any of the following:

  •   General MC+ eligibility information; or     •   MC+ applications to
complete and mail.

  17)   Not conduct or participate in health plan enrollment, disenrollment,
transfer, or opt out activities. The health plan and the providers shall not
influence a member’s enrollment. Prohibited activities include:

  •   Requiring or encouraging the member to apply for an assistance category
not included in MC+ managed care;     •   Requiring or encouraging the member
and/or guardian to use the opt out as an option in lieu of delivering health
plan benefits;     •   Mailing or faxing health plan enrollment forms;     •  
Aiding the member in filling out health plan enrollment forms;

 

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RFP B3Z06118   Page 27

  •   Photocopying blank health plan enrollment forms for potential members;    
•   Distributing blank health plan enrollment forms;     •   Participating in
three way calls to the MC+ managed care enrollment helpline;     •   Suggesting
a member transfer to another health plan; or     •   Other activities in which
the health plan, its representatives, or in-network providers are engaged in
activities to enroll a member in a particular health plan or in any way
assisting a member to enroll in a health plan (their own or another).

  18)   Advise the health plan’s subcontractors of these marketing guidelines
and ensure that subcontractors adhere to them. No subcontract shall operate to
relieve the health plan of its obligations. The health plan shall have written
procedures to ensure subcontractor notification and compliance with these
marketing guidelines.     19)   Use pre-approved MC+ managed care information
and materials for presentations or interviews with print and electronic media.  
  20)   Not use testimonial materials and/or celebrity endorsements.     21)  
Insert new language in the educational and marketing materials and substitute in
a timely manner, as outlined by the state agency, any changes in Federal or
State law or regulation, as amended, as the need arises.     22)   Make an
effort to ensure that presentations shall be available to maximize consumer
access to information, including presentation after normal work hours, and at
sites other than the Family Support Division offices, such as WIC sites, Head
Start centers, health fairs, etc.     23)   Make member education available on
an ongoing basis to provide guidance on how to use a health plan, and how to
assert certain rights with their health plan, if necessary.     24)   Market to
the entire service area     25)   All marketing and educational material shall
maintain a member’s right to confidentiality. In particular, post cards must be
folded to protect the confidentiality of the member.     26)   Not develop
marketing materials that contain any assertion or statement (whether written or
oral) that:

  •   The recipient must enroll with the health plan in order to obtain benefits
or in order not to lose benefits.     •   The health plan is endorsed by CMS,
the Federal or State government or similar entity.

2.6.2   Health Plan Enrollment Procedures:

  a.   The state agency reserves the right to suspend or limit enrollment into a
health plan. In the event the health plan’s enrollment reaches sixty-five
(65) percent of the total MC+ managed care enrollment in the region, the health
plan shall not be offered as a choice for enrollment nor shall the health plan
receive members through the automatic assignment algorithm. However, the health
plan may receive new members as a result of newborn enrollments, reassignments
when a member loses and regains MC+ managed care eligibility within a sixty
(60) day period, other family or case members are members of the health plan,
for the member’s continuity of care, or for just cause determined by

 

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RFP B3Z06118   Page 28

      the state agency. The state agency’s evaluation of a health plan’s
enrollment market share shall take place on a calendar quarter.     b.   The
state agency shall conduct enrollment activities for MC+ managed care eligibles.
The health plan or its subcontractors shall not conduct or participate in
eligibility or enrollment activities.     c.   The health plan shall have
written policies and procedures for enrolling these members within five
(5) business days after receiving notification of the member’s anticipated
enrollment date from the state agency (e.g., if the health plan is informed of a
new member on a Wednesday, it must contact the member by the following Tuesday).
    d.   The health plan shall enroll any MC+ managed care eligible who selects
the health plan or is assigned with the health plan. The only exceptions shall
be if:

  1)   The health plan’s specified enrollment limit has been reached.     2)  
The member was previously disenrolled from the health plan as the result of a
request for disenrollment by the health plan, as allowed herein.

  e.   Enrollment of Program Newborns: The health plan shall have written
policies and procedures for enrolling the newborn children of members effective
to the date of birth. Newborns of members enrolled at the time of the child’s
birth shall be automatically enrolled with the mother’s health plan. The health
plan shall have a procedure in place to refer newborns to the Family Support
Division to initiate eligibility determinations. A mother of a newborn may
choose a different health plan for her child; unless a different health plan is
requested, the child shall remain with the mother’s health plan.

  1)   The mother’s health plan shall be responsible for all medically necessary
services provided under the comprehensive benefit package to the newborn child
of an enrolled mother. The child’s date of birth shall be counted as day one
(1). The health plan shall provide services to the child until the child is
disenrolled from the health plan. When the newborn is assigned a departmental
client number (DCN), the health plan shall receive capitation payment for the
month of birth and for all subsequent months the child remains enrolled with the
health plan.     2)   In the case of an administrative lag in enrolling the
newborn and costs are incurred during that period, the health plan shall hold
the member harmless for those costs. The health plan shall be responsible for
the cost of the newborn including medical services provided prior to completion
of the State enrollment process.

  f.   Changes in Status: The health plan shall encourage its membership to
report to the Family Support Division any changes in the status of families or
members, including changes in family size, income, insurance coverage, and
residence.     g.   Enrollment and Disenrollment Updates: Every business day,
the state agency shall make available, via electronic media, updates on members
newly enrolled into the health plan, or newly disenrolled. The health plan shall
have written policies and procedures for receiving these updates and
incorporating them into the health plan and health care service subcontractors’
management information system each day.     h.   Weekly Reconciliation: On a
weekly basis, the state agency shall make available, via electronic media, a
listing of current members. The health plan shall reconcile this membership list
against the health plan internal records within thirty (30) business days of
receipt and shall notify the state agency of any discrepancies.     i.  
Services for New Members: The health plan shall make available the full scope of
benefits to which a member is entitled immediately upon his or her enrollment.

 

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RFP B3Z06118   Page 29

  j.   New Member Orientation: The health plan shall have written policies and
procedures for orienting new members to their benefits; the role of the primary
care provider; how to utilize services; what to do in an emergent or urgent
medical situation; how to file a grievance or appeal; and how to report
suspected fraud and abuse.

  1)   Member Responsibilities: The health plan shall have written policies that
address the members’ responsibilities for cooperating with providers. These
member responsibility policies must be supplied in writing to all providers and
members. These written policies should address the members’ responsibilities
for:

  •   Providing, to the extent possible, information needed by providers in
caring for the member.     •   Contacting their primary care provider as their
first point of contact when needing medical care.     •   Following appointment
scheduling processes.     •   Following instructions and guidelines given by
providers.

  2)   Member Rights: The health plan shall have written policies regarding
member rights as specified below:

  •   General Rule. Each health plan must comply with any applicable Federal and
State laws that pertain to member rights and ensure that its staff and
affiliated providers take those rights into account when furnishing services to
members.     •   Dignity and privacy. Each member is guaranteed the right to be
treated with respect and with due consideration for his or her dignity and
privacy.     •   Receive information on available treatment options. Each member
is guaranteed the right to receive information on available treatment options
and alternatives, presented in a manner appropriate to the member’s condition
and ability to understand.     •   Participate in decisions. Each member is
guaranteed the right to participate in decisions regarding his or her health
care, including the right to refuse treatment.     •   Free from restraint or
seclusion. Each member is guaranteed the right to be free from any form of
restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation.     •   Copy of medical records. Each member is guaranteed 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 part 164.    
•   Free exercise of rights. Each member is free to exercise his or her rights,
and that the exercise of those rights does not adversely affect the way the
health plan and its providers or the state agency treat the member.

  k.   Assignment of Primary Care Providers: The health plan shall have written
policies and procedures for assigning each of the health plan’s members to a
primary care provider. The process must include at least the following features:

 

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RFP B3Z06118   Page 30

  1)   The health plan shall contact the member within five (5) business days
from the date of the state agency’s notification to the health plan of the
member’s anticipated enrollment date. To the extent provider capacity exists,
the health plan shall offer freedom of choice to members in making a primary
care provider selection.         At the time of the state agency’s notification
to the health plan, the health plan may assign a primary care provider taking
into consideration factors such as current provider relationships, language
needs, (to the extent they are known), and area of residence. When contacting
the member, the health plan shall provide the member with the primary care
provider’s name, location, and telephone number. When contacting the member, the
health plan shall provide options for selecting a primary care provider other
than the primary care provider assigned to the member. The health plan shall
inform the member he/she has fifteen (15) calendar days to choose another
primary care provider if they do not approve of the primary care provider
assigned to them, and if they have not notified the health plan of their
preferred primary care provider within that time frame, the member will remain
with the primary care provider previously assigned to the member.     2)   Prior
to becoming effective with the health plan, if a member does not select a
primary care provider or the health plan has not already assigned a primary care
provider to the member at the time of notification from the state agency of the
member’s anticipated enrollment date, the health plan shall make an automatic
assignment, taking into consideration such known factors as current provider
relationships, language needs (to the extent they are known), and area of
residence. The health plan shall then notify the member in writing of his or her
primary care provider’s name, location, and office telephone number. The member
must have a primary care provider assigned by the time the member is effective
with the health plan. If circumstances are such that the member does not have a
primary care provider assigned on the effective date with the health plan, the
health plan shall not deny services or payment of any service. The health plan
shall submit to the state agency the methodology utilized by the health plan to
assign primary care providers to members.     3)   Members with disabling
conditions or chronic illnesses may request that their primary care providers be
specialists, such as a psychiatrist, oncologist, obstetrician, gynecologist, or
other such specialist. The health plan must have procedures for ensuring access
to needed services for those members or the request shall be granted. The
specialist must accept the member as a primary care patient and accept the
responsibility of a primary care provider as specified herein. The health plan
must communicate its decision to the member within ten (10) calendar days of
request. The adequacy of these policies shall be reviewed by the state agency.  
  4)   The health plan shall have written policies and procedures for notifying
primary care providers of their assigned member prior to the member’s effective
date with the primary care provider.

  l.   Changing Primary Care Providers: The health plan shall have written
policies and procedures for allowing members to select or be assigned to a new
primary care provider within the health plan when such a change is mutually
agreed to by the health plan and member. The health plan shall allow members at
least two such changes per year, and shall inform members of the process for
initiating these changes. However, children in COA 4 may change primary care
providers at will. Possible reasons for a member to change primary care
providers include, but are not limited to:

  1)   Accessibility — transportation problems, provider office hours, does not
return phone calls, waiting times.     2)   Acceptability — sees too many
doctors, uncomfortable with surroundings or location, provider or staff
attitudes, lack of courtesy, following a member’s initial visit to the primary
care provider.

 

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RFP B3Z06118   Page 31

  3)   Quality — treatment (medical), referral related, does not explain
treatment plan/diagnosis. If provider problem, may request primary care provider
changes and second opinion.     4)   Enrollment — primary care provider with
whom the member has an established patient/provider relationship no longer
participates in the health plan. In cases where the primary care provider no
longer participates, the health plan shall allow members to select another
primary care provider or make a re-assignment within fifteen (15) calendar days
of the termination effective date.     5)   An act of cultural insensitivity
that negatively impacts the member’s ability to obtain care.     6)   A primary
care provider change is ordered as part of the resolution to the grievance and
appeal process. A member’s right to request a change in a primary care provider
through the grievance and appeal process or other means shall not be restricted.

  m.   Identification Cards: The state agency shall issue a plastic, magnetic
strip identification card to all Missouri MC+ eligibles. This card is not proof
of eligibility, but to be used as a key for accessing the State’s electronic
eligibility verification systems by Medicaid enrolled providers. These systems
shall contain the most current information available to the state agency,
including specific information regarding health plan enrollment. There will be
no health plan specific information printed on the card. In addition to the
state agency issued card, the health plan should issue a membership card that
contains information more specific to the health plan. The health plan issued
membership card must be issued to the member prior to the member’s effective
date of coverage with the health plan. Upon selection or assignment of a health
plan, the member’s effective date shall be 15 calendar days in the future,
thereby allowing the health plan to send the appropriate enrollment materials,
such as the identification card, to the member prior to the effective date.
Exceptions apply to this policy for newborns and emergency enrollments. The
state agency recognizes those exceptions and such enrollment materials may be
produced as expeditiously as possible, but no later than 15 calendar days from
the notification of the enrollment. At a minimum, the health plan issued
membership card must contain the member’s name, identification number, primary
care provider name and telephone number, instructions for emergencies, and other
relevant toll free lines for access such as mental health, dental, pharmacy, and
nurse advice lines.     n.   Member Handbook: The health plan shall mail a
member handbook, or other written materials with information on how to access
services, to all members within ten (10) business days of being notified of
their future enrollment with the health plan. When there are program changes,
the health plan shall notify the affected members at least thirty (30) calendar
days before implementation of such change. On an annual basis, the health plan
shall review the member handbook and shall document that such review occurred.

  1)   The member handbook must be written at no higher than a sixth grade
level. Suggested reference material to determine whether this requirement is
being met are:

  •   Fry Readability Index     •   PROSE The Readability Analyst (software
developed by Education Activities, Inc.)     •   Gunning FOG Index     •  
McLaughlin SMOG Index     •   The Flesch-Kincaid Index or other word processing
software approved by the state agency.

  2)   At a minimum, the member handbook shall include the information and items
listed below. The health plan may include some of the following information as
inserts to the member

 

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RFP B3Z06118   Page 32

      handbook. The health plan shall include certain passages and language
provided by the state agency in the member handbook. The health plan shall
comply with all changes regarding member handbook content specified by the state
agency in a timely manner as defined by the state agency.

  •   Table of contents.     •   Information about choosing and changing primary
care providers, including notice of how to determine whether a participating
provider is accepting new patients.     •   Information about what to do when
family size changes.     •   Appointment procedures.     •   A description of
all available health plan services and an explanation of any service limitations
or exclusions from coverage and a notice stating that the health plan shall be
liable only for those services authorized by the health plan.     •   A
description of all available services outside the comprehensive benefit package.
Such information shall include information on where and how members may access
benefits not available under the comprehensive benefit package.     •   The
definition of medical necessity used in determining whether benefits will be
covered.     •   A description of all prior authorization or other requirements
for treatments and services.     •   A description of utilization review
policies and procedures used by the health plan.     •   An explanation of a
member’s financial responsibility for payment when services are provided by an
out-of-network provider or by any provider without required authorization or
when a procedure, treatment, or service is not covered by MC+ managed care.    
•   Notice that a member may obtain an out-of network provider when the health
plan does not have an in-network provider with appropriate training and
experience to meet the particular health care needs of the member and the
procedure by which the member can obtain such referral.     •   Notice that a
member with a condition which requires ongoing care from a specialist may
request a standing referral to such a specialist and the procedure for
requesting and obtaining such a standing referral.     •   Notice that a member
with a life-threatening condition or disease or a degenerative and disabling
condition or disease, either of which requires specialized medical care over a
prolonged period of time, may request a specialist responsible for providing or
coordinating the member’s medical care and the procedure for requesting and
obtaining such a specialist.     •   Notice that a member with a
life-threatening condition or disease or a degenerative and disabling condition
or disease, either of which requires specialized medical care over a prolonged
period of time, may request access to a specialty care center and the procedure
by which such access may be obtained.     •   A description of the mechanisms by
which members may participate in the development of the policies of the health
plan.

 

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RFP B3Z06118   Page 33

  •   Notice of all appropriate mailing addresses and telephone numbers to be
utilized by members seeking information or authorization.     •   Procedures for
disenrollment, including an explanation of the member’s right to disenroll with
and without cause.     •   How to contact member services and a description of
its function.     •   Information on grievance, appeal, and fair hearing
procedures and timeframes. Such information includes:

  a)   The right to file grievances and appeals.     b)   The requirement and
timeframes for filing a grievance or appeal.     c)   The availability of
assistance in the filing process.     d)   The toll-free numbers that the member
can use to file a grievance or an appeal by phone.     e)   The procedures for
exercising the rights to appeal or request a State fair hearing.     f)   That
the member may represent himself or use legal counsel, a relative, a friend, or
other spokesperson.     g)   Must explain the specific regulations that support,
or the change in Federal or State law that requires the action.     h)   The
fact that, when requested by the member -

  •   Benefits will continue if the member files an appeal or a request for
State fair hearing within the timeframes specified for filing; and     •   The
member may be required to pay the cost of services furnished while the appeal is
pending, if the final decision is adverse to the member.

  i)   The member’s right to request a State fair hearing, or in cases of an
action based on change in law, the circumstances under which a hearing will be
granted.

  •   A member may request a State fair hearing within 90 calendar days from the
health plan’s notice of action.     •   The state agency must reach its
decisions within the specified timeframes:

  1)   Standard resolution: within 90 calendar days of the date the member filed
the appeal with the health plan if the member filed initially with the health
plan (excluding the days the enrollee took to subsequently file for a State fair
hearing) or the date the member filed for direct access to a State fair hearing.
    2)   Expedited resolution (if the appeal was heard first through the health
plan appeal process): within 3 working days from the state agency’s receipt of a
hearing request for a denial of a service that:

  •   Meets the criteria for an expedited appeal process but was not resolved
using the health plan’s expedited appeal timeframes, or     •   Was resolved
wholly or partially adversely to the member using the health plan’s expedited
appeal timeframes.

  3)   Expedited resolution (if the appeal was made directly to the State Fair
Hearing process without accessing the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request for a denial
of a service that meets the criteria for an expedited appeal process.

  j.   Any appeal rights that the state chooses to make available to providers
to challenge the failure of the organization to cover a service.

  •   How to report suspected fraud and abuse activities.

 

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RFP B3Z06118   Page 34

  •   Pharmacy dispensing fee requirements (if applicable): The health plan must
include a statement that care shall not be denied due to lack of payment of
pharmacy dispensing fee requirements.     •   Provider network listing including
a list of the names, specialty, telephone numbers, service site address of all
providers available for selection, and in the case of physicians, board
certification. The provider network listing can be a separate document apart
from the member handbook.     •   The extent to which, and how, after-hours and
emergency coverage are provided, including the following: (a) What constitutes
an emergency medical condition, emergency services, and post-stabilization
services; (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
locations of any emergency settings and other locations at which providers and
hospitals furnish emergency services and post-stabilization services covered
herein; (e) The fact that the member has a right to use any hospital or other
setting for emergency care; and (f) The post-stabilization care services rules
specified herein.     •   How to obtain emergency transportation and
non-emergency medically necessary transportation.     •   EPSDT services
including immunization and lead guidelines designated by the state agency.     •
  Maternity, family planning, and sexually transmitted diseases services.     •
  Mental health and substance abuse services, including information on how to
obtain such services, the rights the member has to request such services, and
how to access services when in crisis, including the toll free number to be used
to access such services.     •   How to obtain services when out of the member’s
geographic region and for after-hours coverage.     •   Out-of-county and
out-of-state moves.     •   Statement that the health plan shall protect its
members in the event of insolvency. The health plan shall not hold its members
liable for any of the following:

  Ø   The debts of the health plan in the case of health plan insolvency;     Ø
  Services provided to a member in the event the health plan failed to receive
payment from the state agency for such service;     Ø   Services provided to a
member in the event a health care provider with a contractual referral or other
type arrangement with the health plan fails to receive payment from the state
agency or the health plan for such services; or     Ø   Payments to a provider
that furnishes covered services under a contractual referral or other type
arrangement with the health plan in excess of the amount that would be owed by
the member if the health plan had directly provided the services.

  •   Inform the member that if he or she has a worker’s compensation claim, or
a pending personal injury or medical malpractice law suit, or has been involved
in an auto accident, to immediately contact the health plan.

 

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RFP B3Z06118   Page 35

  •   Inform the member that if he or she has another health insurance policy,
all prepayment requirements must be met as specified by the other health
insurance plan. The member must notify the health plan of any changes to their
other health insurance policy. The member can contact the health plan with any
questions.     •   Inform the member of the Health Insurance Premium Payment
program which pays for health insurance for members when it is determined cost
effective.     •   Contributions the member can make towards his or her own
health, appropriate and inappropriate behavior, and any other information deemed
essential by the health plan or the state agency including the member’s rights
and responsibilities.     •   Inform members that multilingual interpreters will
be offered when needed and written information is available in prevalent
languages and how to access those services.     •   Inform the member of the
procedures that will be utilized to notify members affected by termination or
change in benefits, services, or service delivery office/site.     •   Inform
the member that the health plan shall provide information on the health plan’s
physician incentive plan to any member upon request. Enrollment materials/member
handbooks should annually disclose to members their right to adequate and timely
information related to physician incentives.     •   With respect to advance
directives, inform the member of the following:

  a)   Their rights under the law of the state.     b)   The health plan’s
policies respecting the implementation of those rights, including a statement of
any limitation regarding the implementation of advance directives as a matter of
conscience.     c)   The health plan must inform members that complaints
concerning noncompliance with the advance directive requirements may be filed
with the State survey and certification agency.

  •   Additional information that is available upon request, including the
following:

  a)   Information on the structure and operation of the MC+ health plan.

  •   Inform the member how to obtain one free copy of his or her medical
records annually.     •   Inform the member how to request and obtain an
Explanation of Benefits (EOB).

  o.   The health plan shall submit the member handbook to the state agency for
approval prior to distribution to members. The health plan shall make
modifications in member handbook language if ordered by the state agency so as
to comply with the member handbook requirements.     p.   The member must
receive written notification of changes in health plan operations that affect
them at least thirty (30) calendar days before the intended effective date of
the change unless otherwise noted. Examples of such changes are as follows:

  1)   Network changes such as a new Pharmacy Benefit Manager, mental health
subcontractor, or other major subcontractor. Notification is required to all
members.     2)   Primary care provider or other provider seen on a regular
basis leaves the network. The health plan shall provide written notice to the
affected members within 15 calendar days after receipt or issuance of the
termination notice.

 

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RFP B3Z06118   Page 36

  3)   Comprehensive Benefit Package changes from what is explained in the
member handbook. Notification is required to all members.     4)   Utilization
Management Procedure changes from what is explained in the member handbook.
Notification is required to all members.     5)   Prior Authorization Procedure
changes from what is explained in the member handbook. Notification is required
to all members.     6)   Advance directive policy changes as a result of changes
in State law.

  q.   All written member notifications must be prior approved by the state
agency and written at no higher than a sixth grade level. The health plan shall
include certain passages and language provided to the health plan by the state
agency in the member notification. The health plan shall comply with all changes
regarding member notification content specified by the state agency in a timely
manner as defined by the state agency.     r.   Transferring Members Between
Health Plans: It may be necessary to transfer a member between health plans for
a variety of reasons. The health plan shall have written policies and procedures
for transferring relevant member information, including medical records and
other pertinent materials, to or from another health plan. Upon request, a copy
of the member’s medical records and supporting documentation must accompany
disenrollment and transfer requests from the health plan. The state agency shall
monitor, and approve or disapprove all transfer requests for just cause, within
sixty (60) calendar days subject to medical record review. Possible reasons for
a member to request a transfer include, but are not limited to:

  •   Member requests health plan transfer during open enrollment.     •  
Member request health plan transfer during the first 90 days enrolled in the
health plan.     •   Transfer is the resolution to a grievance or appeal.     •
  Enrollment — primary care provider or specialist with whom the member has an
established patient/provider relationship does not participate in the health
plan but does participate in another health plan.     •   The member is pregnant
and her primary care provider or obstetrician does not participate in the health
plan but does participate in another health plan.     •   The member is a
newborn and the primary care provider or pediatrician selected by the mother
does not participate in the health plan but does in another health plan.     •  
Transfer to another health plan is necessary to ensure continuity of care.     •
  An act of cultural insensitivity that negatively impacts the member’s ability
to obtain care and cannot be resolved by health plan.     •   Other reasons,
including but not limited to, poor quality of care, lack of access to services
covered under the contract, or lack of access to providers experienced in
dealing with the member’s health care needs.

  1)   Children in COA 4 shall be allowed automatic and unlimited changes in
health plan choice as often as circumstances necessitate. Foster parents will
normally have the decision making responsibility for which health plan shall
serve the foster child residing with them; however, there will be situations
where the Social Service worker or the courts shall select the health plan for a
child in State custody or foster care placement.

  s.   Member Disenrollment:

 

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RFP B3Z06118   Page 37

  1)   The state agency has sole authority for disenrolling members from the
health plan. The health plan may request disenrollment of members from health
plan providers, subject to the conditions described below:

  •   A persistent refusal of the member to follow prescribed treatments or
comply with health plan requirements that are consistent with federal and state
laws and regulations, as amended.     •   Consistently missed appointments
without prior notification to the provider.     •   Fraudulent misuse of the MC+
managed care program, or abusive or threatening conduct.     •   Request of a
home birth service.

  2)   The health plan must not initiate disenrollment because of a medical
diagnosis or the health status of a member. The health plan shall not request
disenrollment because of the member’s attempt to exercise his or her rights
under the grievance system. The health plan shall not request disenrollment
because of pre-existing medical conditions or high cost medical bills or an
anticipated need for health care. The health plan shall not request a
disenrollment due to behaviors resulting from a medical or mental
illness/disorder.     3)   Prior to requesting a disenrollment or transfer of a
member, the health plan shall document at least three interventions over a
period of 90 calendar days which occurred through treatment, case management,
and care coordination to resolve any difficulty leading to the request, unless
the member has demonstrated abusive or threatening behavior in which case only
one attempt is required. The health plan shall cite at least one of the above
examples of good cause before requesting that the state agency disenroll that
member. If the health plan intends to proceed with disenrollment during the
ninety (90) calendar day period, the health plan must give a notice citing the
appropriate reason to both the member and the state agency at least 30 calendar
days before the end of the ninety (90) calendar day period. The health plan must
document all notifications regarding requests for disenrollment.

  •   Members shall have the right to challenge a health plan initiated
disenrollment to both the state agency and the health plan through the appeal
process within ninety (90) calendar days of the health plan’s request to the
state agency for disenrollment of the member. When a member files an appeal, the
process must be completed prior to the health plan and the state agency
continuing disenrollment procedures.     •   Within fifteen (15) working days of
the final notification (after no appeal or a final hearing decision), members
shall be enrolled in another health plan or transferred to another provider.    
4)   If the health plan recommends disenrollment or transfers for reasons other
than those stated above, the State shall consider the health plan to have
breached the provisions and requirements of the contract.

  t.   Reasons for Disenrollment: The state agency may disenroll members from a
health plan for any of the following reasons:

  1)   Selection of another health plan during open enrollment, the first 90
calendar days of enrollment, or for just cause.     2)   Change of residence
that places the member outside of the health plan’s service area.

 

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RFP B3Z06118   Page 38

  3)   To implement the decision of a hearing officer in a grievance proceeding
by the member against the health plan, or by the health plan against the member.
    4)   Loss of eligibility for either Medicaid or MC+ managed care.

Paragraph 2.6.2 t. 5. inserted by Amendment #001

  5)   Member exercises choice to voluntarily disenroll as specified herein
under Missouri MC+ Managed Care Program eligibility groups. This choice can be
referred to as opt out.

  u.   Disenrollment Effective Dates: Member disenrollments outside of the open
enrollment process shall become effective on the date specified by the state
agency. The health plan shall have written policies and procedures for complying
with state agency disenrollment orders.

Paragraph 2.6.2 v. revised by Amendment #001

  v.   Hospitalization at the Time of Enrollment or Disenrollment: With the
exception of newborns, the health plan shall not assume financial responsibility
for members who are hospitalized in an acute setting on the effective date of
coverage until an appropriate acute inpatient hospital discharge. If the member
is in the Medicaid fee-for-service program at the time of acute inpatient
hospitalization on the effective date of coverage, the member shall remain in
the fee-for-service program until an appropriate acute inpatient hospital
discharge. Members, including newborn members, who are in another health plan at
the time of acute inpatient hospitalization on the effective date of coverage,
shall remain with that health plan until an appropriate acute inpatient hospital
discharge. Members, including newborn members, who are hospitalized in an acute
setting shall not be disenrolled from a health plan until an appropriate acute
inpatient hospital discharge, unless the member is no longer Medicaid or MC+
managed care eligible or opts out.         For the purpose of a member moving
from one health plan to another health plan, in addition to acute inpatient
hospitalizations, admissions to facilities that provide a lower level of care in
lieu of an acute inpatient admission may be considered as an acute inpatient
hospitalization for purposes of this section. The state agency reserves the
right to determine if such an admission qualifies as an acute inpatient
hospitalization. Only acute inpatient hospitalization shall apply when a new
member moves from the Medicaid fee-for-service program to MC+ managed care. The
health plan shall provide timely notification to the state agency of a member’s
acute inpatient hospitalization on the effective date of coverage to effect a
retroactive/prospective adjustment in the coverage dates for MC+ managed care.

2.7   Comprehensive Benefit Package:       Description of Comprehensive Benefit
Package: The health plan shall assume the responsibility for all covered medical
conditions of each MC+ managed care member as of the effective date of coverage.
The health plan shall make the comprehensive benefit package available to
members. Services outside the United States, District of Columbia, and the
following territories: Northern Mariana Islands, American Samoa, Guam, Puerto
Rico, and the Virgin Islands are not covered. Services must be provided
according to the medical needs of the member. The health plan may manage
specific services as long as the health plan provides services that are
medically appropriate. The health plan shall have a process for allowing
exceptions that is in accordance with 13 CSR 70-2.100. The health plan may
develop criteria by which the health plan shall review future treatment options,
set prior authorization criteria, or exercise other administrative options for
the health plan’s administration of medical care benefits. The health plan may
place appropriate limits on a service on the basis of criteria such as medical
necessity; or for utilization control, provided the services furnished can
reasonably be expected to achieve their purpose. The health plan may not
arbitrarily deny or reduce the amount, duration, or scope of a required service
solely because of the diagnosis, type of illness, or condition. Attachment 3
outlines the comprehensive benefit package for all members and the services they
will receive.

2.7.1   The health plan shall include the following services within the
comprehensive benefit package:

  a.   Inpatient hospital services;

 

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RFP B3Z06118   Page 39

  b.   Outpatient hospital services;     c.   Emergency room services;     d.  
Ambulatory surgical center, birthing center;     e.   Physician, advanced
practice nurse, and certified nurse midwife services;

  1)   The health plan shall provide certified nurse midwife services that are
medically appropriate either through the health plan provider network or by
other means outside the health plan provider network at the health plan’s
expense. If the member elects a home birth, the member shall be disenrolled from
MC+ managed care according to the MC+ managed care home birth policy statement.
The disenrolled member shall then receive services through the MC+
fee-for-service program.

  f.   Maternity benefits for inpatient hospital and certified nurse midwife.
The health plan shall provide coverage for a minimum of forty-eight (48) hours
of inpatient hospital services following a vaginal delivery and a minimum of
ninety-six (96) hours of inpatient hospital services following a cesarean
section for a mother and her newly born child in a hospital or any other health
care facility licensed to provide obstetrical care under the provision of
Chapter 197, RSMo, as amended.         The health plan may authorize a shorter
length of hospital stay for services related to maternity and newborn care if a
shorter inpatient hospital stay meets with the approval of the attending
physician after consulting with the mother and is in keeping with federal and
state law, as amended. The physician’s approval to discharge shall be made in
accordance with the most current version of the “Guidelines for Perinatal Care”
prepared by the American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists, or similar guidelines prepared by another
nationally recognized medical organization and be documented in the member’s
medical record.         The health plan shall provide coverage for
post-discharge care to the mother and her newborn. The first post-discharge
visit shall occur within twenty-four (24) to forty-eight (48) hours.
Post-discharge care shall consist of a minimum of two visits at least one of
which shall be in the home, in accordance with accepted maternal and neonatal
physical assessments, by a registered professional nurse with experience in
maternal and child health nursing or a physician. The location and schedule of
the post-discharge visits shall be determined by the attending physician.
Services provided by the registered professional nurse or physician shall
include, but not be limited to, physical assessment of the newborn and mother,
parent education, assistance and training in breast or bottle feeding, education
and services for complete childhood immunizations, the performance of any
necessary and appropriate clinical tests, and submission of a metabolic specimen
satisfactory to the State laboratory. Such services shall be in accordance with
the medical criteria outlined in the most current version of the “Guidelines for
Perinatal Care”, or similar guidelines prepared by another nationally recognized
medical organization. If the health plan intends to use another nationally
recognized medical organization’s guidelines, the state agency must approve
prior to implementation of its use.     g.   Family Planning Services — If
family planning services are sought out-of-network by a member, the health plan
shall be financially liable for payment of those services in accordance with
federal freedom of choice provisions.     h.   Pharmacy benefits excluding
protease inhibitors – pharmacy benefits are included in the comprehensive
benefit package if the health plan included pharmacy benefits in its awarded
proposal;

 

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RFP B3Z06118   Page 40

  1)   The health plan shall submit the information regarding its pharmacy
program to the state agency for prior approval in accordance with the MC+
Managed Care Policy Statements, as amended.

  i.   Dental services related to trauma to the mouth, jaw, teeth or other
contiguous sites as a result of injury. Adults age 21 and over receive treatment
of a disease/medical condition without which the health of the recipient would
be adversely affected through the Fee For Service program.     j.   Laboratory,
radiology, and other diagnostic services;     k.   Prenatal case management;    
l.   One eye examination every 2 years;     m.   Home health services;     n.  
Adult day health care services;     o.   Personal care services;     p.  
Transportation services;

  1)   The health plan shall provide emergency transportation (ground and air)
for its members. The health plan shall provide non-emergency medical
transportation to members who do not have the ability to provide their own
transportation (such as their own vehicle, friends, or relatives) to and from
services required herein as well as Medicaid/MC+ Fee-For-Service covered
services not included in the comprehensive benefit package.

  q.   Hospice services;     r.   Durable medical equipment limited to:
prosthetic devices (with the exception of artificial larynx), respiratory
equipment and oxygen (with the exception of CPAP, BiPAP, and nebulizers),
wheelchairs, diabetic supplies and equipment, and ostomy supplies. Members with
a Home Health Plan of Care receive all medically necessary durable medical
equipment services during the plan of care coverage period.     s.   Podiatry
services with the exception of trimming of nondystrophic nails, any number;
debridement of nail(s) by any method(s), one to five; debridement of nail(s) by
any method(s), six or more; excision of nail and nail matrix, partial or
complete; and strapping of ankle and/or foot.     t.   Services provided by
local public health agencies — The Department of Health and Senior Services and
local public health agencies administer certain public health programs which are
critical to the protection of the public’s health and, therefore, must be made
available to members at local public health agencies whether in-network or
out-of-network. The health plan shall reimburse the local public health agency
according to the most current Medicaid program fee schedule in effect at the
time of service, unless otherwise negotiated. Such services shall include:

  1)   All sexually transmitted disease (STD) services including screening,
diagnosis, and treatment. In-network providers shall follow current Center for
Disease Control (CDC) Sexually Transmitted Diseases Treatment Guidelines and the
United States Department of Health and Human Services Chlamydia Control Project
Screening Criteria, or their equivalent. The STD guidelines may be found on the
Internet at: http://www.dhss.mo.gov/STDSurveillance/. STD screening, diagnosis,
and treatment services shall include:

  •   STD screening exam.

 

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RFP B3Z06118   Page 41

  •   Screening, diagnosis, and treatment for the following STDs: gonorrhea,
syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, genital
herpes, genital warts, trichomoniasis, chlamydia (cervicitis), chlamydia
(urethritis), hepatitis B, and others as may be designated by the state agency.
    •   Screening, diagnosis, and treatment of vaginal or urethral discharge
including non-gonococcal urethritis and mucopurulent cervicitis.     •  
Evaluation and initiation of treatment of pelvic inflammatory disease (PID).    
•   Diagnosis and preventive treatment of members who are reported as
contacts/sex partners of any person and diagnosed with a STD. The member shall
be given the option of seeing an in-network provider first.     •   The local
public health agency shall encourage members to follow-up with their primary
care provider; however, if the member chooses follow-up care at the local public
health agency for confidentiality reasons, the health plan shall reimburse the
local public health agency for follow-up office visits (not to exceed three
visits per episode).

  2)   Human immunodeficiency virus (HIV) services relating to screening and
diagnostic studies. In-network providers shall use current CDC HIV Counseling,
Testing, Referral Standards, and Guidelines or their equivalent. The HIV
guidelines may be found on the internet at:
http://www.dhss.mo.gov/HIV_STD_AIDS/.     3)   Tuberculosis services including
screening, diagnosis, and treatment. In-network providers shall follow current
CDC/American Thoracic Society Guidelines: Treatment of Tuberculosis and
Tuberculosis Infection in Adults and Children, or their equivalent, including
the use of Mantoux PPD skin test to screen for tuberculosis. The Tuberculosis
guidelines may be found on the Internet at: http://www.dhss.mo.gov/Tuberculosis.

  •   All members diagnosed with tuberculosis infection or tuberculosis disease
shall be reported to the local public health agency.     •   All members
receiving treatment for tuberculosis disease shall be referred to the local
public health agency’s tuberculosis contact person for directly observed therapy
(DOT). The health plan shall communicate with the local public health agency’s
tuberculosis contact person to obtain information regarding the member’s health
status. The health plan shall communicate this information to the in-network
provider. The health plan shall be responsible for care coordination and
medically necessary follow-up treatment.     •   All laboratory tests for
tuberculosis shall meet the standards established by the CDC/Missouri Department
of Health and Senior Services. Sensitivity tests shall be performed on all
initial specimens positive for M. Tuberculosis. Department of Health and Senior
Services encourages all sputum specimens to be submitted to the Department of
Health and Senior Services’ Tuberculosis Reference Laboratory at the Missouri
Rehabilitation Center. Positive cultures for M Tuberculosis isolated at private
laboratories must be sent to the TB Reference Laboratory (Required by Missouri
Rule 19 CSR 20-20.080).

  4)   Childhood Immunizations: In-network providers shall fully immunize their
members following the most recent immunization recommendations designated by the
state agency. The state agency shall provide the health plan’s Medical Director
with copies of the most recent recommendations upon contract award and upon
request and when the recommendations change.

 

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RFP B3Z06118   Page 42

  •   The health plan and its in-network providers must enroll and must obtain
vaccines through the Missouri Department of Health and Senior Services Vaccines
for Children (VFC) Program or any such vaccine supply program as designated by
the state agency. Any time a member receives immunizations from a local public
health agency, or at a Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) site, the health plan shall reimburse only the cost
for administration at the current Medicaid program rates in effect at the time
of the service, unless otherwise negotiated.     •   The health plan shall
reimburse governmental public health agencies for the cost of both
administration and vaccines not available through the VFC program or vaccine
supply program as designated by the state agency when the vaccine is deemed
medically necessary.     •   The health plan shall collaborate with the state
agency and the Missouri Department of Health and Senior Services to determine
the health plan’s aggregate immunization level. The Missouri Department of
Health and Senior Services, Immunization Program will offer consultation to the
health plan to foster the exchange of immunization information, and to
in-network providers for purposes of assessment, reminder/recall, and reporting.
    •   The health plan shall establish, as a quality assessment and improvement
measure, a target rate of 90% for the number of two (2) year olds immunized.

  5)   Childhood lead poisoning prevention services shall include screening,
diagnosis, treatment, and follow-up as indicated. In-network providers shall
follow the Centers for Medicare and Medicaid Services (CMS) (formerly the Health
Care Financing Administration) guidelines in effect for the specific time period
and CDC guidelines: Screening Young Children for Lead Poisoning and Managing
Elevated Blood Lead Levels Among Young Children. The Department of Health and
Senior Services shall provide the health plan’s Medical Director with copies of
current protocols and guidelines upon contract award or at any time upon
request. If there is a discrepancy between guidelines, the state agency requires
use of the HCY/EPSDT Lead Risk Assessment Guide developed in accordance with CMS
guidelines. The HCY/EPSDT Lead Risk Assessment Guide may be used separately or
in conjunction with the HCY Screening form.

  u.   Emergency Medical/Mental Health Services. Emergency medical/mental health
services means covered inpatient and outpatient services that are furnished by a
provider that is qualified to furnish these services and are needed to evaluate
or stabilize an emergency medical condition.

  1)   An emergency medical condition means a medical or mental health condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) 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 the following:

  •   Placing the physical or mental health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy;     •   Serious impairment to bodily functions;     •   Serious
dysfunction of any bodily organ or part;     •   Serious harm to self or others
due to an alcohol or drug abuse emergency;     •   Injury to self or bodily harm
to others; or     •   With respect to a pregnant woman having contractions:
(1) that there is inadequate time to effect a safe transfer to another hospital
before delivery, or (2) that transfer may pose a threat to the health or safety
of the woman or the unborn.

 

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RFP B3Z06118   Page 43

  2)   Post-stabilization care services means covered services, related to an
emergency medical condition that are provided after a member is stabilized in
order to maintain the stabilized conditions or to improve or resolve the
member’s condition.

  v.   Early Periodic Screening, Diagnosis, and Treatment Services: The Omnibus
Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid cover all
medically necessary services listed in Section 1905 (a) of the Social Security
Act to children from birth through age 20. In Missouri, this program is known as
the Healthy Children and Youth (HCY) Program. In accordance with the health
plan’s written policies and procedures, the health plan shall conduct outreach
and education of children eligible for the HCY/EPSDT program, provide the full
HCY/EPSDT services to all eligible children and young adults under the age of
21, and conduct and document well child visits (screenings) using the State
HCY/EPSDT screening form as amended. (The HCY screening form may be found on the
Internet at: http://manuals.momed.com/ Look under Missouri Medicaid Provider
Manuals, Forms, List of Forms, Healthy Children and Youth Screening [HCY
Screening].) The health plan shall provide the full scope of HCY/EPSDT services
in accordance with the following:

  1)   The health plan shall conduct HCY/EPSDT well child visits on all eligible
members under age twenty-one (21) to identify health and developmental problems.
The state agency recognizes that the decision to not have a child screened is
the right of the parent or guardian of the child. For those children that have
not had well child visits in accordance with the periodicity schedule
established by the state agency, the health plan shall document its outreach and
educational efforts to the parent or guardian informing them of the importance
of well child visits, that a well child visits is due, that appointment
scheduling assistance is available, and that transportation (except to those
children with ME Codes 71-75) is available. (The current periodicity schedule is
contained in Attachment 3.) The health plan shall follow the MC+ fee-for-service
policies for recognition of completion of all components of a full medical
HCY/EPSDT well child visit service. A full HCY/EPSDT well child visits includes
all of the components listed below. A partial well child visit includes the
first six (6) components listed below. The last three (3) components are
individual screens. An interperiodic screen is defined as any encounter with a
health care professional acting within his or her scope of practice.

  •   A comprehensive health and developmental history including assessment of
both physical and mental health developments;     •   A comprehensive unclothed
physical exam;     •   Health education (including anticipatory guidance);     •
  Laboratory tests as indicated (appropriate according to age and health history
unless medically contraindicated);     •   Appropriate immunizations according
to age;     •   Verbal lead assessment beginning at age six (6) months and
continuing through age seventy-two (72) months. Blood level testing is mandatory
at twelve (12) and twenty-four (24) months or annually if residing in a
high-risk area of Missouri as defined by Department of Health and Senior
Services regulation 19 CSR 20-8.030;     •   Vision screening;     •   Hearing
screening;

 

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      RFP B3Z06118   Page 44

  •   Dental screening (oral exam by primary care provider as part of
comprehensive exam). Recommended that preventive dental services begin at age
six (6) through twelve (12) months and be repeated every six (6) months.

  2)   If a suspected problem is detected during a well child visit, the child
must be evaluated as necessary, using the required assessment protocol, for
further diagnosis. This diagnosis is used to determine treatment needs.     3)  
HCY/EPSDT requires coverage for all follow-up diagnostic and treatment services
deemed medically necessary to ameliorate or correct a problem discovered during
an HCY/EPSDT well child visits. Such medically necessary diagnosis and treatment
services must be provided as long as they are Medicaid covered services as
defined in the Social Security Act.     4)   The health plan shall establish a
tracking system that provides information on compliance with HCY/EPSDT service
provision requirements in the following areas:

  •   Initial visit for newborns. The initial HCY/EPSDT well child visits shall
be the newborn physical exam in the hospital.     •   Preventive pediatric
visits according to the periodicity schedule inclusive of a verbal lead
assessment and blood lead tests.     •   Diagnosis and/or treatment, or other
referrals in accordance with HCY/EPSDT well child visit results.     •   The
health plan shall ensure that the tracking system generates information
consistent with the requirements regarding encounter data as specified elsewhere
herein.

  5)   The health plan shall have an established process for reminders,
follow-ups, and outreach to members. This process shall include, but not be
limited to, notifying the parent(s) or guardian(s) of children of the needs and
scheduling of periodic well child visits according to the periodicity schedule.
The health plan shall provide assistance to new members in accessing HCY/EPSDT
well child visit services within ninety (90) calendar days of health plan
enrollment. The health plan shall provide assistance to members in accessing
subsequent HCY/EPSDT well child visits in accordance with the periodicity
schedule. At the time of notification, the health plan shall offer
transportation and scheduling assistance if necessary. For members with ME Codes
71 through 75, non-emergency medical transportation is not a covered benefit.  
  6)   The health plan should seek innovative, cooperative ways to enhance care
coordination and delivery of HCY/EPSDT. This may include the use of a
standardized data base system among health plans.     7)   The health plan shall
report HCY/EPSDT well child visits through encounter data submissions in
accordance with the requirements regarding encounter data as specified elsewhere
herein. The state agency shall use such encounter data submissions and other
data sources to determine health plan compliance with CMS requirements that
80 percent of eligible members under the age of twenty-one are receiving
HCY/EPSDT well child visits in accordance with the periodicity schedule. The
state agency shall use the participant ratio as calculated using the CMS 416
methodology for measuring the health plan’s performance.

  •   The health plan shall report HCY/EPSDT well child visits in accordance
with the appropriate well child visits codes established by the state agency.
HCY/EPSDT screening codes are identified in MC+ Managed Care Policy Statements.
Services not reported as

 

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      RFP B3Z06118   Page 45

      HCY/EPSDT well child visits in accordance with the appropriate codes will
not be counted toward the health plan’s participant ratio.

  •   In the event the state agency uses other data sources submitted by the
health plan, the health plan shall certify the data provided.

  a.   The data must be certified by one of the following:

  1)   The health plan’s Chief Executive Officer.     2)   The health plan’s
Chief Financial Officer.     3)   An individual who has delegated authority to
sign for, and who reports directly to, the health plan’s Chief Executive Officer
or Chief Financial Officer.

  b.   The certification must attest, based on best knowledge, information, and
belief, as to the accuracy, completeness, and truthfulness of the data.     c.  
The health plan must submit the certification concurrently with the data.

  w.   Mental health and substance abuse services:

  1)   For children covered under MC+ managed care within Category of Aid 4,
mental health and substance abuse services, if medically necessary, shall not be
the financial responsibility of the health plan and shall be provided in
accordance with the requirements regarding coordination with services not
included in the comprehensive benefit package as specified elsewhere herein.

  •   For inpatients with dual diagnoses (physical and mental), the health plan
shall be financially responsible for all inpatient hospital days if the primary,
secondary, or tertiary diagnosis is a combination of physical and mental health.
These admissions are subject to the prior authorization and concurrent review
process identified by the health plan.

  2)   All other members shall receive all medically necessary mental health and
substance abuse services included in the comprehensive benefit package. The
state agency, in conjunction with the Department of Mental Health, has developed
community-based services with an emphasis on the least restrictive setting. The
health plan shall consider, when appropriate, using such services in lieu of
using an out-of-home placement setting for members.     3)   With the member’s
or the member’s parent/guardian’s consent, the health plan shall notify the
member’s primary care provider when a member is admitted for mental health or
substance abuse services.     4)   The health plan shall have protocols for
coordinating the diagnosis, treatment, and care between primary care providers
and mental health and substance abuse providers which include the expected
response time for consults between primary care providers and mental health and
substance abuse providers.     5)   Services shall include, but not be limited
to:

  •   Inpatient hospitalization, when provided by acute hospital, private or
state psychiatric hospital.     •   Outpatient services when provided by a
licensed psychiatrist, licensed psychologist, licensed clinical social worker,
provisional licensed clinical social worker, licensed counselor, provisional
licensed professional counselor, licensed psychiatric advanced practice nurse,
licensed home health psychiatric nurse, or state certified mental health or
substance abuse program. These services must include outreach efforts on an as
needed

 

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      RFP B3Z06118   Page 46

      basis that recognize the unique mental health challenges of some members.
These efforts may include phone contacts and home visits.     •   Crisis
intervention/access services, which may include the provision of a 24-hour
hotline staffed by qualified mental health professionals and qualified substance
abuse counselors providing intake, evaluation and referral services, including
services that are alternatives to out of the home placements and mobile crisis
teams for on-site interventions.     •   Alternative services which are
reasonable, cost effective, and related to the member’s treatment plan.

  6)   The health plan is responsible for payment of mental health and substance
abuse services defined herein that are court ordered, 96 hour detentions, and
for involuntary commitments.     7)   Mental Health and Substance Abuse
Services: To ensure the continuity of care and the transition of members who
have received mental health and substance abuse services from an out-of-network
provider prior to enrollment with the health plan, the state agency encourages
the out-of network provider to contact the health plan to make transition
arrangements with the health plan. Upon enrollment, the health plan shall
transition the member and provide the immediate continuation of mental health
and substance abuse services. The health plan shall authorize out-of-network
providers to continue ongoing mental health and substance abuse treatment,
services, items, and prescriptions for new members until such time as the new
member has been transferred appropriately to the care of an in-network provider.

  •   If the member transferred from an out-of-network provider to an in-network
provider, the health plan shall secure the member’s mental health and substance
abuse medical records from the out-of-network provider. The health plan shall
pay rates comparable to Medicaid, unless otherwise negotiated, to obtain these
records.     •   Mental Health Out-of-Network Referrals: If the health plan
believes that a child or youth may require residential services in order to
receive appropriate care and treatment for a serious emotional disorder, the
health plan may apply to the Missouri Division of Comprehensive Psychiatric
Services (CPS) for placement in accordance with the MC+ managed care policy
statement titled, Mental Health and Substance Abuse Fee-For-Service
Coordination.     •   Services provided by a Community Psychiatric
Rehabilitation provider shall be reimbursed by the state agency on a
fee-for-service basis according to the terms and conditions of the Medicaid
program.     •   Targeted case management services for mental health services
shall be reimbursed by the state agency on a fee-for-service basis according to
the terms and conditions of the Medicaid program.

  x.   Transplant Related Services: The health plan shall permit and authorize
and shall be financially responsible for any inpatient, outpatient, physician,
and related support services including presurgery assessment/evaluation prior to
the date of the actual bone marrow/stem cell or solid organ transplant surgery.
The bone marrow/stem cell or solid organ transplant will be prior authorized by
the state agency and must be performed at a state agency’s approved transplant
facility in accordance with the MC+ members’ freedom of choice. The health plan
shall be responsible for pre-transplant and post-transplant follow-up care and
immuno-suppressive pharmacy products prescribed after the inpatient transplant
discharge. To ensure continuity of care, the health plan must permit and
authorize follow- up services and the health plan shall be responsible for the
reimbursement of such services. The primary care provider must be allowed to
refer a transplant patient to the performing transplant facility for follow-up
transplant care. Reimbursement to out-of-network providers of transplant

 

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      RFP B3Z06118   Page 47

      support services must be no less than the current Medicaid program rates
in effect at the time of the services.

2.7.2   The health plan shall include all the services specified in the
comprehensive benefit package with the exception of non-emergency medical
transportation (NEMT), for uninsured children in ME Codes 71 through 75 (Refer
to Attachment 1, COA 5).   2.7.3   In addition to the services listed in the
Comprehensive Benefit Package, herein, the health plan shall include the
following additional services for children under 21 years of age and pregnant
women with ME codes 18, 43, 44, 45, and 61.

  a.   Dental Services (Dental services for pregnant women age 21 and over with
ME codes 18, 43, 44, 45, and 61 shall be limited to dentures and services
related to trauma to the mouth, jaw, teeth or other contiguous sites as a result
of injury. Services to prepare the mouth for dentures, such as examinations,
X-rays, or extractions will not be covered by the health plan. Ancillary denture
services such as relining, rebasing, and repairs will not be covered by the
health plan. All other Medicaid State Plan dental services for these pregnant
women are covered through the Fee For Service Program);     b.   Hearing aids
and related services;     c.   Optical services (Pregnant women age 21 and over
with ME codes 18, 43, 44, 45, and 61 do not receive eyeglasses except for one
pair following cataract surgery. Eye glasses for these pregnant women are
covered through the Fee-For-Service program);     d.   Comprehensive Day
Rehabilitation (for certain persons with disabling impairments as the result of
a traumatic head injury);     e.   Durable medical equipment (including but not
limited to: orthotic devices, artificial larynx, enteral and parenteral
nutrition, walkers, wheelchair accessories and batteries, CPAP, BiPAP, and
nebulizers);     f.   Diabetes self management training for persons with
gestational, Type I or Type II diabetes;     g.   Podiatry services.

2.7.4   Medically Necessary: The health plan shall determine whether or not a
service(s) furnished or proposed to be furnished is (are) reasonable and
medically necessary for the prevention, diagnosis or treatment of a physical or
mental illness or injury; to achieve age appropriate growth and development; to
minimize the progression of disability; or to attain, maintain or regain
functional capacity; in accordance with accepted standards of practice in the
medical community of the area in which the physical or mental health services
are rendered; and service(s) could not have been omitted without adversely
affecting the member’s condition or the quality of medical care rendered; and
service(s) is (are) furnished in the most appropriate setting. Services must be
sufficient in amount, duration, and scope to reasonably achieve their purpose
and may only be limited by medical necessity.

  a.   In reference to medically necessary care, mental health services shall be
provided in accordance with a process of mental health assessment that
accurately determines the clinical condition of the member and the acceptable
standards of practice for such clinical conditions. The process of mental health
assessment shall include distinct criteria for children and adolescents.     b.
  The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid
provide medically necessary services to children from birth through age 20,
which are necessary to treat or ameliorate defects, physical or mental illness,
or conditions identified by an HCY/EPSDT screen.

 

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      RFP B3Z06118   Page 48

      Services must be sufficient in amount, duration, and scope to reasonably
achieve their purpose and may only be limited by medical necessity.

2.8   Multilingual Services:   2.8.1   During the enrollment process, members
shall be asked if English is their main language. If English is not the member’s
main language, the member shall be asked to identify that language. The
information gathered by the state agency shall be shared with the health plan.  
2.8.2   The health plan shall make interpreter services available as necessary
to ensure that members are able to communicate with the health plan and
providers and receive covered benefits. The health plan shall use certified
interpreters. The health plan shall inform members of the availability of
interpreter services. If the health plan has more than two hundred (200) members
or five (5) percent of its program membership (whichever is less) who speak a
single language other than English as a primary language, the health plan shall
make available general services and materials, such as the health plan’s member
handbook in that language.   2.8.3   In addition, the health plan shall develop
appropriate methods for communicating with visual and hearing impaired members
and accommodating the physically disabled. The health plan shall offer members
standard materials, such as the member handbook and enrollment materials in
alternative formats (i.e., large print, Braille, cassette, and diskette)
immediately upon request from members with sensory impairments.   2.9   Member
Services:   2.9.1   Member Services Staff: The health plan shall provide
adequately trained member services staff to operate at least nine
(9) consecutive hours during the hours of 7:00 a.m. through 7:00 p.m. (i.e.,
8:00 a.m. through 5:00 p.m.), Monday through Friday. The health plan may observe
State designated holidays or the holidays designated in its awarded proposal for
its operation of member services. The health plan’s member services staff shall
be responsible for the following:

  a.   Explaining the operation of the health plan and assisting members in the
selection of a primary care provider. Educating the family about managed care
including the way services typically are accessed under managed care and the
role of the primary care provider.     b.   Specifying member’s rights and
responsibilities.     c.   Explaining covered benefits.     d.   Assisting
members to make appointments and obtain services.     e.   Arranging medically
necessary transportation for members.     f.   Handling, recording, and tracking
member inquiries promptly and timely.     g.   The health plan’s member services
staff must have available a complete and up-to-date list of the in-network
providers in the health plan provider network. The health plan shall have a
policy and procedure for regularly updating the provider listing. Member
services staff must provide the following information to members requesting the
names of providers:

  1)   Whether the provider currently participates in the health plan;     2)  
Whether the provider is currently accepting new patients; and

 

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      RFP B3Z06118   Page 49

  3)   Any restrictions on services, including any referral or prior
authorization requirements the member must meet to obtain services from the
provider.

   h.   The health plan’s member services staff shall be trained on fraud and
abuse policies and procedures.

2.9.2   Toll-Free Telephone Number: The health plan shall maintain a toll-free
member services telephone number. The toll-free member services telephone or
other toll-free voice and telecommunications device for the deaf members must be
staffed twenty-four (24) hours per day to provide needed authorization of
services during evenings and weekends and holidays.   2.10   Provider Services:
  2.10.1   Provider Services Staff: The health plan shall provide adequately
trained provider services staff to operate at least nine (9) consecutive hours
during the hours of 7:00 a.m. through 7:00 p.m. (i.e., 8:00 a.m. through 5:00
p.m.) Monday through Friday. The health plan may observe State designated
holidays or the holidays designated in its awarded proposal for its operation of
provider services. If the health plan observes holidays different than the
State’s, the health plan must obtain the prior written approval of the state
agency.   2.10.2   The health plan’s provider services staff shall be
responsible for the following:

  a.   Establishing a mechanism by which providers may determine in a timely
manner whether a member is covered by the health plan and the member’s primary
care provider assignment;     b.   Educating providers on the above mechanism’s
use;     c.   Educating and assisting providers with the health plan service
accessibility standards including but not limited to prior authorization,
denial, and referral procedures;     d.   Educating and assisting providers with
claims submission and payment procedures;     e.   Educating providers about
conditions under which members may directly access services including, but not
limited to, mental health and substance abuse, family planning, and public
health services;     f.   Educating providers about how a member can access
emergency care and after-hour services;     g.   Educating providers about
pharmacy benefits and formulary guidelines; and     h.   Handling provider
inquiries and complaints.

2.10.3   The health plan shall develop, distribute, and maintain a provider
manual. The health plan shall obtain and document the approval of the provider
manual by the health plan’s Medicaid Plan Administrator and Medical Director and
shall review the provider manual at least annually and maintain documentation
verifying such. The health plan shall issue a copy of the provider manual to
providers at the time of inclusion in the provider network, and shall educate
the provider as to its full content and usage.

  a.   At a minimum, the provider manual shall contain, sections regarding:

  1)   Specific covered health services for which the provider shall be
responsible, including any limitations or conditions on services;     2)  
Claims submission instructions and the procedure for review of denied claims;  
  3)   Prior authorization procedures, and referral procedures including
exceptions, second, or third opinions;

 

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      RFP B3Z06118   Page 50

  4)   Primary care provider responsibilities;     5)   Specialist/ancillary
provider responsibilities;     6)   Provider complaint, grievance, and appeal
processes;

  •   Any State-determined provider appeal rights to challenge the failure of
the health plan to cover a service.

  7)   Member Grievance System;

  •   The member’s right to file grievances and appeals and their requirements
and timeframes for filing;     •   The availability of assistance in filing;    
•   The toll-free numbers to file oral grievances and appeals;     •   The
member’s right to request continuation of benefits during an appeal or State
fair hearing filing and, if the health plan’s action is upheld in a hearing, the
member may be liable for the cost of any continued benefits.     •   The
member’s right to a state fair hearing, how to obtain a hearing, and
representation rules at a hearing;

  (a)   A member may request a State fair hearing within 90 calendar days from
the health plan’s notice of action.     (b)   The State must reach its decisions
within the specified timeframes:

  1)   Standard resolution: within 90 calendar days of the date the member filed
the appeal with the health plan if the member filed initially with the health
plan (excluding the days the member took to subsequently file for a State fair
hearing) or the date the member filed for direct access to a State fair hearing.
    2)   Expedited resolution (if the appeal was heard first through the health
plan appeal process): within 3 working days from the state agency’s receipt of a
hearing request for a denial of a service that:

  •   Meets the criteria for an expedited appeal process but was not resolved
using the health plan’s expedited appeal timeframes, or     •   Was resolved
wholly or partially adversely to the member using the health plan’s expedited
appeal timeframes.

  3)   Expedited resolution (if the appeal was made directly to the State Fair
Hearing process without accessing the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request for a denial
of a service that meets the criteria for an expedited appeal process.

  8)   Procedure for obtaining member eligibility status;     9)  
Appointment/access standards;     10)   Multilingual and TDD availability;    
11)   Quality Assessment and Improvement;     12)   Provider Credentialing;

 

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      RFP B3Z06118   Page 51

  13)   Management and retention of medical records;     14)   Confidentiality;
    15)   Advance directives; and     16)   Fraud and abuse guidelines.

2.10.4   The health plan shall supply the state agency with the federal tax
identification number and professional license number of each provider
performing services for the health plan.   2.10.5   The health plan should
specify in writing the following to out-of-network providers at the time a
service is approved to be performed by the out-of-network provider:

  a.   Claims submission instructions and the procedure for review of denied
claims;     b.   Prior authorization procedures and referral procedures
including exceptions, second, or third opinions;     c.   Provider complaint,
grievance, and appeal procedures;

  1)   Any State-determined provider appeal rights to challenge the failure of
the health plan to cover a service.

  d.   Member Grievance System;

  •   The member’s right to file grievances and appeals and their requirements
and timeframes for filing;     •   The availability of assistance in filing;    
•   The toll-free numbers to file oral grievances and appeals;     •   The
member’s right to request continuation of benefits during an appeal or State
fair hearing filing and, if the health plan’s action is upheld in a hearing, the
member may be liable for the cost of any continued benefits.     •   The
member’s right to a state fair hearing, how to obtain a hearing, and
representation rules at a hearing;

  (a)   A member may request a State fair hearing within 90 calendar days from
the health plan’s notice of action.     (b)   The State must reach its decisions
within the specified timeframes:

  1)   Standard resolution: within 90 calendar days of the date the member filed
the appeal with the health plan if the member filed initially with the health
plan (excluding the days the member took to subsequently file for a State fair
hearing) or the date the member filed for direct access to a State fair hearing.
    2)   Expedited resolution (if the appeal was heard first through the health
plan appeal process): within 3 working days from the state agency’s receipt of a
hearing request for a denial of a service that:

  •   Meets the criteria for an expedited appeal process but was not resolved
using the health plan’s expedited appeal timeframes, or     •   Was resolved
wholly or partially adversely to the member using the health plan’s expedited
appeal timeframes.

 

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      RFP B3Z06118   Page 52

  3)   Expedited resolution (if the appeal was made directly to the State Fair
Hearing process without accessing the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request for a denial
of a service that meets the criteria for an expedited appeal process.

  e.   Procedure for obtaining member eligibility status;     f.   Multilingual
and TDD availability; and     g.   Confidentiality.

2.11   Release for Ethical Reasons:   2.11.1   As a condition to participating
in, or contracting with the health plan, the health plan may not:

  a.   Require a provider to perform any treatment or procedure which is
contrary to the provider’s conscience, religious beliefs, or ethical principles
or policies; or     b.   Prohibit a provider from making a referral to another
health care provider licensed to provide care appropriate to the member’s
medical condition.

2.11.2   The health plan shall have a process by which the provider may refer a
member to another health care provider licensed to provide care appropriate to
the member’s medical condition or withdraw from the case and the health plan
shall assign the member to another provider licensed to provide care appropriate
to the member’s medical condition.   2.11.3   A health plan that is otherwise
required to provide, reimburse for, or provide coverage of, a counseling or
referral service because of the requirement herein may object to the service on
moral or religious grounds. If the health plan objects to service on moral or
religious grounds, the health plan must notify the state agency. Additionally,
the health plan shall notify the state agency whenever the health plan adopts
the policy during the term of the contract. The health plan agrees that such an
objection and subsequent release from providing, reimbursing for, or providing
coverage of, a counseling or referral service shall result in a reduction to the
applicable capitation rates paid to the health plan to reflect such a release as
outlined in paragraph 2.28.4.

  a.   Information to potential members must be provided prior to enrollment
regarding the health plan’s release of provision of such service.     b.   The
health plan shall be required to notify its members 30 calendar days prior to
any change in its policy regarding coverage of a counseling or referral service.
    c.   The health plan shall be required to notify its members of how and
where to obtain the service.

2.12   Coordination With Services not Included in the Comprehensive Benefit
Package:       The health plan is not obligated to provide or pay for any
services not included in the comprehensive benefit package. However, the health
plan must perform care coordination of covered services with services not
included within the comprehensive benefit package. These services include, but
are not limited to, the following:   2.12.1   School Based Services:

  a.   When communities and school boards agree, schools may operate school
based clinics to address unmet medical needs of children. The state agency
supports the efforts of such communities. The health plan shall perform care
coordination with school based clinic services with comprehensive benefit
services that are the responsibility of the health plan. In addition, the health
plan shall have a written process for coordination and collaboration with school
based clinics.

 

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      RFP B3Z06118   Page 53

  b.   The health plan shall not be financially liable for physical therapy
(PT), occupational therapy (OT), or speech therapy (ST) included in an
Individualized Family Service Plan (IFSP) developed under the First Steps
Program or included in an Individual Education Plan (IEP) developed by the
public school. First Steps is an early intervention program required by the
Individuals with Disabilities Education Act (IDEA) — Part C (34 CFR 303 Early
Intervention Program for Infants and Toddlers with Disabilities) which also
defines the IFSP. IEP services are required by the IDEA Part B (34 CFR 300 and
301). IFSPs and IEPs will include therapies which are needed due to
developmental and educational needs. The health plan shall be responsible for
all other medically necessary therapy services that are not identified in an IEP
or IFSP including maintenance and developmental therapy. The health plan shall
be financially responsible for all other Medicaid reimbursable services
identified in the IFSP or IEP and are medically necessary. The health plan shall
be responsible for medically necessary equipment and supplies used in connection
with PT, OT, and ST services for all members. Equipment and supplies are covered
as a Durable Medical Equipment benefit. The health plan shall not delay the
provision of therapies that are medically necessary pending completion of the
IFSP or IEP.

  1)   The First Steps program serves children from birth to age three (3) who
are developmentally delayed or have diagnosed conditions associated with
developmental disabilities. Enrollment in the First Steps program is voluntary
at the choice of the child’s parent or guardian. The intent of the program is,
through early detection and intervention, to improve functioning or decrease
deterioration in order to better prepare the child to participate in school. The
Missouri Department of Elementary and Secondary Education (DESE) operates the
First Steps program. Service Coordinators who contract with DESE are responsible
for determining program eligibility. A multi-disciplinary team determines the
child’s service needs including if medical treatment is needed. The team shall
include the child’s physician. With the parent/guardian consent, the health plan
shall refer children who are potentially eligible for First Steps services to
the local First Steps office (System Point of Entry) or call the state-wide
toll-free number, 866-583-2392, to make a referral.     2)   The health plan
shall have written policies and procedures for promptly transferring medical and
developmental data and for coordinating ongoing care with special education
services.

  c.   Parents as Teachers (PAT) is a home-school-community partnership which
supports parents in their role as their child’s first and most influential
teachers. Every parent of a child age 5 or under is eligible for PAT, regardless
of income. PAT services include personal visits from certified parent educators,
group meetings, developmental screenings, and connections with other community
resources from the time the child is born until he/she enters kindergarten.

  1)   PAT programs collaborate with other agencies and programs to meet
families’ needs, including Head Start, First Steps, the Women Infants and
Children Program (nutrition services), local health departments, the Family
Support Division, etc. Independent evaluations of PAT show that children served
by this program are significantly more advanced in language development, problem
solving, and social development at age 3 than comparison children, 99.5% of
participating families are free of abuse or neglect, and early gains are
maintained in elementary school, based on standardized tests.     2)   The PAT
program is administered at the local level by each public school district in the
state of Missouri. Families interested in PAT may contact their local district
directly. PAT also accepts referrals from other sources including medical
providers. Providers who have contact with families with children age 5 and
under are encouraged to refer those families to PAT. Additional information
about PAT is available at the Department of Elementary and Secondary Education’s
website at www.dese.state.mo.us. (Look under programs, then Early Childhood
Education, then Parents as Teachers.)

 

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      RFP B3Z06118   Page 54

2.12.2   Public Health Programs: Services offered by the Department of Health
and Senior Services and local public health agencies and the method of
reimbursement shall include:

  a.   Environmental lead assessments for health plan children with elevated
blood levels shall be reimbursed directly by the state agency on a
fee-for-service basis according to the terms and conditions of the Medicaid
program.     b.   State Public Health Laboratory Services to Members: In cases
where the health plan is required by law to use the State Public Health
Laboratories (e.g., metabolic testing for newborns) and in cases where the State
Public Health Laboratory and Department of Health and Senior Services designated
local public health agency laboratories perform tests, other than those services
listed herein, on members for public health purposes, the laboratory shall be
reimbursed directly by the state agency on a fee-for-service basis according to
the terms and conditions of the Medicaid program, and such costs shall not be
included in the Medicaid State plan capitated rates.     c.   Newborn Screening
Collection Kits: According to RSMo 191.331, health care providers must purchase
pre-paid newborn screening collection kits from the Department of Health and
Senior Services. The Department of Health and Senior Services sells the kit to
providers. When the provider submits a specimen to the State Department of
Health and Senior Services Laboratory, the laboratory shall process the test,
determine if the member is MC+ eligible, and bill the state agency for the test.
    d.   Special Supplemental Nutrition for Women, Infants and Children
(WIC) Program - Sections 1902(a)(11)(C) and 1902(a)(53) of the Social Security
Act and Title 42, CFR 431.635 require coordination between the state agency and
the WIC program. While WIC services are not the responsibility of the health
plan, the in-network provider shall document and refer eligible members for WIC
services. As part of the initial assessment of members, and as a part of the
initial evaluation of newly pregnant women, the in-network providers shall
provide and document the referral of pregnant, breast-feeding, or postpartum
women, or a parent/guardian of a child under the age of five, as indicated, to
the WIC Program. Upon contract award and upon request, the Department of Health
and Senior Services shall provide the health plan with WIC program eligibility
and referral criteria.

2.12.3   Transplant Services: Solid organ and bone marrow/stem cell transplant
services are not included in the comprehensive benefit package as covered
benefits. These services will be delivered for all populations through separate
arrangements. Transplant services are defined as the hospitalization from the
date of transplant procedure until the date of discharge, including solid organ
or bone marrow/stem cell procurement charges, and related physician services
associated with both procurement and the transplant procedure. The health plan
shall be responsible for any services before and after this admission, including
the evaluation that may be related to the condition, even though these services
may be delivered out-of-network.

  a.   According to 42 CFR 431.51, Medicaid must insure freedom of choice of
providers for services provided to Medicaid beneficiaries when those services
are paid on a fee-for-service basis outside the health plan. When in-network
providers identify a member as a potential transplant candidate, the member must
be referred to a transplant facility of their choice without regard to health
plan preference.

2.12.4   Comprehensive Substance Treatment Abuse and Rehabilitation (C-STAR)
programs are carved out of the MC+ managed care program. Services provided by a
C-STAR Medicaid provider shall be reimbursed by the state agency on a
fee-for-service basis according to the terms and conditions of the Medicaid
program. In order to ensure quality of care, the health plan and its mental
health subcontractors shall maintain open and consistent dialogue with C-STAR
providers. The health plan shall be responsible for care coordination of
services included in the benefit package and C-STAR services in accordance with
the MC+ managed care policy statement titled, Mental Health and Substance Abuse
Fee-For-Service Coordination.

 

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      RFP B3Z06118   Page 55

2.12.5   Mental Health Services for Category Of Aid 4: For children covered
under the health plan within the COA 4 group, the health plan shall not be
financially responsible for the following medically necessary mental health and
substance abuse services:

  a.   Inpatient Mental Health and Substance Abuse Services shall be any
psychiatric stay in an acute care hospital, or in a private or State psychiatric
hospital. The health plan primary care provider and the child’s caseworker shall
coordinate services. Admissions must be in accordance with established
guidelines of the Department of Social Services in conjunction with the
Department of Mental Health. The Department of Social Services in conjunction
with the Department of Mental Health will determine the appropriateness of
inpatient placement, appropriate facility, alternative placement, and
psychiatric diversion. The state agency’s Medical Review Agency must certify
medically necessary inpatient days for mental health and substance abuse
services (billable on an inpatient hospital claim form) beyond the days deemed
medically necessary for physical health.     b.   For inpatients with a dual
diagnoses (physical and mental) identified at either admission or during the
stay, the health plan shall be financially responsible for all inpatient
hospital days if the primary, secondary, or tertiary diagnosis is a combination
of physical and mental health. These admissions are subject to the health plan’s
prior authorization and concurrent review process.     c.   Outpatient Mental
Health and Substance Abuse Services are those services not provided in an
inpatient setting. Examples of appropriate settings are outpatient facility,
office, or clinic setting. These services must be provided by a licensed
psychiatrist, licensed psychologist, licensed clinical social worker,
provisional licensed clinical social worker, licensed counselor, provisional
licensed professional counselor, licensed psychiatric advanced practice nurse,
licensed home health psychiatric nurse, or state certified mental health or
substance abuse program. The services will be provided subject to Medicaid
program benefits and limitations.

Paragraph 2.12.5 d. revised by Amendment #002

  d.   Comprehensive Community Support Services: Comprehensive Community Support
Services are provided to children in the custody of the Children’s Division and
are found to have behavioral conditions which require rehabilitative services at
a residential treatment or specialized foster care level of care or who are
being discharged from these two treatment levels, and who require comprehensive
community support services in order to maintain the rehabilitation treatment
outcome in a less restrictive environment. The Children’s Division identifies
children in the custody of the Children’s Division qualifying for these services
and authorizes provision of comprehensive community support. Comprehensive
community support services include any medical or remedial service reasonable
and necessary for maximum reduction of a behavioral disability and restoration
of the child to his or her best possible functional level. Examples include, but
are not limited to: Intake, Assessment, Evaluation and Treatment Planning;
Community Support; Specialized Sexual Abuse Treatment: 24-hour Crisis
Intervention and Stabilization; Intensive In-Home Services; Medication
Management and Monitoring; Day Treatment/Psychosocial Rehabilitation;
Therapeutic Counseling or Consultation Services not Covered Separately through
the HCY or Physician’s Services Program, Supported Independent Living and
Transitional Living Services; and School-Based Behavioral Support Services not
included in the IEP. The services will be provided subject to Medicaid program
benefits and limitations. The health plan is not financially liable for
comprehensive community support services.

2.12.6   SAFE-CARE Exams: Sexual Assault Forensic Examination and Child Abuse
Resource Education (SAFE-CARE) examinations and related diagnostic studies which
ascertain the likelihood of sexual or physical abuse performed by SAFE-CARE
trained providers shall continue to be reimbursed by the state agency on a
fee-for-service basis according to the terms and conditions of the Medicaid
program. The state agency shall define which services will continue to be
reimbursed by the state agency on a fee-for-service basis according to the terms
and conditions of the Medicaid program when performed or requested by a
SAFE-CARE trained provider. Other medically necessary services may be ordered by
the SAFE-CARE provider by referring to an in-network provider when possible. The
health plan shall be

 

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      RFP B3Z06118   Page 56

    responsible for these services, regardless whether the SAFE-CARE provider is
in or out of the health plan network.

2.12.7   Pharmacy Services: Pharmacy services not included in the health plan’s
awarded proposal shall be reimbursed by the state agency on a fee-for-service
basis according to the terms and conditions of the Medicaid program.   2.12.8  
Protease Inhibitors: Protease inhibitors shall be reimbursed by the state agency
on a fee-for-service basis according to the terms and conditions of the Medicaid
program.   2.12.9   Abortion Services: Abortion services subject to Medicaid
program benefits and limitations shall continue to be reimbursed by the state
agency on a fee-for-service basis according to the terms and conditions of the
Medicaid program.

Paragraph 2.12.10. revised by Amendment #001

2.12.10   Mentally Retarded and Developmental Disabilities (MRDD) Waiver: Home
and community based waiver services for persons in the MRDD waiver are carved
out of the MC+ managed care program. The health plan shall be responsible for
MC+ managed care covered services for MRDD waiver clients enrolled in MC+
managed care, unless specifically excluded. The health plan shall be responsible
for care coordination of services included in the benefit package and the Home
and Community based waiver. The state agency shall identify the MRDD Waiver
participants to the health plan. Information regarding MRDD Waiver Services may
be found in Section 19 of the Missouri Medicaid MRDD Waiver Provider Manual and
the Missouri Medicaid Provider Bulletins located on the internet at
www.dss.mo.gov/dms/providers.htm.   2.12.11   Home Birth Services: In accordance
with the MC+ managed care home birth policy statement, if a member elects a home
birth the member shall be disenrolled from MC+ managed care. The disenrolled
member shall then receive services through the MC+ fee-for-service program for
the home birth.   2.12.12   Services for Children in the Custody of the Jackson
County Office of the Missouri Children’s Division: Under court order (G.L. v.
Stangler, also called the Consent Decree), children in the custody of the
Jackson County office of the Missouri Children’s Division (CD) and residing in
Cass, Clay, Henry, Jackson, Johnson, Lafayette, Platte, Ray, or St. Clair
counties have additional medical care requirements.

  a.   In addition to the services outlined herein, the health plan shall
provide the following services following the effective date of enrollment with
the health plan. If the child is already enrolled with the health plan and
enters custody, the health plan shall provide the following services from the
time the child enters CD custody. The time frames for these examinations begin
with the time and date the child enters CD custody.

  1)   A physical examination within 36 hours. The 36 hour exam is due the next
working day following entry into custody. (This shall be paid by Medicaid on a
fee-for-service basis and arranged by CD if the child is not enrolled in a
health plan at the time of entry into CD custody.) A complete physical
examination may be replaced by partial physical examination if the CD caseworker
and the provider agree that a complete physical examination is unnecessary,
repetitive, or would cause undue stress for the child. If agreement is reached
that a partial physical examination is adequate, the provider shall decide the
scope of the partial physical examination. Agreement that a complete physical
examination is not necessary shall be documented in the child’s medical record.
In all cases, if a child is enrolled with the health plan prior to the 36-hour
deadline, the health plan shall be responsible for providing the examination. If
the health plan does not provide the examination, the health plan shall
reimburse the provider that performs the examination in accordance with the
current Medicaid fee schedule. CD, the Medical Case Management Agency, and the
health plan shall work together to establish a notification process so that the
health plan receives notification of the enrollment of a Consent Decree-covered
child in a timely manner.

 

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      RFP B3Z06118   Page 57

  2)   Within 30 calendar days — Follow-up examinations recommended by the
provider during the 36-hour examination; i.e.: hearing and eye exams, dental
screens or a full HCY screen shall be done in accordance with the most recent
periodicity schedule. A partial HCY screening may be administered if the child
is current with his or her HCY screening schedule and the CD caseworker and
provider agree that a full HCY screening is unnecessary, repetitive, or would
cause undue stress for the child. If agreement is reached that a partial HCY
screening is adequate, the provider shall decide the scope of the partial HCY
screening. Agreement that a full HCY screening is not necessary shall be
documented in the child’s medical record.

  b.   Following the 30 calendar day screening requirements, the HCY schedule
shall be followed for children up to five years of age with annual examinations
after age five unless the child has physical health, mental health, or
developmental health problems identified by the provider that require medically
necessary treatment on a more frequent basis.

  c.   The health plan shall be responsible for determinations regarding
medically necessary treatments, medically necessary appointments, and medically
necessary services.     d.   Consent Decree Medical Case Management: Children in
the custody of the Jackson County office of the Missouri Children’s Division and
residing in Jackson County also receive targeted medical case management
services. Medical case management services are intended to facilitate access to
medical services for the targeted children. Although this medical case
management will be provided through a separate contract between the Department
of Social Services and a Medical Case Management agency, the health plan shall
provide the medical care required by the Consent Decree and all services
specified herein for children in State custody. Per the Consent Decree, G.L. v.
Stangler Amended Revised Operational Guide; March 14, 2002, and the contract
with Medical Case Management agencies, children are followed at three different
levels: Category 1, well children; Category 2, children with behavioral or
mental health needs; and Category 3, children with medical needs. Children
identified as Category 2 and Category 3 will remain in targeted medical case
management during the entire time they are in custody. Category 1 children will
be enrolled for targeted medical case management only during the first 30
calendar days of custody. The medical case management services provided by the
Medical Case Management Agency include, but are not limited to:

  1)   Promoting the effective and efficient access to comprehensive medical
services for the targeted children,     2)   Facilitating the coordination of
medical services,     3)   Maintaining confidential centralized files for each
child,     4)   Assisting in the education of CD staff, caregivers, and health
care providers regarding the child’s medical care,     5)   Providing
information regarding the need for specialized health services,     6)  
Coordinating and monitoring all primary and specialty care necessary for the
child, and     7)   Ensuring that essential medical care received by the child
complies with the Consent Decree, Part III.

  e.   The health plan and providers shall cooperate with the Medical Case
Management Agency in securing medical histories and providing medical records as
required by the Consent Decree. The health plan shall allow case managers to
file an appeal immediately (or within 12 hours if a concern arises after regular
business hours) to the health plan’s MC+ Medical Director if a Consent Decree
case managed child is denied services or has difficulty accessing services
covered in the contract.     f.   The health plan shall designate a person
within the health plan as a primary contact for CD staff, caregivers, and health
care providers for issues involving these targeted children. The health plan
shall also participate and attend medical oversight meetings.

 

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      RFP B3Z06118   Page 58

2.13   Second Opinion: Members have a right to second opinions from qualified
health care professionals, and the health plan shall have policies and
procedures for rendering second opinions both in-network and out-of-network when
requested by a member. The health plan’s policies and procedures shall address
whether there is a need for referral by the primary care provider or
self-referral. The adequacy of these policies and procedures shall be examined
during quality assessment reviews. Missouri Revised Statutes Section 208.152
states that certain elective surgical procedures require a second medical
opinion be provided prior to the surgery. A third surgical opinion, provided by
a third provider, shall be allowed if the second opinion fails to confirm the
primary recommendation that there is a medical need for the specific surgical
operation, and if the member desires the third opinion.   2.14   Service
Accessibility Standards:   2.14.1   Twenty-Four Hour Coverage: The health plan
shall provide coverage to members on a twenty-four (24) hour per day, seven
(7) day per week basis. The health plan shall have written policies and
procedures describing how members and providers can contact the health plan to
receive individual instruction or authorization for treatment of an emergent or
urgent medical, mental health, or substance abuse problem and instruction
regarding receiving care when the member is out of the health plan’s geographic
area. The health plan must make the policies and procedures available in an
accessible format upon request. The health plan must provide for direct contact
with qualified clinical staff through a toll-free member or provider services
telephone number and a telecommunication device for the deaf telephone number.
Recorded messages are not acceptable. The health plan shall provide an
accommodation, if needed, to ensure all members equal access to twenty-four hour
per day health care coverage.   2.14.2   Prior Authorization:

  a.   The health plan shall ensure that prior authorization requirements are
not applied to emergency medical/mental health services as defined herein.    
b.   The health plan shall specify, in writing, the procedures for prior
authorization of non-emergency services and the time frames in which
authorizations will be processed (approved or denied) and providers and members
are notified.     c.   If the health plan requires a referral, assessment, or
other requirement prior to the member accessing requested medical or mental
health services, such requirements shall not be an impediment to the timely
delivery of the medically necessary service. The health plan shall assist the
member to make any necessary arrangements to fulfill such requirements (i.e.,
scheduling appointments, providing comprehensive lists of available providers,
etc.). If such arrangements cannot be made timely, the requested services shall
be approved.     d.   The health plan shall ensure that its prior authorization
procedures meet the following minimum requirements:

  1)   All appeals and denials must be reviewed by a professional with
experience or expertise comparable to the provider requesting the authorization.
    2)   There is a set of written criteria for review based on sound medical
evidence that is updated regularly and consistently applied and for
consultations with the requesting provider when appropriate.     3)   Reasons
for decisions are clearly documented and assigned a prior authorization number
which refers to and documents approvals and denials.     4)   Documentation
shall be maintained on any alternative service(s) approved in lieu of the
original request.

 

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      RFP B3Z06118   Page 59

  5)   There is a well-publicized review process for both providers and members.
    6)   The review process is completed and communicated to the provider in a
timely manner, as indicated below, or the denials shall be deemed approved. For
the purpose of this section, “necessary information” includes the results of any
face-to-face clinical evaluation or second opinion that may be required.

  •   Approval or denial of non-emergency services when determined as such by
emergency room staff shall be provided by the health plan within thirty (30)
minutes of request.     •   Approval or denial shall be provided within
twenty-four (24) hours of request for services determined to be urgent by the
treating provider.     •   Approval or denial shall be provided within two
(2) business days of obtaining all necessary information for routine services.
The health plan shall notify the requesting provider within two business days
following the receipt of the request of service regarding any additional
information necessary to make a determination. In no case shall a health plan
exceed fourteen (14) calendar days following the receipt of the request of
service to provide approval or denial.     •   Involuntary detentions (96 hour
detentions or court ordered detentions) or commitments shall not be prior
authorized.

  e.   The health plan shall ensure that members are not without necessary
medical supplies, oxygen, nutrition, pharmaceutical products, etc., and must
have written procedures for making an interim supply of an item available.    
f.   The health plan shall ensure that the member’s treatment regimens are not
interrupted or delayed (i.e. physical, occupational, and speech therapy;
psychological counseling; home health services; personal care, etc.) by the
prior authorization process.     g.   If the health plan approves purchase of a
custom or power wheelchair, eyeglasses, hearing aids, dentures (excluding
orthodontic services), custom HCY/EPSDT equipment, augmentative communication
devices placed within six months of approval, etc. which is delivered or placed
after enrollment in the health plan ends, the health plan shall be responsible
for payment.     h.   If the health plan requires prior authorization for
pharmacy products, the health plan shall provide a response by telephone or
other telecommunication device within 24 hours of a request for prior
authorization. Approvals must be granted for claims meeting established criteria
approved by the state. The state will approve criteria that follows accepted
national guidelines for appropriate product use. The criteria shall be based on
medical and clinical information and Missouri-specific data, consistent with the
predetermined standards set by one or more of the following:

  •   The American Hospital Formulary Service — Drug Information     •   The
United States Pharmacopoeia Drug Information     •   Peer-reviewed medical
literature.

      Specific details describing pharmacy prior authorization and step therapy
criteria shall be made available to prescribers upon request. Prescribers shall
be informed of the availability of the criteria when a prescription is denied.
The health plan shall provide for the dispensing of at least a 72-hour supply or
a sufficient supply to the next business day of a drug product that requires
prior authorization in an emergency situation.

 

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      RFP B3Z06118   Page 60

  i.   If the health plan prior authorizes health care services, the health plan
shall not subsequently retract its authorization after the services have been
provided, or reduce payment for an item or service unless:

  •   The authorization is based on material misrepresentation or omission about
the treated person’s health condition or the cause of the health condition; or  
  •   The health plan terminates before the health care services are provided;
or     •   The covered person’s coverage under the health plan terminates before
the health care services are provided.

2.14.3   Travel Distance: The health plan shall comply with travel distance
standards as set forth by the Department of Insurance in 20 CSR 400-7.095
regarding Provider Network Adequacy Standards. For those providers not addressed
under 20 CSR 400-7.095, the health plan shall ensure members have access to
those providers within a reasonable travel distance. For those providers
addressed under 20 CSR 400-7.095 but not applicable to the MC+ Managed Care
Program (e.g. chiropractors), the health plan shall not be held accountable for
the distance standards for those providers.

Paragraph 2.14.4 revised by Amendment #002 and BAFO #001

2.14.4   Appointment Standards:

  a.   The average waiting times for primary care appointments shall not exceed
one hour from scheduled appointment time. This includes time spent both in the
lobby and in the examination room prior to being seen by a provider. Providers
can be delayed when they “work in” urgent cases, when a serious problem is
found, or when the member had an unknown need that requires more services or
education than was described at the time the appointment was made.     b.   The
health plan shall have procedures in place that ensure:

  1)   Urgent care appointments for illness injuries which require care
immediately but do not constitute emergencies, within 24 hours (e.g. high
temperature, persistent vomiting or diarrhea, symptoms which are of sudden or
severe onset but which do not require emergency room services).     2)   Routine
care, with symptoms, appointments must be available within one (1) week or five
(5) business days whichever is earlier (e.g. persistent rash, recurring high
grade temperature, nonspecific pain, fever).     3)   Routine care, without
symptoms, appointments must be available within thirty (30) calendar days (e.g.
well child exams, routine physical exams).

Paragraph 2.14.4 b. 4) revised by BAFO #001

  4)   For mental health and substance abuse services, aftercare appointments
shall occur within seven (7) calendar days after hospital discharge.

  c.   For maternity care, the health plan shall be able to provide initial
prenatal care appointments for enrolled pregnant members as follows:

  1)   First trimester, must be available within seven (7) calendar days of
first request.     2)   Second trimester, must be available within seven
(7) calendar days of first request.     3)   Third trimester, must be available
within three (3) calendar days of first request.     4)   High risk pregnancies,
must be available within three (3) calendar days of identification of high risk
to the health plan or maternity care provider, or immediately if an emergency
exists.

 

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RFP B3Z06118   Page 61

  d.   Policies and Procedures: The health plan shall disseminate its
appointment standards to the network. The health plan shall monitor the adequacy
of its appointment standards to ensure the reduction of unnecessary use of
emergency room visits.

  1)   The health plan shall have written policies and procedures concerning
educating the provider network about appointment standards. The health plan
shall monitor compliance with appointment standards and shall have a corrective
action plan when appointment standards are not met.

2.14.5   The health plan shall have established written policies and procedures
concerning how a member may obtain a referral to an out-of-network provider when
the health plan does not have a health care provider with appropriate training
or experience in the network to meet the particular health care needs of the
member.   2.14.6   The health plan shall have established written policies and
procedures concerning how a member, with a condition which requires on-going
care from a specialist, may request a standing referral to such a specialist.  
2.14.7   The health plan shall have established written policies and procedures
concerning how a member, with a life-threatening condition or disease either of
which requires a specialized medical care over a prolonged period of time, may
request and obtain access to a specialty care center.   2.14.8   In accordance
with State law, the health plan must allow members direct access to the services
of the in-network OB/GYN of their choice for the provision of covered services.
  2.14.9   In accordance with State law, the health plan must notify the member
on an annual basis, in writing, of cancer screenings covered by the health plan
and provide the current American Cancer Society guidelines for all cancer
screenings.   2.14.10   The health plan shall have policies and procedures
concerning how it will appropriately work with an out-of-network provider and/or
the previous health plan to effect a transfer of care to appropriate in-network
providers when a newly enrolled member has an existing relationship with a
provider that is not in the health plan’s network. For continuity of care, there
are instances in which care shall continue with the out-of-network provider
(e.g. third trimester pregnancy, in the middle of a course of treatment for
cancer, etc.)   2.14.11   Care Management: The health plan shall provide care
management to members. Care management is coordination of care provided to
members.

  a.   The health plan shall coordinate and deliver services designed to achieve
the following outcomes:

  1)   Improved patient care;     2)   Improved health outcomes;     3)  
Reduction of inappropriate inpatient hospitalization;     4)   Reduction of
inappropriate utilization of emergent services;     5)   Lower total costs; and
    6)   Better educated providers and patients.

  b.   The health plan should have the following components in the care
management program:

  1)   Use of clinical practice guidelines; 2) Provider and patient profiling;  
  3)   Specialized physician and other practitioner care targeted to meet
members special needs;     4)   Provider education;     5)   Patient education;

 

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RFP B3Z06118   Page 62

  6)   Claims analyses; and     7)   Quarterly and yearly outcome measurement
and reporting. The reporting requirements specified in Attachment 6 will satisfy
this component. (Definition used with permission of The Center for Case
Management, 6 Pleasant Street, South Natick, MA 01760.)

  c.   The health plan must have implemented and effective policies and
procedures for case management, care coordination, and disease management:

  1)   Case management is a clinical system that focuses on the accountability
of an identified individual or group for coordinating a patient’s care (or group
of patients) across an episode or continuum of care; negotiating, procuring, and
coordinating services and resources needed by patients/families with complex
issues; insuring and facilitating the achievement of quality, clinical, and cost
outcomes; intervening at key points for individual patients; addressing and
resolving patterns of issues that have a negative quality cost impact; and
creating opportunities and systems to enhance outcomes. (Definition used with
permission of The Center for Case Management, 6 Pleasant Street, South Natick,
MA 01760.) Case management is understood as including, but not limited to the
development of individualized treatment plans and ongoing communication and
coordination with other systems of care. The treatment plans must be:

  •   Developed by the member’s primary care provider with member participation,
and in consultation with any specialists caring for the member;     •   Approved
by the entity in a timely manner, if this approval is required; and     •   In
accord with any applicable State quality assurance and utilization review
standards.

  2)   Care Coordination is a method of coordinating the provision of health
care so as to improve its continuity and quality. (Definition used with
permission of the Center for Health Care Strategies, Inc., Princeton, New
Jersey. “Case Management in Managed Care For People With Developmental
Disabilities: Models, Cost and Outcomes. January, 1999”.)     3)   Disease
Management is the process of intensively managing a particular disease or
syndrome. Disease management encompasses all settings of care and places a heavy
emphasis on prevention and maintenance. It is similar to case management, but
more focused on a defined set of problems relative to an illness or syndrome.
(Definition used with permission of Center for Health Care Strategies, Inc.,
Princeton, New Jersey, “Case Management in Managed Care For People With
Developmental Disabilities: Models, Costs and Outcomes, January, 1999”.)

2.14.12   Certification Review:

  a.   The health plan shall specify, in writing, the procedures for obtaining
initial, concurrent, and retrospective reviews for inpatient admissions and the
time frames in which authorizations will be processed (approved or denied) and
providers and members are notified. The health plan shall ensure that the
procedures meet the following minimum requirements:

  •   A professional with experience or expertise comparable to the provider
requesting the authorization must review all appeals and denials.     •   There
are standard policies and procedures for inpatient hospital admissions,
continued stay reviews, and retrospective reviews and for making determinations
on certifications or extensions of stays based on sound medical evidence that is
updated regularly and consistently applied and for consultations with the
requesting provider when appropriate.

  Ø   For inpatient hospital admissions, continued stay reviews, and
retrospective reviews to specialty pediatric hospitals, the health plan must use
the same criteria as Medicaid fee-for-service.     Ø   For psychiatric inpatient
hospital admissions, continued stay reviews, and retrospective reviews, the
health plan must use the same criteria as Medicaid fee-for-service
(LOCUS/CALOCUS).

 

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RFP B3Z06118   Page 63

  •   Reasons for decisions are clearly documented and assigned a certification
number, which refers to and documents approvals and denials.     •  
Documentation shall be maintained on any alternative service approved in lieu of
the original request.     •   There are fair and unbiased policies and
procedures for reconsideration requests when the attending physician, the
hospital, or the member disagrees with the health plan’s determination regarding
inpatient hospital admission or continued stays.     •   There are written
policies and procedures followed to address the failure or inability of a
provider or a member to provide all necessary information for review. In cases
where the provider or a member will not release necessary information, the
health plan may deny certification of an admission.     •   There is a
well-publicized review process for both provider and members.     •   To the
extent known, inform inpatient providers of the enrollees recent health care
service history at the time of authorization of a psychiatric inpatient
admission. Such information shall include psychiatric inpatient admissions and
emergency room visits for the prior year, psychiatric outpatient services for
the prior six months, and medications for the prior 90 calendar days.
Information about specific episodes of care shall include date, diagnosis,
provider, and procedure. Services related to substance abuse or HIV disorders
are exempt from this requirement.

  b.   The review process shall be completed and communicated to the provider
and member in a timely manner, as indicated below, or the denials shall be
deemed approved. For the purpose of this section, “necessary information”
includes the results of any face-to-face clinical evaluation or second opinion
that may be required.

  •   Approval or denial for initial determinations shall be provided by the
health plan within two (2) working days of obtaining all necessary information.
    •   Approval or denial for concurrent review determinations shall be
provided by the health plan within one (1) working day of obtaining all
necessary information.     •   Approval or denial for retrospective review
determinations shall be provided by the health plan within thirty (30) working
days of receiving all necessary information.     •   The health plan shall
notify the requesting provider within two (2) working days following the receipt
of the request of service regarding any additional information necessary to make
a determination.     •   In no case shall a health plan exceed fourteen
(14) calendar days following the receipt of the request of service to provide
approval or denial for an initial or concurrent review.

2.15   Member Grievance System: The health plan shall have a system in place for
members which includes a grievance process, an appeal process, and access to the
state agency’s fair hearing system.   2.15.1   For purposes of the health plan’s
grievance system, the following definitions shall apply:       Action — The
denial or limited authorization of a requested service, including the type or
level of service; the reduction, suspension, or termination of a previously
authorized service; the denial, in whole or in part, of payment for a service;
the failure of the health plan to provide services in a timely manner as defined
in the appointment standards described herein; or the failure of the health plan
to act within timeframes for the health plan’s Prior Authorization review
process specified herein.       Appeal — A request for review of an action, as
action is defined in this section.       Appeal Process — The health plan’s
process for handling of appeals that complies with the requirements specified
herein, including, but not limited to, the procedural steps for a member to file
an appeal, the process for resolution of an appeal, the right to access the
State fair hearing system, and the timing and manner of required notifications.

 

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RFP B3Z06118   Page 64

    Grievance — An expression of dissatisfaction about any matter other than an
action, as action is defined in this section. Possible subjects for grievances
include, but are not limited to, the quality of care or services provided, and
aspects of interpersonal relationships such as rudeness of a provider or
employee, or failure to respect the member’s rights.       Grievance Process —
The health plan process for handling of grievances that complies with the
requirements specified herein, including, but not limited to, the procedural
steps for a member to file a grievance, the process for disposition of a
grievance, and the timing and manner of required notifications.       Grievance
System — The overall system in place for members that includes a grievance
process, an appeal process, and access to the State fair hearing system.      
Inquiry - A request from a member for information that would clarify health plan
policy, benefits, procedures, or any aspect of health plan function but does not
express dissatisfaction.   2.15.2   General Requirements: The health plan shall
develop and implement written policies and procedures that detail the operation
of the grievance system and provides simplified instructions on how to file a
grievance or appeal and how to request a state fair hearing.

  a.   The policies and procedures must be approved by the state agency prior to
implementation.     b.   The policies and procedures shall be approved by the
health plan’s governing body and be the direct responsibility of the governing
body.     c.   The health plan shall distribute an information packet to members
upon enrollment which contains the grievance system policies and procedures,
specific instructions regarding how to contact the health plan’s member
services, and identifies the person from the health plan who receives and
processes grievances and appeals. The health plan shall also distribute the
information packet to all in-network providers at the time they enter into a
contract and to out-of-network providers within ten (10) calendar days of prior
approval of a service or the date of receipt of a claim whichever is earlier.  
  d.   The policies and procedures shall identify specific individuals who have
authority to administer the grievance system policies.     e.   The grievance
system policies and procedures shall be readily available verbally and in the
member’s primary language. In addition, the health plan shall demonstrate that
they have procedures in place to notify all members in their primary language of
grievance dispositions and appeal resolutions.     f.   As part of the grievance
system, the health plan shall ensure that health plan executives with the
authority to require corrective action are involved in the grievance and appeal
processes.     g.   The health plan shall thoroughly investigate each grievance
and appeal using applicable statutory, regulatory, contractual provisions, and
the health plan’s written policies and procedures. Pertinent facts from all
parties must be collected during the investigation.     h.   The health plan
shall probe inquiries so as to validate the possibility of any inquiry actually
being a grievance or appeal. The health plan shall identify any inquiry pattern.
    i.   The health plan’s grievance system shall not be a substitute for the
State fair hearing process. The state agency shall maintain an independent State
fair hearing process as required by federal law and regulation, as amended. The
State fair hearing process shall provide members an opportunity for a State fair
hearing before an impartial hearing officer. The parties to the State fair
hearing include the health plan as well as the member and his or her
representative or the representative of a deceased member’s estate. The health
plan shall comply with decisions reached as a result of the State fair hearing
process. Health plan members shall have the right to request information
regarding:

 

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RFP B3Z06118   Page 65

  •   The right to request a State fair hearing.     •   The procedures for
exercising the rights to appeal or request a State fair hearing.     •  
Representing themselves or use legal counsel, a relative, a friend, or other
spokesperson.     •   The specific regulations that support or the change in
Federal or State law that requires the action.     •   The individual’s right to
request a state fair hearing, or in cases of an action based on change in law,
the circumstances under which a hearing will be granted.     •   A State fair
hearing within 90 calendar days from the health plan’s notice of action.

  j.   The State must reach its decisions within the specified timeframes:

  1)   Standard resolution: within 90 calendar days of the date the member filed
the appeal with the health plan if the member filed initially with the health
plan (excluding the days the enrollee took to subsequently file for a State fair
hearing) or the date the member filed for direct access to a State fair hearing.
    2)   Expedited resolution (if the appeal was heard first through the health
plan appeal process): within 3 working days from the state agency’s receipt of a
hearing request for a denial of a service that:

  •   Meets the criteria for an expedited appeal process but was not resolved
using the health plan’s expedited appeal timeframes, or     •   Was resolved
wholly or partially adversely to the member using the health plan’s expedited
appeal timeframes.

  3)   Expedited resolution (if the appeal was made directly to the State Fair
Hearing process without accessing the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request for a denial
of a service that meets the criteria for an expedited appeal process.

2.15.3   Record Keeping and Reporting Requirements:

  a.   The health plan shall log and track all inquiries, grievances, and
appeals.     b.   The health plan shall maintain records of grievances, whether
received verbally or in writing, that include a short, dated summary of the
problems, name of the grievant, date of grievance, date of decision, and the
disposition. If the health plan does not have a separate log for MC+ managed
care members, the log shall distinguish MC+ managed care members from other
health plan members.     c.   The health plan shall maintain records of appeals,
whether received verbally or in writing, that include a short, dated summary of
the issues, name of the appellant, date of appeal, date of decision, and the
resolution. If the health plan does not have a separate log for MC+ managed care
members, the log shall distinguish MC+ managed care members from other health
plan members.     d.   The health plan must report grievances and appeals to the
state agency in the format and frequency specified by the state agency. The
state agency shall provide the health plan with no less than ninety (90) days
notice of any change in the format or frequency requested.     e.   The state
agency may publicly disclose summary information regarding the nature of
grievances and appeals and related dispositions or resolutions in consumer
information materials.

2.15.4   Notice of Action Requirements:

 

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RFP B3Z06118   Page 66

  a.   The health plan’s notice must be in writing and must meet the language
and content requirements specified herein to ensure ease of understanding.    
b.   The health plan’s notice must explain the following:

  1)   The action the health plan has taken or intends to take.     2)   The
reasons for the action.     3)   The member’s or the provider’s right to file an
appeal.     4)   The member’s right to request a State fair hearing.     5)  
The procedures for exercising the rights to appeal or request a State fair
hearing.     6)   That the member may represent himself or use legal counsel, a
relative, a friend, or other spokesperson.     7)   Must explain the specific
regulations that support, or the change in Federal or State law that requires
the action.     8)   The member’s right to request a state agency hearing, or in
cases of an action based on change in law, the circumstances under which a
hearing will be granted.     9)   The circumstances under which expedited
resolution is available and how to request it.     10)   The member’s right to
have benefits continue pending resolution of the appeal, how to request that
benefits be continued, and the circumstances under which the member may be
required to pay the costs of these services.

  c.   The health plan must mail the notice to the member within the following
timeframes:

  1)   For termination, suspension, or reduction of previously authorized
covered services, at least ten (10) calendar days before the date of action. The
health plan may mail a notice not later than the date of action under the
following circumstances:

  •   The health plan has factual information confirming the death of a member.
    •   The health plan receives a clear written statement signed by the member
that he or she no longer wishes services or gives information that requires
termination or reduction of services and indicates that he or she understands
that this must be the result of supplying that information.     •   The member’s
whereabouts are unknown and the post office returns health plan mail directed to
the member indicating no forwarding address (refer to 42 CFR 431.231 (d) for
procedures if the member’s whereabouts become known).     •   The member’s
physician prescribes a change in the level of medical care.     •   The health
plan may shorten the period of advance notice to 5 calendar days before date of
action if the health plan has facts indicating that action should be taken
because of probable fraud by the member and the facts have been verified, if
possible, through secondary sources.     •   The member’s admission to an
institution where he is ineligible for further services.     •   The member has
been accepted for Medicaid services by another local jurisdiction.

  2)   For denial of payment decisions that result in member liability, at the
time of any action affecting the claim.     3)   For service authorization
decisions that deny or limit services, within the timeframes required by the
service accessibility standards for prior authorization specified herein.

2.15.5   Grievance Process:

  a.   A member may file a grievance either orally or in writing. A member’s
authorized representative including the member’s provider may file a grievance
on behalf of the member.

 

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RFP B3Z06118   Page 67

  b.   The health plan shall give members any reasonable assistance in
completing forms and taking other procedural steps. This includes, but is not
limited to, providing interpreter services and toll-free numbers that have
adequate TTY/TTD and interpreter capability.     c.   The health plan shall
acknowledge receipt of each grievance in writing within ten (10) business days
after receiving a grievance.     d.   The health plan shall ensure that the
individuals who make decisions on grievances are individuals who were not
involved in any previous level of review or decision-making; and who, if
deciding any of the following, are health care professionals who have the
appropriate clinical expertise, as determined by the state agency, in treating
the member’s condition or disease:

  1)   A grievance regarding denial of expedited resolution of an appeal.     2)
  A grievance that involves clinical issues.

  e.   The health plan shall dispose of each grievance and provide written
notice of the disposition of the grievance, as expeditiously as the member’s
health condition requires but shall not exceed thirty (30) calendar days of the
filing date.     f.   The health plan may extend the timeframe for disposition
of a grievance for up to fourteen (14) calendar days if the member requests the
extension or the health plan demonstrates (to the satisfaction of the state
agency, upon its request) that there is need for additional information and how
the delay is in the member’s interest. If the health plan extends the timeframe,
it must, for any extension not requested by the member, give the member written
notice of the reason for the delay.

2.15.6   Appeal Process:

  a.   A member may file an appeal and may request a State fair hearing within
90 calendar days from the date on the health plan’s notice of action. A
provider, acting on behalf of the member and with the member’s written consent,
may file an appeal.     b.   The member or provider may file an appeal either
orally or in writing. Unless he or she requests expedited resolution, must
follow an oral filing with a written, signed appeal.     c.   The health plan
shall give members any reasonable assistance in completing forms and taking
other procedural steps. This includes, but is not limited to, providing
interpreter services and toll-free numbers that have adequate TTY/TTD and
interpreter capability.     d.   Appeals shall be filed directly with the health
plan’s governing body, or its delegated representatives. The governing body may
delegate this authority to an appeal committee, but the delegation must be in
writing.     e.   The health plan shall acknowledge receipt of each appeal in
writing within ten (10) business days after receiving an appeal.     f.   The
health plan shall ensure that the individuals who make decisions on appeals are
individuals who were not involved in any previous level of review or
decision-making; and who, if deciding any of the following, are health care
professionals who have the appropriate clinical expertise, as determined by the
state agency, in treating the member’s condition or disease:

  1)   An appeal of a denial that is based on lack of medical necessity.     2)
  An appeal that involves clinical issues.

 

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RFP B3Z06118   Page 68

  g.   The appeals process must provide that oral inquiries seeking to appeal
are treated as appeals (to establish the earliest possible filing date for the
appeal) and must be confirmed in writing, unless the member or the provider
requests expedited resolution.     h.   The appeals process must provide the
member a reasonable opportunity to present evidence, and allegations of fact or
law, in person as well as in writing. The health plan must inform the member of
the limited time available for this in the case of expedited resolution.     i.
  The appeals process must provide the member and his or her representative
opportunity, before and during the appeals process, to examine the member’s case
file, including medical records, and any other documents and records considered
during the appeals process.     j.   The appeals process must include as parties
to the appeal the member and his or her representative or the legal
representative of a deceased member’s estate.     k.   The health plan shall
resolve each appeal and provide written notice of the appeal resolution, as
expeditiously as the member’s health condition requires but shall not exceed
forty-five (45) calendar days from date the health plan receives the appeal. For
expedited resolution of an appeal and notice to affected parties, the health
plan has no longer than three (3) working days after the health plan receives
the appeal. For notice of an expedited resolution, the health plan must also
make reasonable efforts to provide oral notice.     l.   The health plan may
extend the timeframe for standard or expedited resolution of the appeal by up to
fourteen (14) calendar days if the member requests the extension or the health
plan demonstrates (to the satisfaction of the state agency, upon its request)
that there is need for additional information and how the delay is in the
member’s interest. If the health plan extends the timeframe, it must, for any
extension not requested by the member, give the member written notice of the
reason for the delay.     m.   The written notice of the appeal resolution must
include the following:

  1)   The results of the resolution process and the date it was completed.    
2)   For appeals not resolved wholly in the favor of the members the right to
request a State fair hearing, and how to do so; the right to request to receive
benefits while the hearing is pending, and how to make the request; and that the
member may be held liable for the cost of those benefits if the hearing decision
upholds the health plan’s action.

  n.   The health plan must establish and maintain an expedited review process
for appeals when the health plan determines (for a request from the member) or
the provider indicates (in making the request on the member’s behalf) that
taking the time for a standard resolution could seriously jeopardize the
member’s life or health or ability to attain, maintain, or regain maximum
function. The health plan must ensure that punitive action is neither taken
against a provider who requests an expedited resolution or supports a member’s
appeal.     o.   If the health plan denies a member’s request for expedited
resolution, it must transfer the appeal to the timeframe for standard resolution
specified herein and must make reasonable efforts to give the member prompt oral
notice of the denial, and follow up within two (2) calendar days with a written
notice.     p.   Continuation of benefits while the health plan appeal and State
fair hearing are pending.

  1)   As used in this section, “timely” filing means filing on or before the
later of the following:

  •   Within ten (10) calendar days of the health plan mailing the notice of
action.     •   The intended effective date of the health plan’s proposed
action.

 

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RFP B3Z06118   Page 69

  2)   The health plan must continue the member’s benefits if the member or the
provider files the appeal timely; the appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment; the
services were ordered by an authorized provider; the original period covered by
the original authorization has not expired; and the member requests extension of
the benefits.     3)   If, at the member’s request, the health plan continues or
reinstates the member’s benefits while the appeal is pending, the benefits must
be continued until one of the following occurs:

  •   The member withdraws the appeal.     •   Ten (10) calendar days pass after
the health plan mails the notice, providing the resolution of the appeal against
the member, unless the member, within the ten (10) calendar day timeframe, has
requested a State fair hearing with continuation of benefits until a State fair
hearing decision is reached.     •   A State fair hearing officer issues a
hearing decision adverse to the member.     •   The time period or service
limits of a previously authorized service has been met.

  4)   If the final resolution of the appeal is adverse to the member, that is,
upholds the health plans action, the health plan may recover the cost of the
services furnished to the member while the appeal is pending, to the extent that
they were furnished solely because of the requirements of this section.

  q.   If the health plan or the State fair hearing officer reverses a decision
to deny, limit, or delay services that were not furnished while the appeal was
pending, the health plan must authorize or provide this disputed services
promptly, and as expeditiously as the member’s health condition requires.     r.
  If the health plan or the State fair hearing officer reverses a decision to
deny authorization of services, and the member received the disputed services
while the appeal was pending, the health plan must pay for those services.

2.16   Provider Inquiries, Complaints, Grievances, and Appeals:       The health
plan shall establish a complaint, grievance, and appeal process that guarantees
the right for a review to any provider of medical services for a member of the
health plan.   2.16.1   For purposes of this document, the following definitions
shall apply:       Inquiry - A request from a provider regarding information
that would clarify health plan policy benefits, procedures, or any aspect of
health plan function that may be in question.       Complaint - A verbal or
written expression by a provider which indicates dissatisfaction or dispute with
health plan policy, procedure, claims, or any aspect of health plan functions.
All complaints must be logged and tracked whether received by telephone, in
person or in writing.       Grievance - A written request for further review of
a provider’s complaint that remains unresolved after completion of the complaint
process.       Appeal - The formal mechanism which allows a provider the right
to appeal a grievance decision.   2.16.2   The health plan shall develop written
policies and procedures which detail the operation of the provider inquiry,
complaint, grievance, and appeal process and provides instructions on how to
file a complaint, grievance, or appeal.

  a.   The policies and procedures must be approved by the state agency prior to
implementation.

 

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RFP B3Z06118   Page 70

  b.   The policies and procedures shall be approved by the health plan
governing body and be the direct responsibility of the governing body.     c.  
The health plan shall distribute an information packet to providers containing
the complaint, grievance, and appeal policies and procedures, specific
instructions regarding how to contact the health plan’s provider services, and
identifies the person from the health plan who receives and processes
complaints, grievances, and appeals. The health plan shall distribute the
policies and procedures to in-network providers at time of subcontract and to
out-of-network providers with the remittance advice of the processed claim.    
d.   The process must be addressed in the provider manual.     e.   The policies
and procedures shall identify specific individuals who have authority to
administer the inquiry, complaint, grievance, and appeal process.

2.16.3   Provider Inquiry, Complaint, Grievance, and Appeal Process:

  a.   Inquiry: The health plan shall operate a provider services function,
which providers can use to ask questions, file inquiries and complaints, and get
problems resolved. The health plan’s provider services function shall be
adequately staffed to receive telephone calls and meet personally with
providers. The health plan shall identify a person from the health plan
specifically designated to receive and process complaints, grievances, and
appeals. The health plan shall probe the inquiries so as to validate the
possibility of any inquiry actually being a complaint. The health plan shall
identify any inquiry patterns.     b.   Complaint: A complaint can be filed
verbally or in writing within one year of the incident that resulted in a
complaint. Complaints shall be resolved within ten (10) calendar days of their
filing. The provider(s) and health plan should attempt to resolve complaints
before proceeding to a grievance.

  1)   At the time of the health plan’s decision regarding a complaint, the
health plan shall notify providers in writing of their right to file a grievance
with the health plan. This notification must be prior approved by the state
agency.

  c.   Grievance: The health plan shall provide a grievance process which
providers can use to file their dissatisfaction with the complaint resolution.
If a provider is dissatisfied with the complaint resolution, the provider may
file a grievance in writing with the health plan within ninety (90) calendar
days of the complaint resolution. The provider must deliver a written,
substantiated disagreement with the complaint resolution to the health plan. The
health plan must acknowledge the receipt of grievances in writing within ten
(10) business days after receiving a grievance. Grievances shall be investigated
by the health plan and reviewed by a designated authority within the health
plan. The health plan shall reach decisions on grievances within thirty
(30) calendar days of their filing date.

  1)   At the time of the health plan’s decision regarding a grievance, the
health plan shall notify the provider in writing of their right to file an
appeal with the health plan. This notification must be prior approved by the
state agency.

  d.   Appeal: The health plan shall operate an appeals process through which
providers can challenge a negative decision to their grievances. Providers shall
have ninety (90) calendar days following written notification of a grievance
decision to appeal. The appeal must be filed in writing either by the provider
or the provider’s representative, or through the provider’s instruction to the
health plan’s representative that the provider wishes to appeal. The health plan
shall acknowledge receipt of each appeal in writing within ten (10) business
days after receiving an appeal. Appeals shall be filed directly to the health
plan’s governing body, or its delegated representatives (The governing body

 

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      may delegate this authority to an appeal committee, but the delegation
must be in writing.). The appeal process shall include an opportunity for
providers or their representatives to present their cases in person to the
appellate body. The health plan shall reach a final decision on an appeal and
provide written notice of the appeal resolution within sixty (60) calendar days
of receipt of the appeal, with extensions possible if approved by the state
agency.     e.   Expedited Review: The health plan shall have a procedure for
expedited review of the complaint or grievance if the standard time frame could
seriously jeopardize the member’s life, physical or mental health, or the
member’s ability to regain maximum function. The expedited review shall be
resolved no later than 72 hours or as expeditiously as the member’s physical or
mental health requires.

2.16.4   As a part of the provider complaint, grievance, and appeal process, the
health plan shall:

  a.   Ensure that health plan executives with the authority to require
corrective action are involved in the complaint, grievance, and appeal process.
    b.   Thoroughly investigate each complaint, grievance, and appeal using
applicable statutory, regulatory, contractual provisions, and the health plan’s
written policies and procedures. Pertinent facts from all parties must be
collected during the investigation.

2.16.5   Records/Reporting:

  a.   The health plan shall log and track all inquiries.     b.   The health
plan shall maintain records of complaints that include a short, dated summary of
each of the questions or problems, name of the complainant, date of complaint,
the response, and the resolution. If the health plan does not have a separate
log for in-network providers, the log shall distinguish in-network providers
from other health plan providers.     c.   The health plan shall maintain
grievance records that include a copy of the original grievance, the response,
and the resolution. This system shall distinguish in-network providers from
other health plan providers and identify the grievant and the date of filing.  
  d.   The health plan must report provider complaints, grievances, and appeals
to the state agency in the format requested by the state agency.     e.   The
health plans must maintain records of all provider complaints, grievances,
appeals, and resolutions.

2.17   Quality Assessment and Improvement:   2.17.1   The state agency regulates
the quality assessment and improvement functions of the health plan. The health
plan therefore must comply with all the state agency’s quality assessment and
improvement programs as described herein. The health plan shall participate in
the State’s efforts to promote the delivery of services in a culturally
competent manner to all members, including those with limited English
proficiency and diverse cultural and ethnic backgrounds. The health plan shall
be held accountable for the ongoing monitoring, evaluation, and actions as
necessary to improve the health of its members and the care delivery systems for
those members. The health plan shall be held accountable for the quality of care
delivered by providers. The state agency’s quality assessment and improvement
program shall consist of internal monitoring by the health plan, oversight by
federal and state governments, and evaluations by an independent, external
review organization. The health plan shall have a quality assessment and
improvement program which integrates an internal quality assessment process that
conforms to Quality Improvement System for Managed Care (QISMC) and additional
current standards and guidelines prescribed by CMS. The health plan shall adhere
to the requirements contained within the state agency’s, Quality Management Plan
located in Attachment 6. The health plan shall have a quality assessment and
improvement program composed of:

 

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RFP B3Z06118   Page 72

  a.   An internal system of monitoring, analysis, evaluation, and improvement
of the delivery of care that includes care provided by all providers;     b.  
Designated staff with expertise in quality assessment, utilization management
and continuous quality improvement;     c.   Written policies and procedures for
quality assessment, utilization management, and continuous quality improvement
that are periodically analyzed and evaluated for impact and effectiveness;    
d.   Results, conclusions, team recommendations, and implemented system changes
which are reported to the health plan’s governing body at least quarterly, and  
  e.   Reports that are evaluated, recommendations that are implemented when
indicated, and feedback provided to providers and members.

2.17.2   Internal Staff: The health plan shall designate a Quality Assessment
and Improvement and Utilization Management Coordinator(s). Specifically, the
Quality Assessment and Improvement and Utilization Management Coordinator must:

  a.   Be a registered nurse, nurse practitioner, or physician. The registered
nurse or nurse practitioner must be licensed in the State of Missouri. The
physician must be Missouri licensed and practice medicine in the United States.
He/she must be board-certified, board-eligible, or have sufficient experience in
his or her field or specialty to be determined competent by the health plan’s
Medical Director or the Credentials Committee.     b.   Be responsible for
assisting the governing body and their designee in the process of continually
developing, implementing, evaluating, and improving the written quality
assessment and improvement program. The continuous improvement process shall
include care delivery objectives, specific activities implemented from issues
identified as a result of the on-going monitoring process, systems methodologies
for continuous tracking of care delivery, and provider review. The process must
include a focus on health outcomes and action plans for improvement of those
outcomes.     c.   Be responsible for the health plan’s utilization management
and quality assessment committee, assist the governing board in directing the
development and implementation of the health plan’s internal quality assessment
and improvement program, and monitor the quality of care that members receive.  
  d.   Oversee the development of clinical care standards and practice
guidelines and protocols for the health plan. The health plan must 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 members;     3)   Are adopted in consultation with contracting health
care professionals; and     4)   Are reviewed and updated periodically as
appropriate.     5)   Dissemination of the guidelines to all affected providers
and, upon request, to members and potential members.     6)   Ensure that
decisions for utilization management, member education, coverage of services,
and other areas to which the guidelines apply should be consistent with the
guidelines.

  e.   Review all potential quality of care problems, both physical and mental
health, and oversee development and implementation of continuous assessment and
improvement of the quality of care provided to members.     f.   Maintain
current medical information pertaining to clinical practice and guidelines.

 

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  g.   Ensure that health education resources are available for the provision of
proper medical care to members.     h.   Utilize staff in an effective and
efficient manner to monitor and assess care delivery.     i.   Specify clinical
or health services areas to be monitored.     j.   Specify the use of quality
indicators that are objective, measurable, and based on current knowledge and
clinical experience for priority areas selected by the state agency as well as
for areas the health plan selects.     k.   Monitor and report on the management
of the health plan’s EPSDT program.     l.   Monitor and report on the health
plan’s referral process for specialty and out-of-network services.     m.  
Ensure that all denied services are reviewed by a physician, physician
assistant, or advanced nurse practitioner. The reason for the denial must be
documented and logged. Any alternative services authorized must be documented.
All denials must identify appeal rights of the member.     n.   Monitor and
report on the health plan’s credentialing and recredentialing activities.     o.
  Monitor and report on the health plan’s process for prior authorizing and
denying services.     p.   Monitor and report on the health plan’s process for
ensuring the confidentiality of medical records and member information.     q.  
Monitor and report on the health plan’s process for ensuring the confidentiality
of the appointments, treatments, and required state agency reporting of
adolescent STDs.     r.   Monitor provider for compliance that reports of
disease and conditions are made to the State Department of Health and Senior
Services in accordance with all applicable State statutes, rules, guidelines,
and policies and with all metropolitan ordinances and policies.     s.   Monitor
provider for compliance that control measures for tuberculosis, STDs, and
communicable diseases are carried out in accordance with applicable laws and
guidelines and such measures are defined in the provider manual.     t.   Serve
as a liaison between the health plan and the in-network providers and
communicate at least quarterly with the in-network providers, including
oversight of provider education, in service training, and orientation.
Newsletter, web sites, and other media may be used to meet this criteria.     u.
  Be available to the health plan’s medical staff for consultation on referrals,
denials, grievances and appeals, and problems.     v.   Monitor and report at
least annually 24-hour access and after hours availability of primary care
providers.

2.17.3   In addition to internal monitoring of quality of care, the health plan
shall submit to the state agency reports regarding the results of their internal
monitoring, evaluation, and action plan implementation. The reports shall
include targeted health indicators monitored by the state agency and specific
quality data periodically requested by the federal government. The reports may
be required on a monthly, quarterly or annual basis or as specified by the state
agency. (Refer to the Quality Management Plan located at Attachment 6 for the
current report format.) The report format shall be periodically reviewed and
updated by the state agency. The state agency shall provide the health plan with
no less than ninety (90) calendar

 

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    days notice of any changes in the format requested. The health plan shall
comply with all subsequent changes specified by the state agency. The health
plan shall provide access to documentation, medical records, premises, and staff
as deemed necessary by the state agency.   2.17.4   The state agency shall
contract with independent, external evaluators to examine the quality of care
provided by the health plan. The health plan shall provide access to
documentation, medical records, premises, and staff as deemed necessary by the
state agency for the independent external review.   2.17.5   Internal
Procedures: The health plan shall have an internal written quality assessment
and improvement program. The health plan shall include monitoring, assessment,
evaluation, and improvement of the quality of care for all clinical and health
service delivery areas. Emphasis should be placed on, but need not be limited
to, clinical areas relating to maternity, pediatric and adolescent development,
EPSDT, family planning, and well woman care, as well as on key access or other
priority issues for members such as reducing the incidence of STDs, acquired
immune deficiency syndrome, and smoking related illnesses. The health plan must
have implemented mechanisms to assess the quality and appropriateness of care
furnished to members with special health care needs. The health plan’s quality
review mechanisms shall address members with special needs as well as COA 1, COA
4, and COA 5 members in the written monitoring, assessment, evaluation, and
improvement plan.

  a.   Internal policies and procedures must:

  1)   Ensure that the utilization management and quality assessment committees
have established operating parameters. The committees shall meet at least
quarterly, on a regular schedule. Committee members must be clearly identified
and representative of the health plan’s providers. The committee shall be
accountable to the Medical Director and governing body. The committees must
maintain appropriate documentation of the committees’ activities, findings,
recommendations, actions, and follow up.     2)   Provide for regular
utilization management and quality assessment reporting to the health plan
management and health plan providers, including profiling of provider
utilization patterns.     3)   Be developed and implemented by professionals
with adequate and appropriate experience in quality assessment and improvement:
quality assessment, utilization management, and continuous improvement
processes.     4)   Provide for systematic data collection, analysis, and
evaluation of performance and member results.     5)   Provide for
interpretation of this data to practitioners.     6)   Provide timelines for
correction, and assign a specific staff person to be responsible for ensuring
compliance and follow up.     7)   Clearly define the roles, functions, and
responsibilities of the quality assessment committee and the Medical Director.

  b.   Utilization Management: The health plan shall have written utilization
management policies and procedures that include protocols for denial of
services, prior approval, hospital discharge planning, physician profiling, and
concurrent, prospective, and retrospective review of claims that comply with
federal and state laws and regulations, as amended. The utilization management
policies and procedures must be clearly specified in provider contracts or
provider manuals and consistently applied in accordance with the established
utilization management guidelines. As part of the health plan’s utilization
management function, the health plan also must have processes to identify both
over and under utilization problems for inpatient and outpatient services,
undertake corrective action, and follow up. This review must consider the
expected utilization of services regarding the

 

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      characteristics and health care needs of the member population. In
addition, the health plan shall use an emergency room log, or equivalent method,
to track emergency room services. Compensation to individuals or entities that
conduct utilization management activities shall not be structured so as to
provide incentives for the individual or entity to deny, limit, or discontinue
medically necessary services to any member.

  c.   Provider Credentialing: The health plan shall have written credentialing
and re-credentialing policies and procedures for determining and assuring that
all in-network providers are licensed by the state in which they practice and
qualified to perform their services. The health plan shall have written policies
and procedures for monitoring the in-network providers, reporting the results of
the monitoring process, and disciplining in-network providers found to be
out-of-compliance with the health plan’s medical management standards. The
health plan shall use the Missouri Standardized Credentialing Form (MoSCF),
pursuant to RSMo 354.442.1 (15) and 20 CSR 400.7.180, as amended.     d.  
Performance Improvement Projects: The health plan must conduct performance
improvement projects that are designed to achieve, through ongoing measurements
and intervention, significant improvement, sustained over time, in clinical care
and nonclinical care areas that are expected to have a favorable effect on
health outcomes and member satisfaction. The health plan must report the status
and results of each project to the state agency as requested. The performance
improvement projects must 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.     5)  
Completion of the performance improvement project 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.     6)   Performance measures and topics for performance improvement
projects specified by CMS in consultation with the state agency and other
stakeholders.

  e.   Member Incentives: The health plan may offer member incentives with a
value of $30.00 or less per eligible member per month. All member incentives
must be prior approved by the state agency. The purpose of the health plan’s
member incentives:

  •   Must be directly related to a health plan quality initiative     •   Must
be measurable via the quality activity     •   Cannot have any relationship to
the health plan’s marketing activities     •   Cannot be convertible to cash or
redemption in any way for alcohol, tobacco products, firearms or ammunition.

  1)   The health plan must monitor their member incentives program to ensure
that the program has met the health plan’s quality initiative and to evaluate on
an ongoing basis the effectiveness of the member incentive program.     2)   The
health plan must report the status and results of member incentives to the state
agency as requested.

2.18   Community Health Assessment:   2.18.1   The health plan shall participate
in a community health status assessment and improvement initiative as approved
by the Department of Health and Senior Services. The health status assessment
and improvement initiative shall be developed by a community-based coalition and
include community

 

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    benchmarks for measuring access, quality, and health status. The Department
of Health and Senior Services shall provide a list of active community-based
health status assessment and improvement initiatives to the health plan. If
there is no approved health status assessment and improvement initiative in the
health plan’s region, the Department of Health and Senior Services shall provide
technical assistance to the health plan to develop the health status assessment
and improvement initiative. Participation in a health status assessment and
improvement initiative shall include:

  a.   Becoming a member of a community-wide planning coalition. Community means
a geographic entity (a county(ies) for the most part) with broad based
representation from community providers, businesses, local organizations,
schools, etc. The Department of Health and Senior Services would notify the
health plan of coalitions that meet the community standard. Where no such
coalition exists, the Department of Health and Senior Services shall work with
the health plan to develop one. The health plan shall not be required to be the
lead agency in establishing a coalition.     b.   Assisting with the collection
and/or analysis of relevant health data and information as defined by the
coalition.     c.   Active involvement in the assessment process including
prioritizing community problems.     d.   Active involvement in the development
and implementation of the community strategic plan to implement health
improvement programs.     e.   Providing feedback on the community strategic
plan and its effectiveness.

2.19   State and Federal Reviews:   2.19.1   The health plan shall make
available to the state agency or its outside reviewers, on an annual basis and
on an as needed basis, medical and other records for review of quality of care,
access, financial, and other issues. The state agency’s quality assessment and
improvement review may include but is not limited to:

  a.   On-site visits and inspections of facilities;     b.   Staff and member
interviews;     c.   Review of utilization, denial of services, and other areas
that will indicate quality of care delivered to members;     d.   Medical
records reviews;     e.   Financial records reviews;     f.   Review of all
quality assessment procedures, reports, committee activities and
recommendations, and corrective actions;     g.   Review of staff and provider
qualifications;     h.   Review of the complaint, grievance, and appeal process
and resolutions;     i.   Review of requests for transfers between primary care
providers within each health plan;     j.   Review of fraud and abuse detection,
prevention, and review process, procedures, cases, and reports; and     k.  
Evaluation and analysis of coordination and continuity of care.

 

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2.19.2   External Reviews: The state agency contracts with independent external
evaluators to examine the quality of care provided by the health plan. CMS
designates an outside review agency to conduct an evaluation of the program and
its progress toward achieving program goals. The health plan shall make
available to CMS’s outside review agency and the state agency’s external
evaluator medical and other records for review as requested. The health plan
shall provide information for External Quality Reviews in the format specified
by the state agency.   2.20   Financial Reporting:   2.20.1   The health plan
shall not hold a member liable for the following:

  a.   The debts of the health plan, in the event of the health plan’s
insolvency;     b.   Services provided to the member in the event the health
plan fails to receive payment from the state agency for such services;     c.  
Services provided to the member in the event a health care provider with a
contractual, referral, or other arrangement with the health plan fails to
receive payment from the state agency or health plan for such services; or    
d.   Payments to a provider that furnishes covered services under a contractual,
referral, or other arrangement with the health plan in excess of the amount that
would be owed by the member if the health plan had directly provided the
services.     e.   In the case of insolvency, the health plan shall continue to
cover services to members during insolvency for the duration of period for which
payment has been made by the state agency, as well as for inpatient admissions
up until discharge.

2.20.2   Financial Data Reporting: The health plan shall submit unaudited
semi-annual reports and an unaudited and audited annual report for their MC+
managed care book of business to the state agency. The health plan shall submit
the semi-annual and annual reports in the format and audit guidelines specified
by the state agency. The current report format and audit guidelines can be found
in Attachment 10. Changes to the report format must be approved by the state
agency prior to submission.

  a.   The semi-annual and unaudited and audited annual reports must be
certified by one of the following:

  1)   The health plan’s Chief Executive Officer.     2)   The health plan’s
Chief Financial Officer.     3)   An individual who has delegated authority to
sign for, and who reports directly to, the health plan’s Chief Executive Officer
or Chief Financial Officer.

  b.   The certification must attest, based on best knowledge, information, and
belief, as follows:

  1)   To the accuracy, completeness, and truthfulness of the data.     2)   To
the accuracy, completeness, and truthfulness of the semi-annual and annual
reports.

  c.   The health plan must submit the certification concurrently with the
semi-annual and annual reports.

2.20.3   Physician Incentive Plan Requirements: The Department of Health and
Human Services published a federal regulation regarding physician incentive
plans in the March 27, 1996, Federal Register. This regulation is designed to
protect beneficiaries enrolled in Medicare and Medicaid Managed Care
Organizations by placing certain limitations on physician incentive plans that
could influence a physician’s care decisions.

 

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RFP B3Z06118   Page 78

  a.   In addition, the physician incentive plan regulation applies to all
subcontractors, including any health care services subcontractors. The physician
incentive plan regulation does not apply outside the scope of incentive plans
for physicians providing services to Medicare or MC+ managed care members.    
b.   The health plan shall not offer financial incentives to induce physicians
to limit or reduce medically necessary services to a specific member. The health
plan shall not offer non-financial incentives to limit or reduce medically
necessary services to a specific member.     c.   A physician group is at
“substantial” financial risk if more than 25% of its potential payment is at
risk for services it does not provide.

  1)   If the physician group is at “substantial” financial risk, the health
plan shall provide adequate protection to limit financial losses. The health
plan has the option of: 1) retaining the risk in its direct provider contracts,
or 2) the MCO, intermediate entity, physician or physician group can reinsure
the risk through a reinsurance carrier. Stop-loss protection must cover at least
ninety percent (90%) of the costs of referral amounts that exceed 25% of the
total potential payment on either a per member per year or an aggregate basis.  
      For the purposes of the PIP regulation, the term “physician” is defined
as: Doctors of medicine, doctors of osteopathy, doctors of dental surgery or
dental medicine, doctors of podiatric medicine, doctors of optometry,
chiropractors, and any limited practice provider that provides services on State
authority to perform such services.     2)   If the physician group is at
“substantial risk”, the health plan must conduct annual member surveys. The
health plan shall survey enrolled and disenrolled members with questions on
satisfaction, quality, and access to services. The result should be submitted to
the state agency.

  d.   In compliance with the federal regulation, the health plan shall disclose
to the members, upon request, whether the health plan used a physician incentive
plan, what type of physician incentive plan it uses, whether stop-loss insurance
is provided, and a summary of any survey results if a survey was required to be
conducted.     e.   On an annual basis and in compliance with the federal
regulation, the health plan must disclose physician incentive plans to CMS, and
the state agency. The information to be disclosed shall include the following:

  1)   Effective date of the physician incentive plan;     2)   The type of
incentive arrangement;     3)   The amount and type of stop-loss protection;    
4)   The patient panel size;     5)   If pooled, a description of the method;  
  6)   The computations of significant financial risk;     7)   Whether the
health plan does not have a physician incentive plan; and     8)   Name,
address, phone number, and other contact information for a person from the
health plan who may be contacted with questions regarding the physician
incentive plan.

  f.   The health plan shall notify the state agency within five (5) business
days of any change to the health plan or the subcontractors’ physician incentive
plan(s).

2.20.4   The health plan shall provide quarterly reports to the state agency
detailing third party savings in a format prescribed by the state agency. The
state agency shall provide the health plan with no less than ninety
(90) calendar days notice of any change in the format requested. These reports
are due on the thirtieth (30) day following the close of the quarter. The health
plan shall maintain records in such a manner as to ensure that all money
collected from third party resources may be identified on behalf of members. The

 

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    health plan shall make these records available for audit and review and
certify that all third party collections are identified and used as a source of
revenue.

  a.   The quarterly reports must be certified by one of the following:

  1)   The health plan’s Chief Executive Officer.     2)   The health plan’s
Chief Financial Officer.     3)   An individual who has delegated authority to
sign for, and who reports directly to, the health plan’s Chief Executive Officer
or Chief Financial Officer.

  b.   The certification must attest, based on best knowledge, information, and
belief, as follows:

  1)   To the accuracy, completeness, and truthfulness of the data.     2)   To
the accuracy, completeness, and truthfulness of the quarterly reports.

  c.   The health plan must submit the certification concurrently with the
quarterly reports.

2.20.5   The health plan shall report the categories of all third party
liability collections to the state agency and shall include a complete
disclosure demonstrating its efforts to obtain payment from liable third parties
and the amounts and nature of all third party payments recovered for members
including, but not limited to, payments for services and conditions which are:

  a.   Employment related injuries or illnesses;     b.   Related to motor
vehicle accidents, whether injured as pedestrians, drivers, passengers, or
bicyclists; and     c.   Contained in diagnosis codes 800 through 999 (ICD 9-M),
with the exception of Code 994.6.

    The reports must be certified by one of the following:

  a.   The health plan’s Chief Executive Officer.     b.   The health plan’s
Chief Financial Officer.     c.   An individual who has delegated authority to
sign for, and who reports directly to, the health plan’s Chief Executive Officer
or Chief Financial Officer.

    The certification must attest, based on best knowledge, information, and
belief, as follows:

  a.   To the accuracy, completeness, and truthfulness of the data.     b.   To
the accuracy, completeness, and truthfulness of the reports.

    The health plan must submit the certification concurrently with the reports.

2.21   Operational Data Reporting:   2.21.1   To measure the MC+ managed care
program’s actual accomplishments in the areas of access to care, utilization,
medical outcomes, health status, and satisfaction, the health plan shall provide
the state agency with information concerning uniform utilization, quality
assessment and improvement, member satisfaction, complaint, grievance, and
appeal, and fraud and abuse detection data on a regular basis. On a periodic
basis, the health plan shall make available clinical outcome data in areas of
concern to the state agency. The health plan shall cooperate with the state
agency in carrying out data validation steps.   2.21.2   The state agency shall
provide report formats and variable definitions for the health plan to use in
reporting operational data. Data elements and reporting requirements are
outlined in the Performance Requirements segment. Final formats will be made
available as finalized.

 

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2.21.3   Quarterly Complaint, Grievance, and Appeal Report: On a quarterly
basis, the health plan shall submit to the state agency a Quarterly Complaint,
Grievance, and Appeal Report, in accordance with the State Management Plan
included as Attachment 6.   2.21.4   Quality Assessment and Improvement
Evaluation and Reports: The health plan shall submit an annual Quality
Assessment and Improvement Evaluation and Report. The format will be
periodically reviewed and updated by the state agency. The health plan shall
comply with all changes as specified by the state agency. The state agency shall
provide the health plan with no less than ninety (90) calendar days notice of
any change in the format requested.   2.21.5   Member Satisfaction Report: The
Department of Health and Senior Services has authority under RSMo 192.068, as
amended, to collect the member satisfaction survey data from the health plan. To
reduce duplication and ensure consistent survey methodology, the state agency
shall rely upon the member satisfaction survey data from this process. The
health plan shall submit member satisfaction data to the Department of Health
and Senior Services in accordance with 19 CSR 10-5.010, as amended. The health
plan shall use the survey instrument specified by the Department of Health and
Senior Services and must fund the cost of the survey.   2.21.6   Presentation of
Findings: The health plan shall obtain the state agency’s approval prior to
publishing or making formal public presentations of statistical or analytical
material based on the health plan’s MC+ managed care membership.   2.22   Third
Party Liability: Third Party Liability is defined as any individual, entity, or
program that is or may be liable to pay all or part of the health care expenses
of a Medicaid beneficiary. Under Section 1902(a) (25) of the Social Security
Act, the State is required to take all reasonable measures to identify legally
liable third parties and treat third party liability as a resource of the
Medicaid beneficiary.   2.22.1   Coordination of Benefits: By law, Medicaid is
the payer of last resort. Therefore, the health plan shall be used as a source
of payment for covered services only after all other sources of payment have
been exhausted. The two methods used in the coordination of benefits are cost
avoidance and post-payment recovery (i.e., “pay and chase “). The health plan
shall act as an agent of the state agency for the purpose of coordination of
benefits.

  a.   If health plan has established the probable existence of liability of a
third party health insurance carrier at the time a claim is filed, the health
plan shall reject the claim and return it to the provider for a determination of
the amount of liability except in certain defined situations referenced below.
This rejection is called cost avoidance. If a service is medically necessary,
the health plan shall ensure that its cost avoidance efforts do not prevent a
member from receiving such service and that the member is not required to pay
any cost-sharing for use of the other insurer’s providers.     b.   The
establishment of liability takes place when the health plan receives
confirmation from the provider or the third party health insurance carrier
indicating the extent of liability taking into account any agreement between the
provider and third party health insurance carrier regarding acceptance of the
carrier’s payment as payment in full with the exception of any patient
cost-sharing. If the probable existence of a liable third party cannot be
established or third party benefits are not available to pay the member’s
medical expenses at the time the claim is filed, the health plan shall pay the
full amount allowed under the health plan’s payment schedule. When the amount of
liability is determined, the health plan shall pay the claim to the extent that
payment allowed under the health plan’s payment schedule exceeds the amount of
the third party health insurance carrier’s payment taking into account any
agreement between the provider and the third party health insurance carrier
regarding acceptance of the carrier’s payment as payment in full with the
exception of any patient cost-sharing. If a third party health insurance carrier
(other than Medicare) requires the member to pay any cost-sharing (such as
copayment, coinsurance, or deductible) the health plan shall pay the
cost-sharing amounts, even if services were provided by an out-of-network
provider. The health plan may require prior authorization of out-of-network
services. The health plan’s liability for such cost-

 

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      sharing amounts shall not exceed the amount the health plan would have
paid under the health plan’s payment schedule for the service. The
out-of-network provider must agree in writing to accept the amount of the health
plan’s payment as payment in full prior to the service being provided. If the
out-of-network provider does not agree to accept the health plan’s payment as
payment in full, the health plan shall inform the member verbally and in writing
that due to lack of such agreement, the member will be liable for the cost
sharing amounts to the out-of-network provider or the member may seek services
without charge from an in-network provider.

  1)   For additional clarity on establishment of the health plan’s liability,
the following examples are provided:

  •   A provider submits a charge for $100 to the health plan for which the
health plan’s allowable is $80. The provider received $75 from the third party
insurance carrier. There is no agreement between the provider and third party
insurance carrier that the amount paid by the carrier is payment in full. The
provider normally bills all patients with this carrier the remaining balance of
$25. The provider would submit a claim to the health plan indicating the
remaining balance of $25 is owed after receiving $75 from the third party
carrier. The amount the health plan pays the provider is the difference between
the health plan’s allowable ($80) and the carrier’s payment ($75) or $5.     •  
A provider has a charge of $100.00. The third party carrier and provider have
agreed that the amount paid by the carrier is payment in full except for any
cost-sharing. The carrier has an allowable of $50 with the remaining $25 to be a
contractual write-off. The member has a co-payment of $25.00. The provider bills
all patients with this carrier only the co-payment amount. The provider bills
the health plan the $25 co-payment. The health plan’s liability is not $30
($80-$50) in this situation as there exists an agreement between the provider
and third party carrier that there is no liability by the patient other than
cost-sharing. The health plan’s pays the provider $25 as the co-payment does not
exceed its allowable of $80.

  c.   The requirement of cost avoidance applies to all covered services except
claims for labor and delivery and postpartum care (costs associated with the
inpatient hospital stay for labor and delivery and postpartum care must be cost
avoided); prenatal care for pregnant women; preventive pediatric services; or if
the claim is for a service that is provided to a member on whose behalf child
support enforcement is being carried out by the Missouri Department of Social
Services, Family Support Division. For these services, the health plan shall
provide such service and then recover payment from the third party health
insurance carrier (“pay and chase”).     d.   The health plan may retain up to
100 percent of its third party collections if all of the following conditions
exist:

  1)   Total collections received do not exceed the total amount of the health
plan’s financial liability for the member.     2)   There are no payments made
by the state agency related to fee-for-service.     3)   Such recovery is not
prohibited by Federal or State law.

  e.   The state agency shall provide the health plan with a daily file of third
party health insurance carrier information (other than Medicare) for the purpose
of updating the health plan’s files. The state agency shall continue to perform
verification of the health insurance information. The state agency does not
warrant that the information is complete or accurate. The file is to be
considered a “lead” file to assist the health plan in identifying legally liable
third parties. The health plan shall timely notify the state agency of any known
changes, additions, or deletions of coverage in a format prescribed by the state
agency.

 

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  f.   The state agency shall annually perform a data match with the United
States Department of Defense to identify members covered by TRICARE. The state
agency shall provide the health plan with the results of the data match annually
and in a format specified by the state agency. The health plan shall perform
post-payment recovery and cost avoidance activities as appropriate based on the
information supplied by the data match.

2.22.2   Casualty/Tort: The health plan shall act as an agent of the state
agency for purposes of third party reimbursement pursuant to RSMo 208.215, as
amended. In addition to coordination of benefits, the health plan shall pursue
reimbursement in the following circumstances: Workers’ Compensation,
Tortfeasors, Motorist Insurance, and Liability/Casualty Insurance.

  a.   The health plan shall take action to identify those paid claims for
members that contain diagnosis codes 800 through 999 (ICD 9-CM), with the
exception of 994.6, for the purpose of determining the legal liability of third
parties so that the health plan may process claims under the third party
liability payment procedures specified in 42 CFR 433.139 (b) through (f), as
amended.     b.   The state agency shall perform a data match with the
Department of Labor, Division of Workers’ Compensation to identify members that
the Division of Workers’ Compensation has a record of a work-related injury
claim. The state agency shall provide the health plan with the results of the
data match monthly and in a format specified by the state agency. The health
plan shall perform post payment recovery and cost avoidance activities as
appropriate based on the information supplied by the data match. If the probable
existence of third party liability cannot be established or third party benefits
are not available to pay the member’s medical expenses at the time the claim is
filed, the health plan shall pay the full amount allowed under the health plan’s
payment schedule.     c.   The state agency shall perform a data match with the
State Traffic Accident Reporting System (STARS) of the Missouri Highway Patrol
to identify members that the STARS system has a record of a member involved in a
motor vehicle accident. The state agency shall provide the health plan with the
results of the match monthly and in a format specified by the state agency. The
health plan shall perform further validation activities when using information
supplied by the data match to ensure the member is in fact the person referenced
in the match. If the probable existence of third party liability cannot be
established or third party benefits are not available to pay the member’s
medical expenses at the time the claim is filed, the health plan shall pay the
full amount allowed under the health plan’s payment schedule.     d.   The
health plan shall perform all research, investigations, and payment of
lien-related costs, including but not limited to, attorney fees and costs
related to such cases.     e.   If a member initiates a legal action as a result
of an injury that occurred during the health plan contract period, the health
plan may file a lien for reimbursement for medical services provided to treat
the injury that occurred during the contract period even after the contract
period has ended.     f.   If the health plan initiates a lien during the
contract period but the case remains unsettled at the end of the contract
period, the health plan may continue pursuit of the action for the medical
services related to the injury that were provided during the contract period.  
  g.   If the member enrolls with a new health plan while legal action is
pending, each health plan may file separate liens to recover reimbursement for
medical services related to the injury that were provided during the respective
contract periods.

2.23   Reinsurance: The state agency will not administer a reinsurance program
funded from capitation payment withholdings.   2.24   Reserving: As part of its
accounting and budgeting function, the health plan shall establish an
actuarially sound process for estimating and tracking incurred but not reported
costs. The health plan should reserve

 

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    funds by major categories of service (e.g., hospital inpatient; hospital
outpatient) to cover both incurred but not reported, and reported but unpaid
claims. As part of its reserving methodology, the health plan should conduct
annual reviews to assess its reserving methodology and make adjustments as
necessary.

2.25   Claims Processing and Management Information System:   2.25.1   The
health plan shall have a Claims Processing and Management Information System
(MIS) capable of meeting the MC+ managed care program requirements and
maintaining satisfactory performance throughout the life of the contract. The
health plan shall have the capability to transmit and receive data, support
provider payments, and data reporting requirements as specified herein. The
health plan shall have the capability to process claims, retrieve and integrate
enrollment data, assign primary care providers, maintain provider network data,
and submit encounter data. The Claims Processing and MIS should be of sufficient
capacity to expand as needed due to member enrollment or program changes.  
2.25.2   The health plan shall transmit encounter data and all required files in
accordance with the Health Plan Record Layout Manual, as amended. The health
plan shall maintain an encounter overall acceptance rate of at least 95 % as
measured by the state agency.

  a.   The health plan shall submit encounter data for all services provided
including those services that are reimbursed by the health plan through a
capitated arrangement or other subcontracted arrangement.

  1)   The encounter data must be certified by one of the following:

  •   The health plan’s Chief Executive Officer.     •   The health plan’s Chief
Financial Officer     •   An individual who has delegated authority to sign for,
and who reports directly to, the health plan’s Chief Executive Officer or Chief
Financial Officer.

  2)   The certification must attest, based on best knowledge, information, and
belief, as to the accuracy, completeness, and truthfulness of the encounter
data.     3)   The health plan must submit the certification concurrently with
the encounter data.

  b.   The health plan shall transmit primary care provider assignments and
changes or additions to the provider demographic file.

2.25.3   The health plan shall accept claims electronically from all providers.
The health plan shall make every effort to encourage providers to submit claims
electronically using HIPAA compliant formats.   2.25.4   The health plan shall
employ or have available, the resources necessary to make modifications to
claims processing edits or expansion of MIS capabilities as a result of changes
in MC+ managed care policies and/or procedures. The state agency shall make
every effort to give the health plan 60 calendar days notice of changes in the
MC+ managed care program that may require the health plan to make system changes
in order to comply.

Paragraph 2.25.5 inserted by Amendment #001

2.25.5   Timeliness of Claim Adjudication Report: On a quarterly basis, the
health plan shall submit to the state agency a “Timeliness of Claims
Adjudication Report” in accordance with the quarterly reporting schedule
outlined in Attachment 6 in a format specified by the state agency.   2.26  
Records Retention:   2.26.1   The health plan shall maintain books and records
relating to MC+ managed care services and expenditures, including reports to the
state agency and source information used in preparation of these reports. The
books and records shall include, but are not limited to, financial statements,
records relating to quality of care, medical records, and prescription files.

 

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2.26.2   The health plan shall also comply with all standards for record keeping
specified by the state agency.   2.26.3   The health plan shall maintain and
retain all financial and programmatic records, supporting documents, statistical
records, and other records of members for five (5) years. If any litigation,
claim, negotiation, audit or other action involving the records has been started
before the expiration of the five (5) year period, the health plan shall retain
the records until completion of the action and resolution of all issues which
arise from it or until the end of the regular five (5) year period, whichever is
later.   2.26.4   The health plan shall retain the source records for the health
plan’s data reports for a minimum of five (5) years and must have written
policies and procedures for storing this information.   2.26.5   Medical
Records: The health plan shall have written policies and procedures for the
maintenance of medical records so that the records are documented accurately and
in a timely manner, are readily accessible, and permit prompt and systematic
retrieval of information. Complete medical records shall include but are not
limited to medical charts, health status screens, prescription files, hospital
records, physician specialists, consultant and other health care professionals’
findings, and other documentation sufficient to disclose the quantity, quality,
appropriateness, and timeliness of services provided. The health plan shall make
such medical records available to duly authorized representatives of the state
agency and the United States Department of Health and Human Services to
evaluate, through inspections or other means, the quality, appropriateness, and
timeliness of services performed. The health plan must have procedures to
provide for prompt transfer of member records upon request to other in-network
or out-of-network providers for the medical management of the member.

  a.   In accordance with Senate Bill No. 1024, enacted by the General Assembly
of the State of Missouri, Section A., Chapter 334, RSMo, amended to be known as
Section 334.097, physicians shall maintain an adequate and complete patient
record for each patient and may maintain electronic records provided the record
keeping format is capable of being printed for review. An adequate and complete
patient record shall include documentation of the following information:

  •   Identification of the patient, including name, birthdate, address and
telephone number;     •   The date or dates the patient was seen;     •   The
current status of the patient, including the reason for the visit;     •  
Observation of pertinent physical findings;     •   Assessment and clinical
impression of diagnosis;     •   Plan for care and treatment, or additional
consultations or diagnostic testing, if necessary. If treatment includes
medication, the physician shall include in the patient record the medication and
dosage of any medication prescribed, dispensed or administered; and     •   Any
informed consent for office procedures.     1)   Patient records remaining under
the care, custody, and control of the physician shall be maintained by the
physician, or the physician’s designee, for a minimum of seven (7) years from
the date of when the last professional service was provided.     2)   Any
correction, addition, or change in any patient record made more than forty-eight
hours after the final entry is entered in the record and signed by the physician
shall be clearly marked and identified as such, and the date, time, and name of
the person making the correction, addition, or change shall be included, as well
as the reason for the correction, addition, or change.     3)   A consultative
report shall be considered an adequate medical record for a radiologist,
pathologist, or a consulting physician.

  b.   The member’s medical record is the property of the provider who generates
the record. Upon the written request of a member, guardian, or legally
authorized representative of a member the health

 

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      plan shall furnish a copy of the medical records of the member’s health
history and treatment rendered. Such medical records shall be furnished within a
reasonable time of the receipt of the written request. Each member is entitled
to one free copy of his or her medical records annually. The fee for additional
copies shall not exceed the actual cost of time and materials used to compile,
copy, and furnish such records.     c.   The health plan shall provide the state
agency with access to all members’ medical records, whether electronic or paper,
within thirty (30) calendar days of receipt of written request at no charge. The
health plan shall provide the state agency with access to a single or small
volume of medical records within five (5) calendar days of receipt of written
request at no charge. The health plan shall provide the state with immediate
access for on-site review of medical records. For on-site review of medical
records, the state agency may provide the health plan with an advance notice of
a partial list of medical records. The health plan shall fax or send by
overnight mail to the state agency all medical records involving an emergency or
urgent care issue when requested by the state agency at no charge. Access to
record requirements applies to the health plan and all providers.     d.   The
health plan shall have written standards for documentation on the medical record
for legibility, accuracy, and plan of care.     e.   The health plan shall
require its providers to maintain medical records in a detailed and
comprehensive manner which conforms to good professional medical practice,
permits effective professional medical review and medical audit processes, and
facilitates an adequate system for follow-up treatment. Medical records must be
legible, signed and dated.     f.   When a member changes primary care
providers, upon request, his or her medical records or copies of medical records
must be forwarded to the new primary care provider within ten (10) business days
from receipt of request or prior to the next scheduled appointment to the new
primary care provider whichever is earlier.     g.   The state agency is not
required to obtain written approval from a member before requesting the member’s
record from the provider.     h.   If the state agency requests, the health plan
shall gather all medical records from their providers.

2.27   Health Plan Disputes With Other Providers: All disputes between the
health plan and any affiliated or unaffiliated provider, or between the health
plan and any other subcontractors, shall be solely between such provider or
subcontractors and the health plan. The health plan shall indemnify, defend,
save and hold harmless the State of Missouri, the Department of Social Services
and its officers, employees and agents and enrolled MC+ managed care members
from any and all actions, claims, demands, damages, liabilities, or suits of any
nature whatsoever arising out of the contract because of any breach of the
contract by the health plan, its subcontractors, agents, providers or employees,
including but not limited to any negligent or wrongful acts, occurrence of
omission of commission or negligence of the health plan, its subcontractors,
agents, providers or employees.   2.28   Rate Adjustments for Performance Based
on HCY/EPSDT Participant Ratio and Remedies for Violation, Breach, or
Non-Compliance of Contract Requirements:   2.28.1   Rate Adjustments for
Performance Based on HCY/EPSDT Participant Ratio: In accordance with CMS
guidelines, the state agency requires 80 percent of eligible members to have
HCY/EPSDT well child visits and, accordingly, has included an 80 percent
participant ratio in the rates paid to the health plan. In accordance with CMS
416 reporting methodology, the state agency shall measure the health plan’s
performance regarding the percentage of eligible members having HCY/EPSDT well
child visits (participant ratio). The state agency applies state specific
criteria to the CMS methodology to reflect the MC+ managed care program. The
state specific criteria reflects performance by Category of Aid and rate cell,
the measurement schedule in Attachment 11, and recognition of a month to be
greater than 27 days.

 

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    The participant ratio is defined as the number of total eligibles receiving
at least one initial or periodic well child visit divided by the number of total
eligibles who should receive at least one initial or periodic well child visit.
The current HCY/EPSDT Measurement Schedule is reflected in Attachment 11. The
state agency reserves the right to amend the HCY/EPSDT Measurement Schedule and
shall give the health plan prior written notice of such amendment.

  a.   In the event that the HCY/EPSDT participant ratio is not equal to
80 percent of eligible members having an HCY/EPSDT well child visit as
calculated using the HCFA 416 reporting methodology, the state agency shall with
five (5) calendar days prior notice make a pro rata adjustment to the monthly
capitation payment to the health plan for each percentage point above or below
80 percent, but not to exceed 100 percent. This pro rata adjustment shall be
based on the portion of the monthly capitation payment related to HCY/EPSDT well
child visits and shall be applied to each rate cell in which well child visits
are required. Refer to Attachment 13. The state agency shall continue making
such adjusted monthly capitation payments until the next scheduled measurement.
    b.   If the health plan is new to a MC+ managed care region, the health plan
shall agree that its capitation rate shall reflect the average participant ratio
of the MC+ managed care health plans that are not new to the region by rate cell
and category of assistance for the applicable measurement period reflected in
Attachment 11. Beginning January 2007, the new health plan shall agree that
their future capitation rates shall be adjusted by the health plan’s actual
12-month HCY/EPSDT participant ratio.

2.28.2   Adjustments for Performance Based on HEDIS Performance Ratings: The
health plan’s results of HEDIS performance measures as identified in Attachment
6 shall annually be rated by the state agency as high (HI), average (AV), low
(LO), Not Applicable (NA), or Not Reported (NR). This rating shall be determined
by computing the statewide average of all health plans in all regions and
determining whether a health plan’s individual results, from a statistical level
of confidence, vary from the statewide average and to what degree the results
are precise and accurate. Those HEDIS performance measures that are rated as
high shall be assigned a numeric value of three (3). Those HEDIS performance
measures that are rated as average shall be assigned a numeric value of two (2).
Those HEDIS performance measures that are rated as low shall be assigned a
numeric value of one (1). Any performance measure that according to HEDIS
specifications should not be reported shall be rated as Not Applicable and shall
be assigned a value of zero (0). Any performance measure not reported due to the
health plan’s failure shall be rated as Not Reported and assigned a value of
negative one (-1). The state agency shall then total the numeric value of each
HEDIS measure. The HEDIS measures relating to the CAHPS member satisfaction
shall not be included in the total. The state agency shall use only combined
measures, where applicable, when computing the total. The totals are then
averaged ignoring values of zero (0) and rounded to the nearest whole number.
The health plan shall maintain a minimum performance standard of an overall
score of average with a value of two (2).

  a.   The first annual rating shall occur upon receipt of the HEDIS measures
due June 30, 2007.     b.   The second annual rating shall occur upon receipt of
the HEDIS measured due June 30, 2008.     c.   The third annual rating shall
occur upon receipt of the HEDIS measured due June 30, 2009.     d.   The first
time a health plan achieves an average of low with a value of one (1), the
health plan shall develop and implement a corrective action to improve the
substandard performance.

  1)   The state agency shall inform enrollees in enrollment materials that the
health plan failed to achieve the minimum performance standard.     2)   The
state agency shall reduce the random auto assignment percentage assigned to the
health plan by one half (1/2). The random auto assignment percentage that was
removed from the low performing health plan shall be distributed to the highest
rated health plan(s) within the same MC+ Managed Care region.

 

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  e.   The first time a health plan achieves an average of high with a value of
three (3), the state agency shall inform enrollees in enrollment materials that
the health plan(s) achieved above the minimum performance standard.     f.   The
second time a health plan achieves an average of low with a value of one (1),
the health plan shall develop and implement a corrective action to improve the
substandard performance.

  1)   The state agency shall inform enrollees in enrollment materials that the
health plan failed to achieve the minimum performance standard.     2)   The
state agency shall reduce the random auto assignment percentage assigned to the
health plan by one half (1/2). The random auto assignment percentage that was
removed from the low performing health plan shall be distributed to the highest
rated health plan(s) within the same MC+ Managed Care region.

  g.   The second time a health plan achieves an average of high with a value of
three, the state agency shall inform enrollees in enrollment materials that the
health plan or health plans achieved above the minimum performance standard.    
h.   The third time a health plan achieves an average of low with a value of one
(1), the state agency shall with five (5) calendar days prior notice make a
.25 percent reduction to the total amount paid the health plan in monthly
capitation payments.

  1)   The state agency shall inform enrollees in enrollment materials that the
health plan failed to achieve the minimum performance standard.     2)   The
reduction of total monthly capitation payments from any low performing health
plan shall be distributed equally to the health plan(s) rated high within the
same MC+ Managed Care region.

  i.   The third time a health plan achieves an average of high with a value of
three (3), the state agency shall inform enrollees in enrollment materials that
the health plan achieved above the minimum performance standard.

2.28.3   Federal Sanctions: Section 1903(m)(5)(A) and (B) of the Social Security
Act vests the Secretary of the Department of Health and Human Services with the
authority to deny Medicaid payments to a health plan for members who enroll
after the date on which the health plan has been found to have committed one or
more of the violations identified below. Therefore, whenever, and for so long
as, federal payments are denied, the state agency shall deduct the total amount
of federal payments denied from the next monthly capitation payment made to the
health plan.

  a.   Substantial failure to provide required medically necessary items or
services when the failure had adversely affected (or has substantial likelihood
of adversely affecting) a member,     b.   Discrimination among members with
respect to enrollment, re-enrollment, or disenrollment on the basis of the
member’s health status or requirements for health care services,     c.  
Misrepresentation or falsification of certain information, or     d.   Failure
to comply with the requirements for physician incentive plans as specified
herein.

2.28.4   Liquidated Damages for Failure to Provide Covered Services: In the
event the state agency determines the health plan failed to provide one or more
of the covered services, the state agency shall direct the health plan to
provide such service. If the health plan continues to refuse to provide the
covered

 

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    service(s), the state agency shall authorize the member to obtain the
covered service from another source and shall notify the health plan in writing
that the health plan shall be charged the actual amount of the cost of such
service. In such event, the charges to the health plan shall be obtained by the
state agency in the form of deductions of that amount from the next monthly
capitation payment made to the health plan. With such deductions, the state
agency shall provide a list of the members from whom payments were deducted, the
nature of the service(s) denied, and payments the state agency made or will make
to provide the medically necessary covered services.   2.28.5   Remedies for
Failure to Perform Administrative Services: Whenever the state agency determines
that the health plan has failed to perform an administrative function required
per the requirements of the contract, the state agency shall notify the health
plan of the health plan’s failure to perform required administrative services
pursuant to the requirements of the contract and shall give the health plan five
(5) working days to develop an acceptable action plan for correcting the
administrative services failure. For the purposes these provisions,
“administrative services” are defined as any contract requirements other than
the actual provision of covered services.

  a.   If the health plan submits an action plan for correcting the failure and
if the plan is acceptable to the state agency, no action shall be taken at that
time, provided that the health plan implements the corrective action as approved
by the state agency.     b.   If the health plan fails to submit an action plan
within the five working days or if the health plan does not implement the
corrective action plan within the time frame stated in the action plan, the
state agency shall withhold payment from the next capitation payment due the
health plan as stated below:

  1)   The amount withheld shall be up to three percent (3%) of the total amount
of the next capitation payment due the health plan.     2)   The state agency
shall continue to withhold up to three percent (3%) until successful correction
of the administrative services failure by the health plan.     3)   After
successful correction of the administrative services failure, the state agency
shall pay the health plan the total amount of all payments withheld.

  c.   If the health plan implements the corrective action according to the
approved plan but does not successfully correct the administrative services
failure within the time frame approved in the action plan, the state agency
shall withhold payment from the next capitation payment due the health plan
according to the same provisions as stated above.

2.28.6   Remedies for Failure to Comply with Marketing Requirements: In the
event the state agency determines that the health plan has failed to comply with
any of the marketing requirements of the contract, one or more of the remedial
actions listed below shall apply. The state agency shall notify the health plan
in writing of the determination of the non-compliance, of the action(s) that
must be taken, and of any other conditions related thereto such as the length of
time the remedial actions shall continue and of the corrective actions that the
health plan must perform.

  a.   The state agency shall require the health plan to recall the previously
authorized marketing materials.     b.   The state agency shall suspend
enrollment of new members to the health plan.     c.   The state agency shall
deduct the amount of capitation payment for members enrolled as a result of
non-compliant marketing practices from the next monthly capitation payment made
to the health plan and shall continue to deduct such payment until correction of
the failure.     d.   The state agency shall require the health plan to contact
each member who enrolled during the period while the health plan was out of
compliance, in order to explain the nature of the non-compliance and inform the
member of his or her right to transfer to another health plan.

 

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  e.   The state agency shall prohibit future marketing activities by the health
plan for an amount of time specified by the state agency.

2.28.7   Attorney Fees: In the event the state agency should prevail in any
legal action arising out of the performance or non-performance of the contract,
the health plan shall pay, in addition to any damages, all expenses of such
action including reasonable attorney’s fees and costs. The term “legal action”
shall be deemed to include administrative proceedings of all kinds, as well as
all actions at law or equity.   2.28.8   Remedial Actions: The state agency may
pursue all remedial actions with the health plan that are taken with
fee-for-service providers. The state agency will work with the health plan and
the health plan providers to change and correct problems and will recoup funds
only if the health plan fails to correct a problem within a timely manner.  
2.28.9   In addition to above referenced described rate adjustments and
remedies, if the state agency determines that the health plan is not taking
proper action to correct the identified failures, the state agency shall have
the right to implement any other legal processes deemed necessary including
cancellation of the contract, recovery of damages, suspension of enrollment to
the health plan, etc.   2.28.10   Intermediate Sanctions. The state agency may
establish and specify intermediate sanctions that may be imposed when a health
plan acts or fails to act as specified below. The state agency may require a
corrective action plan, as referenced in section 2.28.5, to be developed and
approved by the state agency in situations where intermediate sanctions may be
imposed. The state agency shall approve and monitor implementation of such a
plan and set appropriate timelines to bring activities of the health plan into
compliance with state and federal regulations. The state agency may monitor via
required reporting on a specified basis and/or through on-site evaluations, the
effectiveness of the plan. Before imposing intermediate sanctions, the state
agency shall give the health plan timely written notice that explains the basis
and nature of the sanction and any other due process protections that the state
agency elects to provide.

  a.   Fails substantially to provide medically necessary services that the
health plan is required to provide, under law or under the contract, to a member
covered under the contract.     b.   Imposes on members premiums or charges that
are in excess of the premiums or charges permitted under the Medicaid program.  
  c.   Acts to discriminate among members on the basis of their health status or
need for health care services.     d.   Misrepresents or falsifies information
that it furnishes to CMS or to the state agency.     e.   Misrepresents or
falsifies information that it furnishes to a member, potential member, or a
health care provider.     f.   Fails to comply with the requirements for
physician incentive plans, as set forth (for Medicare) in 42 CFR 422.208 and
422.210.     g.   Distributes directly, or indirectly through any agent or
independent contractor, marketing materials that have not been approved by the
state agency or that contain false or materially misleading information.     h.
  Violates any of the other applicable requirements of sections 1903(m) or 1932
of the Act and any implementing regulations.

 

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  i.   Violates any of the other applicable requirements of sections 1932 or
1905(t)(3) of the Act and any implementing regulations.

2.28.11   Intermediate Sanctions: Types. The types of intermediate sanctions
that the state agency may impose upon the health plan include:

  a.   Civil monetary penalties in the following specified amounts:

  1)   A maximum of $25,000 for each determination of failure to provide
services; misrepresentation or falsification of statements to members, potential
members or health care providers; failure to comply with physician incentive
plan requirements; or marketing violations.     2)   A maximum of $100,000 for
each determination of discrimination among members on the basis of their health
status or need for services; or misrepresentation or falsification to CMS or the
state agency.     3)   A maximum of $15,000 for each member the state agency
determines was discriminated against based on the member’s health status or need
for services (subject to the $100,000 limit above).     4)   A maximum of
$25,000 or double the amount of the excess charges (whichever is greater), for
charging premiums or charges in excess of the amounts permitted under the
Medicaid program. The state agency shall return the amount of overcharge to the
affected member(s).

  b.   Appointment of temporary management for a health plan as provided in 42
CFR 438.706.     c.   Granting members the right to terminate enrollment without
cause and notifying the affected members of their right to disenroll.     d.  
Suspension of all new enrollment, including default enrollment, after the
effective date of the sanction.     e.   Suspension of payment for members
enrolled after the effective date of the sanction and until CMS or the state
agency is satisfied that the reason for imposition of the sanction no longer
exists and is not likely to recur.     f.   Additional sanctions allowed under
state statutes or regulations that address areas of noncompliance described
above.

2.28.12   Sanction by Centers for Medicare and Medicaid Services: Special Rules
for MCOs and Denial of Payment. Payments provided for under the contract for new
members when, and for so long as payment for those members is denied by CMS in
accordance with the requirements in 42 CFR 438.730.   2.28.13   Special Rules
for Temporary Management. The state agency shall specify the circumstances under
which the sanction of temporary management will be imposed upon the health plan.

  a.   Optional: Temporary management may be imposed by the state agency only if
it finds that:

  1)   There is continued egregious behavior by the health plan, including, but
not limited to behavior that is described in 42 CFR 438.700, or that is contrary
to any requirements of sections 1903(m) and 1932 of the Act; or     2)   There
is substantial risk to members’ health; or     3)   The sanction is necessary to
ensure the health of the health plan’s members while improvements are made to
remedy violations under 42 CFR 438.700 or until there is an orderly termination
or reorganization of the health plan.

 

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  b.   Required: The state agency shall impose temporary management if it finds
that the health plan has repeatedly failed to meet substantive requirements in
section 1903(m) or section 1932 of the Act. The state agency shall also grant
members the right to terminate enrollment without cause and shall notify the
affected members of their right to terminate enrollment.     c.   The state
agency’s election to appoint temporary management shall not act as an implied
waiver of the state agency’s right to terminate the contract, suspend
enrollment, or to pursue any other remedy available to the state agency under
the contract.

2.28.14   Termination of a Health Plan Contract:

  a.   Nothing in this section shall limit the state agency’s right to terminate
the contract or to pursue any other legal or equitable remedies. Pursuant to 42
CFR 438.708, the state agency may terminate the contract as a sanction and
enroll that health plan’s members in other health plans or provide their
benefits through other options included in the state plan if the state agency,
at its sole discretion, determines that the health plan has failed to:

  1)   Carry out the substantive terms of the contract.     2)   Meet applicable
requirements in sections 1932, 1903(m) and 1905(t) of the Act.

  b.   After a state agency notifies the health plan that it intends to
terminate the contract, the state agency may do the following:

  1)   Give the health plan’s members written notice of the state agency’s
intent to terminate the contract.     2)   Allow members to disenroll
immediately without cause.

  c.   Before terminating a health plan’s contract under 42 CFR 438.708, the
state agency shall provide the health plan a pre-termination hearing. The state
agency shall:

  1)   Give the health plan written notice of its intent to terminate, the
reason for termination, and the time and place of hearing;     2)   Give the
health plan (after the hearing) written notice of the decision affirming or
reversing the proposed termination of the contract, and for an affirming
decision, the effective date of termination; and     3)   For an affirming
decision, give members of the health plan notice of the termination and
information, consistent with 42 CFR 438.10, on their options for receiving
Medicaid services following the effective date of termination.

2.29   Access to Premises: During normal business hours (defined as 8:00 a.m.
through 5:00 p.m., Monday through Friday, except State designated holidays), the
health plan shall allow duly authorized agents or representatives of the Federal
or State government access to the health plan’s premises or the health plan’s
subcontractor’s premises to inspect, audit, monitor, or otherwise evaluate the
performance of the health plan or its subcontractors.   2.30   Advance
Directives:   2.30.1   The health plan shall maintain written policies and
procedures related to advance directives. At the time of enrollment, the health
plan shall provide written information to all adult members regarding the
member’s rights under the Missouri law to make decisions concerning medical
care.   2.30.2   As part of recredentialing, the health plan shall audit records
of primary care provider, hospitals, home health agencies, personal care
providers, and hospices to determine whether the provider is following the
policies and procedures related to advance directives.

 

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2.30.3   The health plan shall provide education to the health plan’s staff and
members on issues concerning advance directives.   2.30.4   The above provisions
shall not be construed to prohibit the application of any Missouri law which
allows for an objection on the basis of conscience for any provider or agent of
such provider.   2.31   Fraud and Abuse:

Paragraph 2.31.1 revised by BAFO #001

2.31.1   The following definitions are taken from “Guidelines for Addressing
Fraud and Abuse in Medicaid Managed Care”, A Product of the National Medicaid
Fraud and Abuse Initiative, Health Care Financing Administration National
Initiative, October 2000. These definitions are provided to assist the health
plan in preventing, coordinating, detecting, investigating, enforcing, and
reporting fraud and abuse:       Medicaid Managed Care Fraud: Any type of
intentional deception or misrepresentation made by an entity or person in a
capitated MCO, PCCM program, or other managed care setting with the knowledge
that the deception could result in some unauthorized benefit to the entity,
himself, or some other person.       Medicaid Managed Care Abuse: Practices in a
capitated MCO, PCCM program, or other managed care setting that are inconsistent
with sound fiscal, business, or medical practices, and result in an unnecessary
cost to the Medicaid program, or in reimbursement for services that are not
medically necessary or that fail to meet professionally recognized standards or
contractual obligations for health care. The abuse can be committed by an MCO,
contractor, subcontractor, provider, State employee, Medicaid beneficiary, or
Medicaid managed care enrollee, among others. It also includes beneficiary
practices in a capitated MCO, PCCM program, or other managed care setting that
result in unnecessary cost to the Medicaid program or MCO, contractor,
subcontractor, or provider. It should be noted that Medicaid funds paid to an
MCO, then passing to subcontractors, are still Medicaid funds from a fraud and
abuse perspective   2.31.2   The health plan shall implement internal controls,
policies, and procedures designed to prevent, detect, review, report to the
state agency, and assist in the prosecution of fraud and abuse activities by
providers, subcontractors, and members. The policies and procedures shall
articulate the health plan’s commitment to comply with all applicable Federal
and State standards. In order to implement the above, the health plan must
submit a written fraud and abuse plan to the state agency for approval prior to
implementation. Any changes to the approved fraud and abuse plan must have state
agency approval prior to implementation.

  a.   The health plan’s fraud and abuse plan must include, but is not limited
to the following components:

  1)   The designation of a compliance officer and a compliance committee that
are responsible for the health plan’s fraud and abuse program and activities.
The compliance officer is supervised by and reports to the Chief Executive
Officer (CEO), health plan administrator, or the governing body;     2)  
Provision for a data system, resources and staff to perform the fraud, abuse,
and other compliance responsibilities;     3)   Procedures for internal
prevention, detection, reporting, review, and corrective action;     4)  
Procedures for prompt response to detected offenses;     5)   Procedures for
reporting to the state agency, including timelines and use of state approved
forms;     6)   Written standards for organizational conduct;

 

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  7)   A compliance committee that periodically meets and documents review of
compliance issues. These issues include fraud, abuse, and regulatory and
contractual compliance.     8)   Effective training and education for the
compliance officer and the organization’s employees, management, board members,
and subcontractors;     9)   Inclusion of information about fraud and abuse
identification and reporting in provider and member materials; and     10)  
Enforcement of standards through well-publicized disciplinary guidelines.

  b.   The health plan’s fraud and abuse activities should include, but not be
limited to the following:

  1)   Conducting regular reviews and audits of operations to guard against
fraud and abuse;     2)   Assessing and strengthening internal controls to
ensure claims are submitted and payments are made properly;     3)   Educating
employees, network providers, and beneficiaries about fraud and abuse and how to
report it;     4)   Effective organizational resources to respond to complaints
of fraud and abuse;     5)   Establishing procedures to process fraud and abuse
complaints;     6)   Establishing procedures for reporting information to the
state agency; and     7)   Developing procedures to monitor utilization/service
patterns of providers, subcontractors, and beneficiaries.

Paragraph 2.31.3 revised by BAFO #001

2.31.3   The health plan must quarterly report suspected fraud or abuse cases to
the state agency. The health plan must initiate an immediate investigation to
gather facts regarding the suspected fraud or abuse. In addition, the health
plan shall provide reports of its investigative, corrective, and legal
activities to the state agency in accordance with contractual and regulatory
requirements.   2.31.4   The health plan and its subcontractors shall cooperate
fully in any state reviews or investigations and in any subsequent legal action.
The health plan must implement corrective actions in instances of fraud and
abuse detected by the state agency, or other authorized agencies or entities.  
2.31.5   The health plan must also provide a quarterly report of fraud and abuse
activities to the state agency. The report must be submitted in accordance with
state agency guidelines contained within the fraud and abuse policy statement.
An annual evaluation of the effectiveness of the fraud and abuse program must be
provided to the state agency. This evaluation must be a component of the annual
evaluation of the effectiveness of the quality assessment and improvement
program.   2.31.6   Identification of Debarred Individuals or Excluded Providers
in Health Plans: The health plan shall exclude providers from the health plan
network that have been identified as having Office of Inspector General
(OIG) sanctions, having failed to renew license or certification registration,
having a revoked professional license or certification, or have been terminated
by the state agency. The health plan can access debarred and OIG sanction
information on the Internet. The health plan should also access information from
the Professional Registration Boards Internet site to identify State initiated
terminations. The state agency or its authorized agent shall conduct a periodic
review to determine if appropriate exclusions and corrective action have
occurred.

 

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RFP B3Z06118   Page 94

2.31.7   Health Plan Pharmacy Lock-In: The health plan must submit its lock-in
policies and procedures to the state agency for approval prior to
implementation. The policies and procedures must include the member and provider
communication documents that shall be utilized for the lock-in process. The
lock-in policy must comply with the requirements located in 13 CSR 70-4.070,
Title XIX Recipient Lock-In Program.       The health plan must provide services
in accordance with the requirements located in Attachment 3, Managed Care
Policies Governing MC+ Services. If the health plan determines inappropriate
utilization of pharmacy services by a member, the health plan may restrict the
member to obtaining pharmacy services from one pharmacy provider. The health
plan must initiate an investigation to identify the extent of the fraud or
abuse. When a member is suspected of fraud or abuse (i.e., presenting an altered
prescription), the health plan should notify the state agency within ten
(10) calendar days of identification of the suspected activity in accordance
with 2.31.2 and 2.31.3.   2.31.8   Member Explanation of Benefits (EOB): The
health plan must provide an EOB to members upon request. The EOB will consist of
a list of services that were billed to the health plan. The list shall contain
paid and unpaid claims; for any unpaid claims, the list shall provide the reason
the claim was not paid.   2.32   Other Requirements:   2.32.1   Unless otherwise
specified herein, the health plan shall furnish all materials, labor,
facilities, equipment, and supplies necessary to perform the service required
herein.   2.32.2   Within five (5) business days after issuance of the Notice of
Award by the Division of Purchasing and Materials Management, the health plan
shall submit a written identification and notification to the state agency of
the name, title, address, and telephone number of one (1) individual within its
organization as a duly authorized representative to whom all correspondence,
official notices, and requests related to the health plan’s performance under
the contract shall be addressed. The health plan shall have the right to change
or substitute the name of the individual described above as deemed necessary
provided that the state agency is notified immediately.   2.32.3   The health
plan shall understand and agree that the contract, in part, shall implement the
MC+ managed care program. Therefore, the health plan shall conform to such
requirements or regulations as the United States Department of Health and Human
Services issues.   2.32.4   If the state agency receives written notice from the
United States Department of Health and Human Services that the health plan does
not meet the definition of a Health Maintenance Organization as set forth in the
Medicaid State Plan and 42 CFR 434 or receives written notice from the
Department of Insurance that the health plan does not have a certificate of
authority to establish or operate a HMO, the Division of Purchasing and
Materials Management may cancel the contract with the health plan pursuant to
contract cancellation provisions contained herein.   2.32.5   In the event that
changes in federal or state law require the Division of Purchasing and Materials
Management to modify the contract, a written amendment shall be issued to the
health plan pursuant to provisions for contract amendment stated herein.

  a.   The terms of the contract and any amendment thereto must receive the
approval of the United States Department of Health and Human Services. The
United States Department of Health and Human Services failure to approve a
provision of the contract shall render the provision null and void. The contract
is contingent on the health plan meeting the definition of a Health Maintenance
Organization as set forth in the Medicaid State Plan and 42 CFR 434.

2.32.6   The health plan shall guarantee and certify that no State of Missouri
legislator or State of Missouri employee holds a controlling interest in the
health plan.

 

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RFP B3Z06118   Page 95

2.32.7   The health plan shall guarantee and certify that no funds paid to the
health plan by the state agency shall be used for the purpose of influencing or
attempting to influence an officer or employee of any Federal or State agency, a
member of the United States Congress, or State Legislature. The health plan
shall disclose if any funds other than those paid to the health plan by the
state agency have been used or will be used to influence the persons or entities
indicated above and will assist the state agency in making such disclosures to
CMS.   2.32.8   Termination or cancellation of the contract does not eliminate
the health plan’s responsibility to the state agency for overpayments made to
the health plan. If the contract is terminated or canceled, the health plan
shall return to the state agency any payments advanced to the health plan for
coverage of members for periods after the date of contract termination or
cancellation. The health plan shall return such payments to the state agency
within ninety (90) calendar days of contract termination/cancellation.

  a.   If the contract is terminated, the health plan shall promptly supply all
information necessary for the reimbursement of any outstanding claims.

2.32.9   In the event the contract is canceled, the state agency shall notify
all members of the date of cancellation and process by which the members will
continue to receive contract services and the health plan shall be responsible
for all expenses related to said notification under these circumstances. In the
event the contract is terminated by mutual consent, the state agency shall
notify all members of the date of termination and process by which the members
will continue to receive contract services; and the state agency shall be
responsible for all expenses relating to said notification.   2.32.10   The
health plan shall have a written policy regarding the illegality of sexual
harassment. At a minimum, the policy shall include:

  a.   The definition of sexual harassment under federal and state law, as
amended;     b.   The health plan’s internal complaint process including
penalties;     c.   The legal recourse, investigative, and complaint process
available for members through the state agency and for employees through the
Missouri Commission on Human Rights; and     d.   Instructions on how to contact
the state agency and the Missouri Commission on Human Rights.

2.32.11   The health plan shall understand and agree that the State of Missouri
(its departments and employees) does not maintain commercial liability
insurance.   2.32.12   If the performance of any part of the contract is
prevented, hindered or delayed by fire, flood or an act of God, then the health
plan or the state agency shall be excused from such performance during the
continuance of such events. This clause shall not become operative until the
party whose performance is hindered notifies the other party of the occurrence
and the reasons for the delay.   2.32.13   Members are the intended
beneficiaries of the contracts and as such are entitled to the remedies accorded
to third party beneficiaries under the law.   2.32.14   The health plan is
prohibited from using MC+ managed care funds for services provided in the
following circumstances:

  a.   Non-emergency services provided by or under the direction of an excluded
individual,     b.   Any funds not used under the Assisted Suicide Funding
Restriction Act of 1997,
    c.   Any amount expended for roads, bridges, stadiums, or any other item.

 

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RFP B3Z06118   Page 96

2.32.15   The Missouri Department of Insurance regulates the health plans
licensed in Missouri including their financial stability. Therefore, the health
plan must comply with all Department of Insurance applicable standards.   2.33  
Invoicing and Payment Requirements: On a monthly basis, as near as practical to
the fifth day of the calendar month following the month for which services have
been performed and for which payment is being made, the state agency shall make
payments to the health plan via electronic funds transfer in accordance with the
following:   2.33.1   For each member enrolled on the first of the month, the
state agency shall pay the health plan the firm fixed per member, per month net
capitation amount specified on the specific region’s Pricing Page for the
Category of Aid Rate Subgroup for the member. The per member, per month net
capitation amount shall reflect any reduction or increase pursuant to the health
plan’s performance in screening 80 percent of eligible members as measured in
accordance with the CMS 416 reporting methodology.

  a.   The state agency shall pro-rate the net capitation amount when the
member’s birth date necessitates a change to a different Category of Aid or Rate
Subgroup in a given month.     b.   For members enrolled at any time after the
beginning of the month’s payment cycle, the state agency shall pro-rate the net
capitation amount for the first partial month.     c.   For members whose
enrollment lapses for any period of a month in which a capitation payment was
made due to loss of eligibility, death, or other circumstance, the state agency
shall adjust its next monthly capitation payment to recoup the portion of the
capitation payment to which it is due a refund.     d.   Any payment pro-rations
shall be on a daily basis.

2.33.2   The health plan shall accept capitation payments as specified herein
and must have written policies and procedures for receiving and processing the
capitation payments.   2.33.3   The health plan shall agree and understand that
the capitation payments specified herein shall be the only payments made to the
health plan for all services required herein and that no other payment or
reimbursement for any reason whatsoever shall be made to the health plan. In
exchange for the capitation payments, the health plan shall be liable or “at
risk” for the costs of all covered services.   2.33.4   In the event that the
Missouri General Assembly appropriates funds expressly for the services required
herein, the State of Missouri shall amend the contract. In such event, the
health plan shall pass fee increases to its providers commensurate with the
Missouri General Assembly’s intent. It must clearly be the intent of the
Missouri General Assembly that increases be added during an ongoing contract
period for any such amendment to take place   2.34   Business Associate
Provisions:   2.34.1   Health Insurance Portability and Accountability Act of
1996 (HIPAA) — The state agency is subject to and must comply with provisions of
the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all
regulations promulgated pursuant to authority granted therein. The health plan
constitutes a “Business Associate” of the state agency as such term is defined
in the Code of Federal Regulations (CFR) at 45 CFR 160.103. Therefore, the term,
“health plan” as used in this section shall mean “Business Associate.”

  a.   The health plan shall agree and understand that for purposes of the
Business Associate Provisions contained herein, terms used but not otherwise
defined shall have the same meaning as those terms defined in 45 CFR parts 160
and 164, including, but not limited to the following:

 

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RFP B3Z06118   Page 97

  1)   “Privacy Rule” shall mean the Standards for Privacy of Individually
Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and
E.     2)   “Security Rule” shall mean the Security Standards for the Protection
of Electronic Protected Health Information at 45 CFR part 164, subpart C.     3)
  “Individual” shall have the same meaning as the term “individual” in 45 CFR
164.501 and shall include a person who qualifies as a personal representative in
accordance with 45 CFR 164.502 (g).     4)   “Protected Health Information”
shall mean individually identifiable health information:

- (1) Except as provided in paragraph (2) of this definition, that is: (i)
Transmitted by electronic media; or (ii) Maintained in electronic media; or
(iii) Transmitted or maintained in any other form or medium.
- (2) Protected Health Information excludes individually identifiable health
information in (i) Education records covered by the Family Educational Rights
and Privacy Act, as amended, 20 U.S.C. 1232g; (ii) Records described at 20
U.S.C. 1232g(a)(4)(B)(iv); and (iii) Employment records held by a covered entity
[state agency] in its role as employer.

  5)   “Electronic Protected Health Information” shall mean information that
comes within paragraphs (1)(i) or (1)(ii) of the definition of protected health
information as specified above.

  b.   The health plan shall agree and understand that wherever in this document
the term Protected Health Information is used, it shall also be deemed to
include Electronic Protected Health Information.     c.   The health plan shall
agree the state agency must comply with 45 CFR 160 and 45 CFR 164, as currently
in effect and as may be amended at some later date, and that to achieve such
compliance, the health plan must appropriately safeguard Protected Health
Information (as that term is defined in 45 CFR 164.501), which the health plan
receives from or creates or receives on behalf of the state agency. To provide
reasonable assurance of appropriate safeguards, the health plan shall comply
with the business associate provisions stated herein.     d.   The state agency
and the health plan agree to amend the contract as is necessary for the state
agency to comply with the requirements of the Privacy Rule and HIPAA
requirements.

2.34.2   Permitted uses and disclosures of Protected Health Information:

  a.   The health plan may use or disclose Protected Health Information to
perform functions, activities, or services for, or on behalf of, the state
agency as specified in the contract, provided that such use or disclosure would
not violate the Privacy Rule as the Privacy Rule applies to the state agency.  
  b.   The health plan may use Protected Health Information to report violations
of law to appropriate Federal and State authorities, consistent with 45 CFR
164.502(j)(1) and shall notify the state agency by no later than ten
(10) calendar days after the health plan becomes aware of the disclosure of the
Protected Health Information.     c.   If required to properly perform the
contract and subject to the terms of the contract, the health plan may use or
disclose Protected Health Information if necessary for the proper management and
administration of the health plan’s business.     d.   If the disclosure is
required by law, the health plan may disclose Protected Health Information to
carry out the legal responsibilities of the health plan.     e.   The health
plan may use Protected Health Information to provide Data Aggregation services
to the state agency as permitted by 45 CFR 164.504(e)(2)(i)(B).

2.34.3   Obligations of the Health plan:

 

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RFP B3Z06118   Page 98

  a.   The health plan shall not use or disclose Protected Health Information
other than as permitted or required by the contract or as otherwise required by
law.     b.   The health plan shall use appropriate safeguards to prevent use or
disclosure of the Protected Health Information other than as provided for by the
contract. Such safeguards may include, but shall not be limited to:

  1)   Workforce training on the appropriate uses and disclosures of Protected
Health Information pursuant to the terms of the contract.     2)   Policies and
procedures implemented by the health plan to prevent inappropriate uses and
disclosures of Protected Health Information by its workforce.     3)   Any other
safeguards necessary to prevent the inappropriate use or disclosure of Protected
Health Information.

  c.   With respect to Electronic Protected Health Information, the health plan
shall implement administrative, physical and technical safeguards that
reasonably and appropriately protect the confidentiality, integrity and
availability of the Electronic Protected Health Information that health plan
creates, receives, maintains or transmits on behalf of the state agency.     d.
  The health plan shall require that any agent or subcontractor to whom the
health plan provides any Protected Health Information received from, created by,
or received by the health plan pursuant to the contract, also agrees to the same
restrictions and conditions stated herein that apply to the health plan with
respect to such information.     e.   By no later than ten (10) calendar days of
receipt of a written request from the state agency, or as otherwise required by
state or federal law or regulation, or by another time as may be agreed upon in
writing by the state agency, the health plan shall make the health plan’s
internal practices, books, and records, including policies and procedures and
Protected Health Information, relating to the use and disclosure of Protected
Health Information received from, created by, or received by the health plan on
behalf of the state agency available to the state agency and/or to the Secretary
of the Department of Health and Human Services or designee for purposes of
determining compliance with the Privacy Rule.     f.   The health plan shall
document any disclosures and information related to such disclosures of
Protected Health Information as would be required for the state agency to
respond to a request by an individual for an accounting of disclosures of
Protected Health Information in accordance with 45 CFR 164.528. By no later than
five (5) calendar days of receipt of a written request from the state agency, or
as otherwise required by state or federal law or regulation, or by another time
as may be agreed upon in writing by the state agency, the health plan shall
provide an accounting of disclosures of Protected Health Information regarding
an individual to the state agency.     g.   In order to meet the requirements
under 45 CFR 164.524, the health plan shall, within five (5) calendar days
following a state agency request, or as otherwise required by state or federal
law or regulation, or by another time as may be agreed upon in writing by the
state agency, provide the state agency access to the Protected Health
Information in an individual’s Designated Record Set. However, if requested by
the state agency, the health plan shall provide access to the Protected Health
Information in a Designated Record Set directly to the individual for whom such
information relates.     h.   At the direction of the state agency, the health
plan shall promptly make any amendment(s) to Protected Health Information in a
Designated Record Set pursuant to 45 CFR 164.526.     i.   The health plan shall
report to the state agency’s Security Officer any security incidents no later
than five (5) calendar days of becoming aware of such incident. For purposes of
this paragraph, security

 

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RFP B3Z06118   Page 99

      incident shall mean the unauthorized access, use, modification or
destruction of information or interference with systems operations in an
information system.     j.   By no later than five (5) calendar days after the
health plan becomes aware of any use or disclosure of the Protected Health
Information not permitted or required as stated herein, the health plan shall
notify the state agency’s Privacy Officer, in writing, of the unauthorized use
or disclosure and shall take immediate action to stop the unauthorized use or
disclosure. The health plan shall include a description of any remedial action
taken to mitigate any harmful effect of such disclosure. The health plan shall
also provide the state agency’s Privacy Officer with a proposed written plan of
action for approval that describes plans for preventing any such future
unauthorized uses or disclosures.

2.34.4   Obligations of the State Agency:

  a.   The state agency shall notify the health plan of limitation(s) that may
affect the health plan’s use or disclosure of Protected Health Information, by
providing the health plan with the state agency’s notice of privacy practices in
accordance with 45 CFR 164.520.     b.   The state agency shall notify the
health plan of any changes in, or revocation of, authorization by an Individual
to use or disclose Protected Health Information.     c.   The state agency shall
notify the health plan of any restriction to the use or disclosure of Protected
Health Information that the state agency has agreed to in accordance with 45 CFR
164.522.     d.   The state agency shall not request the health plan to use or
disclose Protected Health Information in any manner that would not be
permissible under the Privacy Rule as the Privacy Rule applies to the state
agency.

2.34.5   Expiration/Termination/Cancellation — Except as provided in the
subparagraph below, upon the expiration, termination, or cancellation of the
contract for any reason, the health plan shall return to the state agency or
shall destroy all Protected Health Information received by the health plan from
the state agency, or created or received by the health plan on behalf of the
state agency, and shall not retain any copies of such Protected Health
Information. This provision shall also apply to Protected Health Information
that is in the possession of subcontractors or agents of the health plan.

  a.   In the event the health plan determines and the state agency agrees that
returning or destroying the Protected Health Information is not feasible, the
health plan shall extend the protections of the contract to the Protected Health
Information for as long as the health plan maintains the Protected Health
Information and shall limit the use and disclosure of the Protected Health
Information to those purposes that made return or destruction of the information
infeasible. If at any time it becomes feasible to return or destroy any such
Protected Health Information maintained pursuant to this paragraph, the health
plan must notify the state agency and obtain instructions from the state agency
for either the return or destruction of the Protected Health Information.

2.34.6   Breach of Contract – In the event the health plan is in breach of
contract with regard to the business associate provisions included herein, the
health plan shall agree and understand that in addition to the requirements of
the contract related to cancellation of contract, if the state agency determines
that cancellation of the contract is not feasible, the State of Missouri may
elect not to cancel the contract, but the state agency shall report the
contractual breach to the Secretary of the Department of Health and Human
Services.

 

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3.   GENERAL CONTRACTUAL REQUIREMENTS:   3.1   Contract : A binding contract
shall consist of: (1) the RFP, amendments thereto, and any Best and Final Offer
(BAFO) request(s) with RFP changes/additions, (2) the health plan’s proposal
including any BAFOs and (3) the Division of Purchasing and Materials
Management’s acceptance of the proposal by “notice of award” or by “purchase
order”. All Exhibits and Attachments included in the RFP shall be incorporated
into the contract by reference.   3.1.1   The notice of award does not
constitute a directive to proceed. Before providing equipment, supplies and/or
services, the health plan must receive a properly authorized purchase order
unless the purchase is equal to or less than $3,000. Purchases equal to or less
than $3,000 may be processed with a purchase order at the discretion of the
state agency.   3.1.2   The contract expresses the complete agreement of the
parties and performance shall be governed solely by the specifications and
requirements contained therein.   3.1.3   Any change to the contract, whether by
modification and/or supplementation, must be accomplished by a formal contract
amendment signed and approved by and between the duly authorized representative
of the health plan and the Division of Purchasing and Materials Management or by
a modified purchase order prior to the effective date of such modification. The
health plan expressly and explicitly understands and agrees that no other method
and/or no other document, including correspondence from the state agency, acts,
and oral communications by or from any person, shall be used or construed as an
amendment or modification to the contract.   3.2   Contract Period: The original
contract period shall be as stated on page 1 of the Request for Proposal (RFP).
The contract shall not bind, nor purport to bind, the state for any contractual
commitment in excess of the original contract period. The Division of Purchasing
and Materials Management shall have the right, at its sole option, to renew the
contract for two (2) additional one-year periods, or any portion thereof. In the
event the Division of Purchasing and Materials Management exercises such right,
all terms and conditions, requirements and specifications of the contract shall
remain the same and apply during the renewal period, pursuant to the following:
  3.2.1   The state agency will include in each year’s budget request to the
Office of Administration, Division of Budget and Planning, a rate change based
on the state agency’s review of recent health plan financial experience, medical
trends from other state Medicaid programs and national trend indices (CPI/DRI),
and pharmacy market trends including specific drug introductions and expiring
patents. The rate changes will be reflective of anticipated programmatic
changes.   3.2.2   If the State of Missouri elects to renew the contract for the
first renewal option, the health plan shall accept the amount appropriated by
the Governor and the Missouri General Assembly.   3.2.3   If the State of
Missouri elects to renew the contract for the second renewal option and if the
health plan intends to renew the contract for the second renewal option, the
State of Missouri and the health plan shall negotiate the firm, fixed rates
applicable to the second renewal period. The State of Missouri shall commence
such negotiation process approximately six months prior to the expiration of the
first renewal period. Individual negotiations shall be conducted with each
health plan in accordance with the negotiation provisions provided elsewhere
herein.

  a.   The health plan must submit information which establishes and supports
the actuarial soundness of the proposed rates and a certification of said
soundness from an Associate of the Society of Actuaries (ASA), a Fellow of
Society of Actuaries (FSA), or a Member of the American Academy of Actuaries
(MAAA).     b.   If the State of Missouri and the health plan are unable to
agree upon the firm, fixed rates for the second renewal period, the pending
contract renewal shall be canceled. In the event of such, the

 

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RFP B3Z06118   Page 101

State of Missouri reserves its right to extend the contract at the current firm,
fixed rates for no more than 180 days from the date such determination is made.

  c.   If the health plan does not intend to renew the contract for the second
renewal option and does not desire to enter into the negotiation process, the
health plan shall provide written notification to the State of Missouri of such
within at least 180 calendar days prior to the expiration of the contract
period.

3.2.4   During the second and final renewal option, the State of Missouri may
issue a public notice of the pending contract expiration and the upcoming
opportunity to contract with the State of Missouri for MC+ managed care
services. If no health plans, other than the health plans the State of Missouri
currently contracts with, indicate interest in contracting with the State of
Missouri for such, the State of Missouri may elect to renew the contract with
the health plan for the continuation of the MC+ managed care services. In the
event of such, the State of Missouri and the health plan shall negotiate the
firm, fixed rates applicable to the renewal period. The State of Missouri shall
have the option of issuing such notification on an annual basis.   3.3   Price:
All prices shall be as indicated on the specific region’s Pricing Page. The
state shall not pay nor be liable for any other additional costs including but
not limited to taxes, shipping charges, insurance, interest, penalties,
termination payments, attorney fees, liquidated damages, etc.   3.4  
Termination: The Division of Purchasing and Materials Management reserves the
right to terminate the contract at any time, for the convenience of the State of
Missouri, without penalty or recourse, by giving written notice to the health
plan at least thirty (30) calendar days prior to the effective date of such
termination. In the event of termination pursuant to this paragraph, all
documents, data, reports, supplies, equipment, and accomplishments prepared,
furnished or completed by the health plan pursuant to the terms of the contract
shall, at the option of the Division of Purchasing and Materials Management,
become the property of the State of Missouri. The health plan shall be entitled
to receive just and equitable compensation for services and/or supplies
delivered to and accepted by the State of Missouri pursuant to the contract
prior to the effective date of termination.   3.5   Transition:   3.5.1   Upon
expiration, termination, or cancellation of the contract, the health plan shall
assist the state agency to insure an orderly transfer of responsibility and/or
the continuity of those services required under the terms of the contract to an
organization designated by the state agency, if requested in writing. At a
minimum, the health plan shall perform the following related to transition:

  a.   For a period not to exceed ninety (90) calendar days after the
expiration, termination, or cancellation of the contract, the health plan shall
continue providing any part or all of the services in accordance with the terms
and conditions, requirements, and specifications of the contract for a price not
to exceed those prices set forth in the contract.     b.   In addition, for 365
calendar days after expiration, termination, or cancellation of the contract,
the health plan shall provide those administration functions that cannot be
completed prior to the expiration, termination, or cancellation of the contract
due to the nature of the function. Such administrative functions, shall include,
but are not limited to, payment of claims for service dates prior to expiration,
termination, or cancellation of the contract; operation of the member grievance
system and provider complaints, grievances, and appeals; operational data
reporting, financial reporting, and communication links with the state agency.  
  c.   The health plan shall deliver, FOB destination, all records,
documentation, reports, data, recommendations, master, or printing elements,
etc., which were required to be produced under the terms of the contract to the
state agency and/or to the state agency’s designee within thirty (30) days after
receipt of the written request.

 

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RFP B3Z06118   Page 102

  d.   The state agency, at its sole option, may discontinue enrolling new
membership to the health plan, on a date specified by the state agency, prior to
expiration, cancellation, or termination of the contract.

3.6   Health Plan Liability: The health plan shall be responsible for any and
all personal injury (including death) or property damage as a result of the
health plan’s negligence involving any equipment or service provided under the
terms and conditions, requirements and specifications of the contract. In
addition, the health plan assumes the obligation to save the State of Missouri,
including its agencies, employees, and assignees, from every expense, liability,
or payment arising out of such negligent act.

  a.   The health plan also agrees to hold the State of Missouri, including its
agencies, employees, and assignees, harmless for any negligent act or omission
committed by any subcontractor or other person employed by or under the
supervision of the health plan under the terms of the contract.     b.   The
health plan shall not be responsible for any injury or damage occurring as a
result of any negligent act or omission committed by the State of Missouri,
including its agencies, employees, and assignees.     c.   Under no
circumstances shall the health plan be liable for any of the following:
(1) third party claims against the state for losses or damages (other than those
listed above); (2) loss of, or damage to, the state’s records or data; or (3)
economic consequential damages (including lost profits or savings) or incidental
damages, even if the health plan is informed of their possibility.

3.7   Insurance: The health plan shall understand and agree that the State of
Missouri cannot save and hold harmless and/or indemnify the health plan or
employees against any liability incurred or arising as a result of any activity
of the health plan or any activity of the health plan’s employees related to the
health plan’s performance under the contract. Therefore, the health plan shall
maintain adequate liability insurance in the form(s) and amount(s) sufficient to
protect the State of Missouri, its agencies, its employees, its clients, and the
general public against any loss, damage, and/or expense related to his/her
performance under the contract.

  a.   The insurance coverage shall include, but shall not necessarily be
limited to, general liability, professional liability, etc. In addition,
automobile liability coverage for the operation of any motor vehicle must be
maintained if the terms of the contract require any form of transportation
services.     b.   The limits of liability for all types of coverage shall not
be less than $2,000,000 per occurrence.     c.   The health plan shall provide
written evidence of the insurance to the state agency. Such evidence shall
include, but shall not necessarily be limited to: effective dates of coverage,
limits of liability, insurer’s name, policy number, endorsement by
representatives of the insurance company, etc. Evidence of self-insurance
coverage or of another alternate risk financing mechanism may be utilized
provided that such coverage is verifiable and irrevocably reliable. The evidence
of insurance coverage must be submitted before or upon award of the contract.
The contract number must be identified on the evidence of insurance coverage.  
  d.   In the event the insurance coverage is canceled, the state agency must be
notified immediately.

3.8   Subcontractors: Any subcontracts for the products/services described
herein must include appropriate provisions and contractual obligations to ensure
the successful fulfillment of all contractual obligations agreed to by the
health plan and the State of Missouri and to ensure that the State of Missouri
is indemnified, saved, and held harmless from and against any and all claims of
damage, loss, and cost (including attorney fees) of any kind related to a
subcontract in those matters described in the contract between the State of
Missouri and the health plan.

 

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3.8.1   The health plan shall expressly understand and agree that he/she shall
assume and be solely responsible for all legal and financial responsibilities
related to the execution of a subcontract.   3.8.2   The health plan shall agree
and understand that utilization of a subcontractor to provide any of the
products/services in the contract shall in no way relieve the health plan of the
responsibility for providing the products/services as described and set forth
herein. The health plan must obtain acknowledgement from the State of Missouri
prior to establishing any new subcontracting arrangements and before changing
any subcontractors.   3.8.3   All subcontracts for health care services must be
in writing and shall comply with all provisions of the contract and shall
include at least the items listed below. In addition, all subcontractors shall
comply with the applicable provisions of federal and state laws and regulations,
as amended, and policies. Before any delegation of any functions and
responsibilities to any subcontractor, the health plan shall evaluate the
prospective subcontractor’s ability to perform the activities to be delegated.
The health plan shall have policies and procedures to monitor the performance of
health care service subcontractors to ensure that such subcontractors comply
with the provisions of the RFP. The health plan shall prepare and issue an
annual report to the state agency regarding the results of its monitoring
activities in previous calendar year for each health care service subcontractor
and any corrective actions implemented as a result of its monitoring activities.
The annual report shall be due by November 30 of each year. In addition, the
health plan shall fully investigate and timely respond to issues involving
subcontractors upon request of the state agency.

  a.   A description of services to be provided or other activities performed.
This description shall be in such form as to permit the state agency to
ascertain definitively which contractual obligations have been subcontracted.  
  b.   Provision(s) for release to the health plan of any information necessary
for the health plan to perform any of its obligations under the contract
including but not limited to compliance with all reporting requirements (for
example encounter data reporting requirements), timely payment requirements, and
quality assessment requirements.     c.   The provision available to a health
care provider to challenge or appeal the failure of the health plan to cover a
service.     d.   Provision(s) that (1) the subcontractor’s facilities and
records shall be open to inspection by the health plan and appropriate federal
and state agencies and, (2) the medical records, or copies thereof, shall be
provided to the health plan, upon request, for transfer to subsequent
subcontractors for review by the state agency.     e.   Provisions that require
each health care provider to maintain comprehensive medical records for a
minimum of five years.     f.   A provision that when no member co-payment is
required, the subcontractor shall look solely to the health plan for
compensation for services provided to member.     g.   Provision(s) that
prohibit any financial incentive arrangement to induce subcontractors to limit
medically necessary services. A description of all financial incentive
arrangements shall be included in the subcontract. In the event of a change to
these financial incentive arrangements, the subcontractor shall immediately
notify the health plan of such change so the health plan can meet its
requirement to notify the state agency.     h.   Provisions that the health plan
may not prohibit, or otherwise restrict, a health care professional acting
within the lawful scope of practice, from advising or advocating on behalf of a
member who is his or her patient:

 

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RFP B3Z06118   Page 104

  1)   For the member’s health status, medical care, or treatment options,
including any alternative treatment that may be self-administered.     2)   For
any information the member needs in order to decide among all relevant treatment
options.     3)   For the risks, benefits, and consequences of treatment or
non-treatment.     4)   For the member’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.

  i.   Provisions that subcontractors shall not conduct or participate in health
plan enrollment, disenrollment, transfer, or opt out activities. The
subcontractors shall not influence a member’s enrollment. Prohibited activities
include:

  1)   Requiring or encouraging the member to apply for an assistance category
not included in MC+ managed care;     2)   Requiring or encouraging the member
and/or guardian to use the opt out provision as an option in lieu of delivering
health plan benefits;     3)   Mailing or faxing health plan enrollment forms;  
  4)   Aiding the member in filling out health plan enrollment forms;     5)  
Photocopying blank health plan enrollment forms for potential members;     6)  
Distributing blank health plan enrollment forms;     7)   Participating in three
way calls to the MC+ managed care enrollment helpline;     8)   Suggesting a
member transfer to another health plan; or     9)   Other activities in which
subcontractors are engaged in to enroll a member in a particular health plan or
in any way assisting a member to enroll in a health plan.

  j.   If a subcontract is with a federally qualified health center (FQHC) or
rural health clinic (RHC) to provide services to members under a prepayment
arrangement, a provision that the state agency shall reimburse the FQHC or RHC
100% of its reasonable cost for covered services.     k.   All hospital
subcontracts must require that the hospital subcontractor notify the health plan
of births where the mother is a member. The subcontracts must specify which
entity is responsible for notifying the Family Support Division of the birth.  
  l.   For contracted services, the subcontractor shall follow the claim
processing requirements set forth by RSMo 376.383 and 376.384, as amended.    
m.   Provisions in accordance with federal and state laws and regulations, as
amended, and policy regarding termination of the subcontract between the health
plan and the subcontractor.     n.   Provisions that in the event of the
subcontractor’s insolvency or other cessation of operations, covered services to
members shall continue through the period for which a capitation payment has
been made to the health plan or until the member’s discharge from an inpatient
facility, whichever time is greater.     o.   The health plan and its
subcontractors shall establish reasonable timely filing requirements for claims
to be filed by a provider for reimbursement. The subcontractor shall inform its
provider network of the timely filing requirements.

 

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RFP B3Z06118   Page 105

  1)   In the case of capitated arrangements with providers, the subcontractor
shall establish reasonable reporting of encounters to the health plan in
sufficient detail to meet the health plan’s encounter data reporting
requirements.     2)   In the case of services provided by out-of-network
providers, the health plan shall comply with state law regarding timely filing
requirements.

  p.   Provision for revoking the subcontract agreement or imposing other
sanctions if the subcontractor’s performance is inadequate.     q.   The health
plan shall agree and understand that consumer protection shall be integral to
the MC+ managed care program. All contracts between the health plan and
providers shall ensure that the provider complies with the consumer protection
provisions outlined in the marketing guidelines.     r.   Provision(s) that
entitle each member to one free copy of his or her medical records annually. The
fee for additional copies shall not exceed the actual cost of time and materials
used to compile, copy, and furnish such records.

3.9   Assignment:   3.9.1   The health plan shall not transfer any interest in
the contract, whether by assignment or otherwise, without the prior written
consent of the Division of Purchasing and Materials Management.   3.9.2   The
health plan shall agree and understand that, in the event the Division of
Purchasing and Materials Management consents to a financial assignment of the
contract in whole or in part to a third party, any payments made by the State of
Missouri pursuant to the contract, including all of those payments assigned to
the third party, shall be contingent upon the performance of the prime health
plan in accordance with all terms and conditions, requirements and
specifications of the contract.   3.10   Substitution of Personnel: The health
plan agrees and understands that the State of Missouri’s agreement to the
contract is predicated in part on the utilization of the specific individual(s)
and/or personnel qualifications identified in the proposal. The health plan
further agrees that any substitution made pursuant to this paragraph must be
equal or better than originally proposed.   3.11   Health Plan Status: The
health plan represents himself or herself to be an independent health plan
offering such services to the general public and shall not represent
himself/herself or his/her employees to be an employee of the State of Missouri.
Therefore, the health plan shall assume all legal and financial responsibility
for taxes, FICA, employee fringe benefits, workers compensation, employee
insurance, minimum wage requirements, overtime, etc., and agrees to indemnify,
save, and hold the State of Missouri, its officers, agents, and employees,
harmless from and against, any and all loss; cost (including attorney fees); and
damage of any kind related to such matters.   3.12   Coordination: The health
plan shall fully coordinate all contract activities with those activities of the
state agency. As the work of the health plan progresses, advice and information
on matters covered by the contract shall be made available by the health plan to
the state agency or the Division of Purchasing and Materials Management
throughout the effective period of the contract.   3.13   Property of State:  
3.13.1   All reports, documentation, and material developed or acquired by the
health plan as a direct requirement specified in the contract shall become the
property of the State of Missouri.   3.13.2   The health plan shall agree and
understand that all discussions with the health plan and all information gained
by the health plan as a result of the health plan’s performance under the
contract, including member information, medical records, data, and data elements
established, collected, maintained, or used

 

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RFP B3Z06118   Page 106

in the administration of the contract shall be confidential and that no reports,
documentation, or material prepared as required by the contract shall be
released to the public without the prior written consent of the state agency.

  a.   The health plan shall provide safeguards that restrict the use or
disclosure of information concerning members to purposes directly connected with
the administration of the contract.     b.   The health plan shall not disclose
the contents of member information or records to anyone other than the state
agency, the member or the member’s legal guardian, or other parties with the
member’s written consent.     c.   In complying with the requirements of this
section, the health plan and the state agency shall follow the requirements of
42 Code of Federal Regulations Part 431, Subpart F, as amended, regarding
confidentiality of information concerning applicants and members of public
assistance and 42 Code of Federal Regulations Part 2, as amended, regarding
confidentiality of alcohol and drug abuse patient records.     d.   The health
plan shall have written policies and procedures for maintaining the
confidentiality of data, including medical records, member information, and
appointment records for adult and adolescent STDs and adolescent family planning
services.

3.14   Performance Security Deposit: The health plan must furnish a performance
security deposit in the form of an original bond issued by a surety company
authorized to do business in the State of Missouri (no copy or facsimile is
acceptable), check, cash, bank draft, or irrevocable letter of credit to the
Office of Administration, Division of Purchasing and Materials Management within
thirty (30) days after award of the contract and prior to performance of service
under the contract.

  a.   The performance security deposit must be made payable to the State of
Missouri in an amount equal to the in the amount of $1,000,000. In the event the
health plan is awarded a contract for more than one region, the health plan
shall provide a separate performance security deposit in the amount of
$1,000,000.00 for each region.     b.   The contract number and contract period
must be specified on the performance security deposit.     c.   In the event the
Division of Purchasing and Materials Management exercises an option to renew the
contract for an additional period, the health plan shall maintain the validity
and enforcement of the security deposit for the said period, pursuant to the
provisions of this paragraph, in an amount stipulated at the time of contract
renewal     d.   Additionally, during the 365 day transition period, the health
plan shall maintain the validity and enforcement of the performance security
deposit for performance of the administrative functions pursuant to the
provisions of this paragraph, in an amount stipulated via written notification
by DPMM.

3.15   Federal Funds Requirements — The health plan shall understand and agree
that the contract may involve the use of federal funds.   3.15.1   Steven’s
Amendment — In accordance with the Departments of Labor, Health and Human
Services, and Education and Related Agencies Appropriations Act, Public Law
101-166, Section 511, “Steven’s Amendment”, the health plan shall not issue any
statements, press releases, and other documents describing projects or programs
funded in whole or in part with Federal money unless the prior approval of the
state agency is obtained and unless they clearly state the following as provided
by the state agency:

  a.   The percentage of the total costs of the program or project which will be
financed with Federal money;

 

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RFP B3Z06118   Page 107

  b.   The dollar amount of Federal funds for the project or program; and     c.
  The percentage and dollar amount of the total costs of the project or program
that will be financed by nongovernmental sources.

3.16   Terminology   3.16.1   All references to the term “contractor” as used in
the Terms and Conditions attached hereto shall mean “health plan”.

 

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RFP B3Z06118   Page 108

4.   PROPOSAL SUBMISSION INFORMATION   4.1   Submission of Proposals:   4.1.1  
ELECTRONIC SUBMISSION OF PROPOSALS THROUGH THE ON-LINE BIDDING WEB SITE IS NOT
AVAILABLE FOR THIS RFP.   4.1.2   Proposal Security Deposit Required: The
offeror must furnish a proposal security deposit in the form of an original bond
(copies or facsimiles shall not be acceptable), check, cash, bank draft, or
irrevocable letter of credit to the Office of Administration, Division of
Purchasing and Materials Management by the proposal opening date and time. The
Request for Proposal number must be specified on the proposal security deposit.

  a.   The proposal security deposit must be made payable to the State of
Missouri in the amount of $500,000 for each proposed region.     b.   Any
proposal security deposit submitted shall remain in force until such time as the
health plan submits a performance security deposit pursuant to the contract
requirements specified elsewhere herein. Failure to submit a performance
security deposit in the time specified or failure to accept award of the
contract shall be deemed sufficient cause to forfeit the proposal security
deposit.     c.   If the proposal security deposit is submitted in the form of
cash or a check, it will be deposited. However, the Division of Purchasing and
Materials Management shall issue a check in the same amount as the offeror’s
proposal security deposit to the offeror either once the performance security
deposit is received if the offeror is awarded the contract, or at the time of
award of the contract if the offeror is not awarded a contract.

4.1.3   When submitting a proposal, the offeror should include nine
(9) additional copies along with their original proposal. The front cover of the
original proposal should be labeled “original” and the front cover of all copies
should be labeled “copy”.

  a.   In addition the offeror should provide one (1) copy of their entire
proposal, including all attachments, in Microsoft compatible format on
diskette(s) or CD(s).     b.   Both the original and the copies should be
printed on recycled paper and double sided.     c.   Imaging Ready — In
addition, all proposals are scanned into the Division of Purchasing and
Materials Management imaging system after a contract is executed, or all
proposals are rejected.

  1)   The scanned information will be able to be viewed through the Internet
from the Public Record Search system. Therefore, the offeror is advised not to
include personal identifying information such as social security numbers in the
proposal.     2)   In preparing a proposal, the offeror should be mindful of
document preparation efforts for imaging purposes and storage capacity that will
be required to image the proposals. Glue bound materials should not be used.

4.1.4   To facilitate the evaluation process, the offeror is encouraged to
organize their proposal into distinctive sections that correspond with the
individual evaluation categories described herein. The offeror is cautioned that
it is the offeror’s sole responsibility to submit information related to the
evaluation categories and that the State of Missouri is under no obligation to
solicit such information if it is not included with the proposal. The offeror’s
failure to submit such information may cause an adverse impact on the evaluation
of the proposal.

  a.   Each distinctive section should be titled with each individual evaluation
category and all material related to that category should be included therein.  
  b.   The proposal should be page numbered.

 

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RFP B3Z06118   Page 109

  c.   The signed page one from the original RFP and all signed amendments
should be placed at the beginning of the proposal.

4.1.5   The offeror should complete and submit Exhibit A, Miscellaneous
Information.   4.1.6   Offeror’s Contacts:

  a.   Offerors and their agents (including subcontractors, employees,
consultants, or anyone else acting on their behalf) must direct all of their
questions or comments regarding the RFP, the evaluation, etc. to the buyer of
record indicated on the first page of this RFP. The buyer may be contacted via
e-mail or phone as shown on the first page, or via facsimile to 573-526-9817.  
  b.   Offerors and their agents may not contact any other state employee
regarding any of these matters during the solicitation and evaluation process.
Inappropriate contacts are grounds for suspension and/or exclusion from specific
procurements. Offerors and their agents who have questions regarding this matter
should contact the buyer of record.     c.   Offerors are advised that any
questions received less than three weeks prior to the RFP opening date may not
be answered.

4.2   Competitive Negotiation of Proposals — The offeror is advised that under
the provisions of this Request for Proposal, the Division of Purchasing and
Materials Management reserves the right to conduct negotiations of the proposals
received or to award a contract without negotiations. If such negotiations are
conducted, the following conditions shall apply:   4.2.1   Negotiations may be
conducted in person, in writing, or by telephone.   4.2.2   Negotiations will
only be conducted with potentially acceptable proposals. The Division of
Purchasing and Materials Management reserves the right to limit negotiations to
those proposals which received the highest rankings during the initial
evaluation phase. All offerors involved in the negotiation process will be
invited to submit a best and final offer.   4.2.3   Terms, conditions, prices,
methodology, or other features of the offeror’s proposal may be subject to
negotiation and subsequent revision. As part of the negotiations, the offeror
may be required to submit supporting financial, pricing and other data in order
to allow a detailed evaluation of the feasibility, reasonableness, and
acceptability of the proposal.

  a.   The offeror must submit information which establishes and supports the
actuarial soundness of the proposed rates and a certification of said soundness
from an Associate of the Society of Actuaries (ASA), a Fellow of Society of
Actuaries (FSA), or a Member of the American Academy of Actuaries (MAAA).     b.
  The offeror shall understand that the decision of the State of Missouri
regarding whether or not a rate is within actuarially sound rate ranges and does
not exceed the cost to the state agency of providing those same services on a
fee-for-service basis shall be final and without recourse.

4.2.4   The mandatory requirements of the Request for Proposal shall not be
negotiable and shall remain unchanged unless the Division of Purchasing and
Materials Management determines that a change in such requirements is in the
best interest of the State of Missouri.

 

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4.3   Evaluation and Award Process:   4.3.1   After determining that a proposal
was submitted by a responsible and reliable offeror and after confirming that
the offeror is responsive to the mandatory requirements stated in the Request
for Proposal, a subjective evaluation and an objective analysis of the proposals
shall be conducted in accordance with the evaluation criteria stated below and
further described elsewhere herein. .

  a.   Objective Criteria:

  1) Cost Evaluation   20 points 2) Blind/Sheltered Workshops   5 points

  b.   Subjective Criteria:

  1) Organizational Experience   45 points 2) Proposed Method of Performance  
30 points

4.3.2   After an initial screening process, a question and answer conference,
interview, and/or negotiation discussion may be conducted with the offeror, if
deemed necessary by the Division of Purchasing and Materials Management. In
addition, the offeror may be asked to make an oral presentation of their
proposal during the conference. Attendance cost at the conference shall be at
the offeror’s expense. All arrangements and scheduling shall be coordinated by
the Division of Purchasing and Materials Management.   4.3.3   Separate
evaluations shall be conducted by each area (East, Central, and West). One
subjective evaluation shall be conducted as identified in the Subjective
Criteria section of the RFP and points assigned accordingly. Two separate cost
evaluations shall be conducted as identified in the Objective Criteria,
Evaluation of Cost. The first evaluation of cost shall be for those offerors
proposing to include pharmacy services from the MC+ managed care benefit package
benefits and points assigned accordingly. The second evaluation of cost shall be
for those offerors proposing to exclude the pharmacy services from the MC+
managed care benefit package and points assigned accordingly. For auto assign
purposes, the sum of the subjective points and cost points for all offerors in
an area will be grouped together.

Paragraph 4.1.1 renumbered correctly by Amendment #001

4.3.4   The State of Missouri shall award multiple contracts.   4.4   Offeror’s
Organization (Responsible and Reliable):   4.4.1   If the offeror is not
Federally qualified, the offeror must disclose the following information on
certain types of business transactions the offeror has with a “party in
interest” as defined in the Public Health Services Act.

  a.   Any sale, exchange, or lease of any property between the offeror and a
“party in interest”;     b.   Any lending of money or other extension of credit
between the offeror and a “party in interest”; and     c.   Any furnishing for
consideration of goods, services (including management services), or facilities
between the offeror and a “party in interest”. This does not include salaries
paid to employees for services provided in the normal course of their
employment.     d.   If the offeror has operated previously in the commercial or
Medicare markets, the offeror must disclose the information listed below
regarding business transactions for the previous year. The offeror must report
all of the offeror’s business transactions, not just the transactions relating
to serving the Medicaid enrollment.

  1)   The name of the “party in interest” for each business transaction;

 

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RFP B3Z06118   Page 111

  2)   A description of each business transaction and the quantity or units
involved;     3)   The accrued dollar value of each business transaction during
the fiscal year; and     4)   Justification of the reasonableness of each
business transaction.

  e.   For purposes of the above information, a “party in interest” shall be
defined as:

  1)   Any director, officer, partner, or employee responsible for management or
administration of an HMO; any person who is directly or indirectly the
beneficial owner of more than 5% of the equity of the HMO; any person who is the
beneficial owner of a mortgage, deed of trust, note, or other interest secured
by, and valuing more than 5% of the HMO; or, in the case of an HMO organized as
a nonprofit corporation, an incorporator or member of such corporation under
applicable State corporation law;     2)   Any organization in which a person as
described above is director, officer, or partner; has directly or indirectly a
beneficial interest of more than 5% of the equity of the HMO; or has a mortgage,
deed of trust, note, or other interest valuing more than 5% of the assets of the
HMO.     3)   Any person directly or indirectly controlling, controlled by, or
under common control with a HMO; or     4)   Any spouse, child, or parent of a
person as described in above.

4.4.2   The offeror must provide full and complete information by disclosing the
following related to the identity of each “person or corporation with an
ownership or control interest” in the offeror, or any health service
subcontractor in which the offeror has a 5% or more ownership interest for the
prior 12-month period. The offeror may satisfy this requirement by providing a
completed Form CMS-855 (Medicare and Other Federal Health Care Programs
Provider/Supplier Enrollment Application).

  a.   The name and address of each person with an ownership or controlling
interest of 5% or more in the offeror or in any subcontractor in which the
offeror has direct or indirect ownership of 5% or more;     b.   A statement as
to whether any such person with ownership or control interest is related to any
other of the persons named with ownership or control interest; as spouse,
parent, child, or sibling, and     c.   The name of any other organization in
which the person also has ownership or control interest. This is required to the
extent that the offeror can obtain this information by requesting it in writing.
The offeror must keep copies of all of these requests and responses to them,
make them available upon request, and advise the State of Missouri when there is
no response to a request.     d.   For purposes of providing the above
information, the offeror shall understand that a “person with an ownership or
control interest” shall mean a person or corporation that (1) owns directly or
indirectly, 5% or more of the offeror’s capital or stock or received 5% or more
of its profits; or (2) has an interest in any mortgage, deed of trust, note, or
other obligation secured in whole or in part by the offeror or by its property
or assets, and that interest is equal to or exceeds 5% of the total property and
assets of the offeror, or (3) is an officer or director of the offeror (if it is
organized as a corporation) or is a partner in the offeror (if it is organized
as a partnership).

  1)   The percentage of direct ownership or control is calculated by
multiplying the percent of interest which a person owns by the percent of the
offeror’s assets used to secure the obligation (e.g., if a person owns
10 percent of a note secured by 60 percent of the offeror’s assets, the person
owns 6% of the offeror).     2)   The percentage of indirect ownership or
control is calculated by multiplying the percentages of ownership in each
organization (e.g., if a person owns 10 percent of the stock in a corporation
which owns 80 percent of the stock of the offeror, the person owns 8% of the
offeror).

  e.   Financial statements for all owners with 5% or more shall be submitted.

 

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RFP B3Z06118   Page 112

4.4.3   The offeror must provide the following financial information pertaining
to the offeror’s organization (the legal entity that is submitting the proposal
and that will be the party responsible for any contract awarded).

  a.   Audited financial statements and balance sheets for the previous three
(3) years, or as many years up to three (3) years that the entity has been in
operation. If the offeror has not been in operation for at least one year, the
offeror must submit unaudited financial statements and balance sheets. If the
offeror is an existing Health Maintenance Organization, a financial statement
must be submitted on the form as prescribed by the National Association of
Insurance (NAIC) and must include an actuarial certification.     b.   Financial
plan for the offeror’s current fiscal year.     c.   Information about the
offeror’s financial forecasts for the contract period and possible contract
renewal periods. These forecasts shall include at least income statements and
enrollment forecasts.     d.   Names and addresses of independent auditors.    
e.   Documentation of insurance coverage such as a list of the insurers used
(including contact person and address) and the type and amounts of each policy
held.     f.   Proof of reinsurance.     g.   Documentation of any outstanding
litigation and malpractice settlements since January 1, 1998.

4.4.4   Debarment Certification — The offeror certifies by signing the signature
page of this original document and any amendment signature page(s) that the
offeror is not presently debarred, suspended, proposed for debarment, declared
ineligible, voluntarily excluded from participation, or otherwise excluded from
or ineligible for participation under federal assistance programs. The offeror
should complete and return the attached certification regarding debarment, etc.,
Exhibit B with the proposal. This document must be satisfactorily completed
prior to award of the contract.   4.4.5   Business Compliance — The offeror must
be in compliance with the laws regarding conducting business in the State of
Missouri. The offeror certifies by signing the signature page of this original
document and any amendment signature page(s) that the offeror and any proposed
subcontractors are presently in compliance with such laws. The offeror shall
provide documentation of compliance upon request by the Division of Purchasing
and Materials Management. The compliance to conduct business in the state shall
include, but not necessarily be limited to:

  a.   Registration of business name (if applicable)     b.   Certificate of
authority to transact business/certificate of good standing (if applicable)    
c.   Taxes (e.g., city/county/state/federal)     d.   State and local
certifications (e.g., professions/occupations/activities)     e.   Licenses and
permits (e.g., city/county license, sales permits)     f.   Insurance (e.g.,
worker’s compensation/unemployment compensation)

4.5   Confirmation of Compliance with Requirements:

The offeror must submit all of the following information in order to determine
if the offeror satisfies the mandatory requirements of the Request for Proposal.
The State of Missouri reserves the right to reject any offeror’s proposal which
does not include the required information.
In addition, the offeror should address the requirements contained in the
Performance Requirements section of the RFP. Specifically, the offeror should
address the individual requirements in the

 

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Performance Requirements section of the RFP and provide a description of how,
when, by whom, with what, to what degree, why, where, etc., the requirement will
be satisfied.
The offeror should not provide a separate response to both the Performance
Requirements section and this section. Rather, the offeror’s response to the
following items should be included within the offeror’s response to the
Performance Requirements.
To the extent possible, the specific paragraph number of the applicable section
of the Performance Requirements is provided with the following items and is
denoted in parenthesis. The State does not guarantee that all references have
been provided.

4.5.1   The offeror shall submit proof that the offeror has a Certificate of
Authority from the Missouri Department of Insurance to operate a Health
Maintenance Organization in each county specified herein. (2.1.2.a)

  a.   If the offeror does not currently have a certificate for a certain
county, the offeror shall provide documentation that the offeror has or will
submit an application to the Department of Insurance for such certification.

4.5.2   Physician Incentive Plans: The offeror must provide a minimum of the
following information regarding each of the offeror’s physician incentive plans
(PIP) and each of the offeror’s subcontractor’s PIPs with their downstream
providers, if the PIPs place the providers at significant financial risk (SFR).
(2.20.3)

  a.   Effective date of the physician incentive plan,     b.   The type of
incentive arrangement,     c.   The amount and type of stop-loss protection,    
d.   The patient panel size,     e.   If the patient panel is pooled, provide a
description of the method,     f.   The computations of significant financial
risk, and     g.   The name, address, telephone number, and other contact
information for a person from the offeror’s organization who may be contacted
with questions regarding the physician incentive plan.

If the offeror does not have any PIPs with the health care service providers,
the offeror must confirm in the proposal that no such arrangements exist. If the
offeror’s subcontractors do not have any PIPs with their downstream providers,
the offeror must confirm in the proposal that no such arrangements exist and
maintain documentation that demonstrates that no such arrangements exist.

4.5.3   Networks

  a.   The offeror shall submit documentation demonstrating that the offeror’s
networks comply with travel distance access standards as set forth by the
Department of Insurance in 20 CSR 400-7.095 regarding Provider Network Adequacy
Standards. For any demonstrated access that differs from these standards, the
offeror must submit proof of approval of the differences by the Department of
Insurance. (2.14.3)     b.   The offeror shall provide documentation verifying
that the offeror’s network has adequate capacity. Such documentation shall
include, but it is not limited to, appointment availability, 24 hour/7 days a
week access, sufficient experienced providers to serve special needs
populations, waiting times, open panels, and PCP to member rations. (2.3.1)    
c.   The offeror shall describe how it will provide tertiary care providers
including trauma centers, burn centers, level III (high risk) nurseries,
rehabilitation facilities, and medical sub-specialists available twenty-four
(24) hours per day in the region. If the offeror does not have a full range of
tertiary care providers, the offeror shall describe how the services will be
provided including transfer protocols and arrangements with out of network
facilities. (2.3.17)

 

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4.5.4   The offeror shall list each proposed health care service subcontractor
to whom the offeror proposes to delegate contract requirements. Examples
include, but are not limited to, mental health services, vision, dental, or
pharmacy. The offeror shall describe the services and activities that will be
provided by such health service subcontractor. (3.8.3)   4.5.5  
Personnel/Staffing: The offeror shall submit information related to the
qualifications of the proposed personnel concerning their experience in serving
the Medicaid population including education, training, and previous work
assignments. In particular, the offeror must submit the following:

  a.   Resumes, job descriptions, and full time equivalent status for the
offeror’s Medicaid Plan Administrator, medical director, quality assessment and
improvement and utilization management coordinator, special programs
coordinator, mental health coordinator, and chief financial officer. (2.2.2)    
b.   Information for other personnel, including dental consultant, grievance and
appeal coordinator, MIS director, and compliance officer. (2.2.1)     c.  
Information on staffing levels, job descriptions, and qualifications for prior
authorization staff, concurrent review staff, member services staff, and
providers service staff. (2.2.1)

4.5.6   Claims Payment Processes — The offeror must submit the following
information regarding the offeror’s claims payment processes: (2.25)

  a.   Information describing the offeror’s claim adjudication processes — The
offeror shall provide a flow chart or written description that details the flow
of claims from receipt until payment. Information shall be provided documenting
the offeror’s audit trail of all claims that enter the system and any review
processes that are in place.     b.   The offeror shall document the offeror’s
past and current performance with regard to the timely payment to in-network and
out-of-network providers.     c.   A description of the offeror’s claims
processing and management information system functions, including, but not
limited to information about the offeror’s liability management practices
regarding its “Incurred But Not Reported Claims” and “Received But Unadjudicated
Claims”.

4.5.7   Additional Benefits — The offeror must provide a listing, description,
and conditions under which it will offer additional benefits to its members.
Examples of such services are nurse advice lines; non-emergency transportation
(NEMT) for those members who do not have NEMT as part of their benefit package;
sponsorship in youth programs such as Boy Scouts or YMCA; or smoking cessation
programs. This is not an exhaustive list of such services but only provides
examples of the types of services that may qualify as an additional benefit.
(2.6.1.a. 13))

  a.   Member Services and Provider Services — The offeror shall describe the
hours of operation, holiday schedule, member and provider communication and
education plans, and staff training plans for member services and provider
services. (2.9 and 2.10)     b.   Member Grievance System — The offeror shall
describe the offeror’s member grievance system being sure to address the
grievance process, the appeal process, expedited resolution process, and process
for ensuring that members receive proper notice of action. (2.15)     c.  
Release for Ethical Reasons — The offeror must state if reimbursement for, or
provider coverage, of a counseling or referral service will be objected to based
on moral or religious grounds. (2.11.3)

 

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4.6   Objective Criteria:   4.6.1   Preference for Organizations for the Blind
and Sheltered Workshops — Pursuant to 34.165 RSMo, a five (5) bonus point
preference shall be granted to offerors including products and/or services
manufactured, produced or assembled by a qualified nonprofit organization for
the blind established pursuant to 41 U.S.C. sections 46 to 48c or a sheltered
workshop holding a certificate of approval from the Department of Elementary and
Secondary Education pursuant to section 178.920 RSMo. Five bonus points will be
added to the total evaluation points for offerors qualifying for the preference.

  a.   If the offeror is an organization for the blind or sheltered workshop,
the offeror should provide evidence of qualifications (i.e., copy of certificate
or certificate number).     b.   If the offeror is utilizing an organization for
the blind or a sheltered workshop as a subcontractor, the offeror should submit:
(1) a letter of intent signed by the organization for the blind or sheltered
workshop describing the products/services they will provide and indicating their
commitment to aid the contractor’s performance under the prospective state
contract and (2) evidence that the subcontractor qualifies as an organization
for the blind or sheltered workshop.     c.   A list of Missouri sheltered
workshops can be found at the following internet address:

http://www.dese.mo.gov/divspeced/shelteredworkshops/index.html.

4.6.2   Evaluation of Cost:

  a.   The objective evaluation of cost shall be computed by using the firm,
fixed Per Member Per Month (PMPM) Net Capitation Rates for each Category of Aid
Rate Subgroup as quoted by the offeror on the Pricing Pages multiplied by the
corresponding projected member months stated in UPL/Rate Development Process
(see Attachment 9). The State shall not consider awarding a contract to any
offeror with a rate for any Category of Aid rate subgroup which exceeds the
State’s Maximum Net Capitation Rate listed in Column 1 on the Pricing Page.    
b.   Requirements promulgated by the federal government stipulate that the State
of Missouri can only contract for services at rates that are within actuarially
sound rate ranges. The actuarial soundness of rates differing from those of the
state shall be reviewed by the State of Missouri during the formal evaluation of
proposals.     c.   The offeror must submit information which establishes and
supports the actuarial soundness of the proposed rates and a certification of
said soundness from an Associate of the Society of Actuaries (ASA), a Fellow of
Society of Actuaries (FSA), or a Member of the American Academy of Actuaries
(MAAA).     d.   The offeror shall understand that the decision of the State of
Missouri regarding whether or not a rate is within actuarially sound rate ranges
shall be final and without recourse.     e.   Cost points shall be calculated
based on the sum from the above calculation using the following formula:

                             
Lowest Responsive Offeror’s Price
 
Compared Offeror’s Price
  X     20     =   Cost evaluation points    

 

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RFP B3Z06118   Page 116

4.7   Subjective Criteria:   4.7.1   Organizational Experience: The offeror’s
organization and the offeror’s health care service subcontractor’s organizations
shall be subjectively judged. Therefore, the offeror should submit sufficient
information to document successful and reliable experience in past/current
performances of the offeror and the offeror’s health care service
subcontractor’s. The offeror should document experience with a Missouri Medicaid
population, or if not available, document experience with another State’s
Medicaid population.

  a.   The offeror should document its experience in positively impacting the
healthcare status of Missouri Medicaid population, or if not available, another
State’s Medicaid population. Examples of areas of interest include, but are not
limited to the following:

  1)   EPSDT     2)   Lead     3)   Children with special health care needs    
4)   Asthma     5)   Reduction of inappropriate utilization of emergent services
    6)   Case management     7)   Pre-natal care     8)   Dental     9)   Mental
health     10)   Partnering with stakeholders (e.g. community based service
providers, local public health agencies, schools, state agencies, FQHCs,
consumer groups, etc.) for delivery of care     11)   Reduction of racial and
ethnic health care disparities to improve health status     12)   Complaints,
Grievances, and Appeals     13)   Denials     14)   Access

  b.   The offeror should provide a description of focus studies performed,
quality improvement projects, and any improvements the offeror has implemented
and their outcomes. Such outcomes should include cost savings realized, process
efficiencies, and improvements to member health status. Such descriptions should
address such activities since 1998. The offeror should address how issues and
root causes were identified, and what was changed.

4.7.2   Proposed Method of Performance —

  a.   The offeror’s proposed Quality Improvement Programs shall be subjectively
evaluated. Therefore, the offeror should address the Quality Improvement
Programs proposed to be implemented during the term of the contract. The offeror
should address how the proposed Quality Improvement Programs will expand the
quality improvement services beyond what the offeror is currently providing (as
addressed in response to item 4.7.1 a. and b.) and the difference between the
offeror’s current programs and the proposed programs. The offeror should also
indicate how the proposed Quality Improvement Program will improve the health
care status of the Missouri Medicaid population. The offeror should address the
rationale for selecting the particular programs including the identification of
particular health care problems and issues within the Missouri Medicaid
population that each program will address and the underlying cause(s) of such
problems and issues. The proposed Quality Improvement programs may include, but
is not necessarily, limited to the following:

  1)   New innovative programs and processes.     2)   New contracts and/or
partnerships being established to enhance the delivery of health care such as
contracts/partnerships with school districts.     3)   The continuation,
expansion, and/or increase of the current quality improvement programs as listed
in response to 4.7.1 a. and b.

 

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  b.   Economic Impact to Missouri:

  1)   The offeror should provide a description of the proposed services that
will be performed and/or the proposed products that will be provided by
Missourians and/or Missouri products.     2)   The offeror should provide a
description of the economic impact returned to the State of Missouri through tax
revenue obligations.     3)   The offeror should provide a description of the
company’s economic presence within the State of Missouri, including employee
status.

 

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RFP B3Z06118   Page 118

5. PRICING PAGES

5.1   Instructions for Completing Pricing Page: The offeror shall provide firm,
fixed prices for providing all required services for all specified counties
within a region pursuant to the requirements of this Request for Proposal. The
offeror must choose to include Pharmacy services as a MC+ managed care benefit
or choose to exclude Pharmacy services from the MC+ managed care benefit
package. The offeror shall provide either a firm, fixed Per Member Per Month
(PMPM) Net Capitated Rate for each Category of Aid rate subgroup with Pharmacy
services included in the MC+ managed care benefit package or a firm, fixed PMPM
Net Capitated Rate for each Category of Aid rate subgroup with Pharmacy services
excluded from the MC+ managed care benefit package. All costs associated with
providing the required services shall be included in the offeror’s quoted rates.
      If the offeror is proposing to provide services for the Western region,
the offeror must complete Pricing Page 5.2.       If the offeror is proposing to
provide services for the Eastern region, the offeror must complete Pricing Page
5.3.       If the offeror is proposing to provide services for the Central
region, the offeror must complete Pricing Page 5.4.   5.1.1   Requirements
promulgated by the federal government stipulate that the State of Missouri can
only contract for services at rates that are actuarially sound. Column 1A on the
Pricing Pages lists the State’s Maximum Net Capitation Rate for each Category of
Aid rate subgroup with Pharmacy service costs included in the MC+ managed care
benefit package. Each rate listed in Column 1A is actuarially sound, compliant
with federal regulations, and is the maximum amount that the State will allow.
Column 2A on the Pricing Pages lists the State’s maximum Net Capitation Rate for
each Category of Aid rate subgroup with Pharmacy service costs excluded from the
MC+ managed care benefit package. Each rate listed in the Column 2A is
actuarially sound, compliant with federal regulations, and is the maximum amount
that the State will allow.   5.1.2   To assist the offeror in completion of the
Pricing Page, the offeror should use the information provided in Attachment 9.
However, the offeror is advised that this information should not be used as the
only source of information in making pricing decisions. The offeror is solely
responsible for research, preparation, and documentation of the offeror’s
proposal including the offeror’s rates as quoted on the Pricing Page.   5.1.3  
The offeror must complete either Column 1B or 2B on the Pricing Page by
providing a firm, fixed PMPM rate for each Category of Aid rate subgroup.

  a.   The offeror’s firm, fixed rates must not include:

  1)   Estimates for services which are not the offeror’s responsibility.     2)
  Cost of marketing as an administrative expense.     3)   Cost for Pharmacy
services, if the offeror chooses to exclude Pharmacy services from the MC+
managed care benefit package.

  b.   The offeror’s firm, fixed rates shall be net of Third Party Liability
recoveries.     c.   The offeror should calculate medical expenses by specific
Category of Aid rate subgroup and make adjustments for administrative, profit,
and contingency and risk charges to obtain the proposed Firm Fixed Net
Capitation rates.     d.   The offeror’s firm, fixed PMPM Net Capitated Rate for
each Category of Aid rate subgroup must not exceed the State’s Maximum Net
Capitation Rate listed in Column 1A or 2A. The State shall

 

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RFP B3Z06118   Page 119

      not consider awarding a contract to an offeror with any quoted rate which
exceeds the State’s Maximum Net Capitation Rate list in Column 1A or 2A.

******The Pricing Pages are a separate link in Excel Format that must be
downloaded separately from the Division of Purchasing and Materials Management’s
Internet web site at: https://www.moolb.mo.gov. There is separate tab in the
excel spreadsheet for each region. ******

 

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EXHIBIT A
MISCELLANEOUS INFORMATION
Organizations for the Blind or Sheltered Workshop
If the offeror qualifies as either a nonprofit organization for the blind or a
sheltered workshop, or if the offeror is proposing to include products and/or
services manufactured, produced, or assembled by such an organization, the
offeror should identify the name of the organization in the space below and
should attach all supporting documentation, as referenced elsewhere herein.

     
Name & Address of Organization for Blind/Sheltered
   
 
   
Workshop:
   
 
   

Outside United States
If any products and/or services offered under this RFP are being manufactured or
performed at sites outside the continental United States, the offeror MUST
disclose such fact and provide details in the space below or on an attached
page.

                 
Are products and/or services being manufactured or performed at sites outside
the continental United States?
  Yes __   No __
 
               
Describe and provide details:
               

Employee Bidding/Conflict of Interest
Offerors who are employees of the State of Missouri, a member of the General
Assembly or a statewide elected official must comply with Sections 105.450 to
105.458 RSMo regarding conflict of interest. If the offeror and/or any of the
owners of the offeror’s organization are currently an employee of the State of
Missouri, a member of the General Assembly or a statewide elected official,
please provide the following information.

                 
Name of State Employee, General Assembly Member, or Statewide Elected Official:
               
 
               
In what office/agency are they employed?
               
 
               
Employment Title:
               
 
               
Percentage of ownership interest in offeror’s organization:
    ____________ %        

 

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EXHIBIT B
Certification Regarding
Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions
This certification is required by the regulations implementing Executive Order
12549, Debarment and Suspension, 29 CFR Part 98 Section 98.510, Participants’
responsibilities. The regulations were published as Part VII of the May 26,
1988, Federal Register (pages 19160-19211).
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS FOR CERTIFICATION)

(1)   The prospective recipient of Federal assistance funds certifies, by
submission of this proposal, that neither it nor its principals are presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or
agency.   (2)   Where the prospective recipient of Federal assistance funds is
unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.

 
Name and Title of Authorized Representative

     
 
   
Signature
  Date

Instructions for Certification

1.   By signing and submitting this proposal, the prospective recipient of
Federal assistance funds is providing the certification as set out below.   2.  
The certification in this clause is a material representation of fact upon which
reliance was placed when this transaction was entered into. If it is later
determined that the prospective recipient of Federal assistance funds knowingly
rendered an erroneous certification, in addition to other remedies available to
the Federal Government, the Department of Labor (DOL) may pursue available
remedies, including suspension and/or debarment.   3.   The prospective
recipient of Federal assistance funds shall provide immediate written notice to
the person to which this proposal is submitted if at any time the prospective
recipient of Federal assistance funds learns that its certification was
erroneous when submitted or has become erroneous by reason of changed
circumstances.   4.   The terms “covered transaction,” “debarred,” “suspended,”
“ineligible,” “lower tier covered transaction,” “participant,” “person,”
“primary covered transaction,” “principal,” “proposal,” and “voluntarily
excluded,” as used in this clause, have the meanings set out in the Definitions
and Coverage sections of rules implementing Executive Order 12549. You may
contact the person to which this proposal is submitted for assistance in
obtaining a copy of those regulations.   5.   The prospective recipient of
Federal assistance funds agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into
any lower tier covered transaction with a person who is debarred, suspended,
declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the DOL.   6.   The prospective recipient of
Federal assistance funds further agrees by submitting this proposal that it will
include the clause titled “Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion — Lower Tier Covered Transactions,”
without modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.   7.   A participant in a
covered transaction may rely upon a certification of a prospective participant
in a lower tier covered transaction that it is not debarred, suspended,
ineligible, or voluntarily excluded from the covered transaction, unless it
knows that the certification is erroneous. A participant may decide the method
and frequency by which it determines the eligibility of its principals. Each
participant may but is not required to check the List of Parties Excluded from
Procurement or Nonprocurement Programs.   8.   Nothing contained in the
foregoing shall be construed to require establishment of a system of records in
order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which
is normally possessed by a prudent person in the ordinary course of business
dealings.   9.   Except for transactions authorized under paragraph 5 of these
instructions, if a participant in a covered transaction knowingly enters into a
lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntary excluded from participation in this transaction, in
addition to other remedies available to the Federal Government, the DOL may
pursue available remedies, including suspension and/or debarment.

 

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STATE OF MISSOURI
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT
TERMS AND CONDITIONS — REQUEST FOR PROPOSAL
1. TERMINOLOGY/DEFINITIONS

    Whenever the following words and expressions appear in a Request for
Proposal (RFP) document or any amendment thereto, the definition or meaning
described below shall apply.   a.   Agency and/or State Agency means the
statutory unit of state government in the State of Missouri for which the
equipment, supplies, and/or services are being purchased by the Division of
Purchasing and Materials Management (DPMM). The agency is also responsible for
payment.   b.   Amendment means a written, official modification to an RFP or to
a contract.   c.   Attachment applies to all forms which are included with an
RFP to incorporate any informational data or requirements related to the
performance requirements and/or specifications.   d.   Proposal Opening Date and
Time and similar expressions mean the exact deadline required by the RFP for the
receipt of sealed proposals.   e.   Offeror means the person or organization
that responds to an RFP by submitting a proposal with prices to provide the
equipment, supplies, and/or services as required in the RFP document.   f.  
Buyer means the procurement staff member of the DPMM. The Contact Person as
referenced herein is usually the Buyer.   g.   Contract means a legal and
binding agreement between two or more competent parties, for a consideration for
the procurement of equipment, supplies, and/or services.   h.   Contractor means
a person or organization who is a successful offeror as a result of an RFP and
who enters into a contract.   i.   Exhibit applies to forms which are included
with an RFP for the offeror to complete and submit with the sealed proposal
prior to the specified opening date and time.   j.   Request for Proposal (RFP)
means the solicitation document issued by the DPMM to potential offerors for the
purchase of equipment, supplies, and/or services as described in the document.
The definition includes these Terms and Conditions as well as all Pricing Pages,
Exhibits, Attachments, and Amendments thereto.   k.   May means that a certain
feature, component, or action is permissible, but not required.   l.   Must
means that a certain feature, component, or action is a mandatory condition.  
m.   Pricing Page(s) applies to the form(s) on which the offeror must state the
price(s) applicable for the equipment, supplies, and/or services required in the
RFP. The pricing pages must be completed and submitted by the offeror with the
sealed proposal prior to the specified proposal opening date and time.   n.  
RSMo (Revised Statutes of Missouri) refers to the body of laws enacted by the
Legislature which govern the operations of all agencies of the State of
Missouri. Chapter 34 of the statutes is the primary chapter governing the
operations of DPMM.   o.   Shall has the same meaning as the word must.   p.  
Should means that a certain feature, component and/or action is desirable but
not mandatory.

2. APPLICABLE LAWS AND REGULATIONS

a.   The contract shall be construed according to the laws of the State of
Missouri. The contractor shall comply with all local, state, and federal laws
and regulations related to the performance of the contract to the extent that
the same may be applicable.   b.   To the extent that a provision of the
contract is contrary to the Constitution or laws of the State of Missouri or of
the United States, the provisions shall be void and unenforceable. However, the
balance of the contract shall remain in force between the parties unless
terminated by consent of both the contractor and the DPMM.   c.   The contractor
must be registered and maintain good standing with the Secretary of State of the
State of Missouri and other regulatory agencies, as may be required by law or
regulations.   d.   The contractor must timely file and pay all Missouri sales,
withholding, corporate and any other required Missouri tax returns and taxes,
including interest and additions to tax.   e.   The exclusive venue for any
legal proceeding relating to or arising out of the RFP or resulting contract
shall be in the Circuit Court of Cole County, Missouri.

3. OPEN COMPETITION/REQUEST FOR PROPOSAL DOCUMENT

a.   It shall be the offeror’s responsibility to ask questions, request changes
or clarification, or otherwise advise the DPMM if any language, specifications
or requirements of an RFP appear to be ambiguous, contradictory, and/or
arbitrary, or appear to inadvertently restrict or limit the requirements stated
in the RFP to a single source. Any and all communication from offerors regarding
specifications, requirements, competitive proposal process, etc., must be
directed to the buyer from the DPMM, unless the RFP specifically refers the
offeror to another contact. Such communication should be received at least ten
calendar days prior to the official proposal opening date.   b.   Every attempt
shall be made to ensure that the offeror receives an adequate and prompt
response. However, in order to maintain a fair and equitable procurement
process, all offerors will be advised, via the issuance of an amendment to the
RFP, of any relevant or pertinent information related to the procurement.
Therefore, offerors are advised that unless specified elsewhere in the RFP, any
questions received less than ten calendar days prior to the RFP opening date may
not be answered.   c.   Offerors are cautioned that the only official position
of the State of Missouri is that which is issued by the DPMM in the RFP or an
amendment thereto. No other means of communication, whether oral or written,
shall be construed as a formal or official response or statement.   d.   The
DPMM monitors all procurement activities to detect any possibility of deliberate
restraint of competition, collusion among offerors, price-fixing by offerors, or
any other anticompetitive conduct by offerors which appears to violate state and
federal antitrust laws. Any suspected violation shall be referred to the
Missouri Attorney General’s Office for appropriate action.   e.   The RFP is
available for viewing and downloading on the state’s On-Line Bidding/Vendor
Registration System website. Premium registered offerors are electronically
notified of the proposal opportunity based on the information maintained in the
State of Missouri’s vendor database. If a Premium registered offeror’s e-mail
address is incorrect, the offeror must update the e-mail address themselves on
the state’s On-Line Bidding/Vendor Registration System website.   f.   The DPMM
reserves the right to officially amend or cancel an RFP after issuance. Premium
registered offerors who received e-mail notification of the proposal opportunity
when the RFP was established and Premium registered offerors who have responded
to the RFP on-line prior to an amendment being issued will receive e-mail
notification of the amendment(s). Premium registered offerors who received
e-mail notification of the proposal opportunity when the RFP was established and
Premium registered offerors who have responded to the proposal on-line prior to
a cancellation being issued will receive e-mail notification of a cancellation
issued prior to the exact closing time and date specified in the RFP.

4. PREPARATION OF PROPOSALS

a.   Offerors must examine the entire RFP carefully. Failure to do so shall be
at offeror’s risk.   b.   Unless otherwise specifically stated in the RFP, all
specifications and requirements constitute minimum requirements. All proposals
must meet or exceed the stated specifications and requirements.   c.   Unless
otherwise specifically stated in the RFP, any manufacturer names, trade names,
brand names, information and/or catalog numbers listed in a specification and/or
requirement are for informational purposes only and are not intended to limit
competition. The offeror may offer any brand which meets or exceeds the
specification for any item, but must state the manufacturer’s name and model
number for any such brands in the proposal. In addition, the offeror shall
explain, in

 

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B3Z06118   Page 123

    detail, (1) the reasons why the proposed equivalent meets or exceeds the
specifications and/or requirements and (2) why the proposed equivalent should
not be considered an exception thereto. Proposals which do not comply with the
requirements and specifications are subject to rejection without clarification.
  d.   Proposals lacking any indication of intent to offer an alternate brand or
to take an exception shall be received and considered in complete compliance
with the specifications and requirements as listed in the RFP.   e.   In the
event that the offeror is an agency of state government or other such political
subdivision which is prohibited by law or court decision from complying with
certain provisions of an RFP, such a offeror may submit a proposal which
contains a list of statutory limitations and identification of those prohibitive
clauses which will be modified via a clarification conference between the DPMM
and the offeror, if such offeror is selected for contract award. The
clarification conference will be conducted in order to agree to language that
reflects the intent and compliance of such law and/or court order and the RFP.
Any such offeror needs to include in the proposal, a complete list of statutory
references and citations for each provision of the RFP which is affected by this
paragraph.   f.   All equipment and supplies offered in a proposal must be new,
of current production, and available for marketing by the manufacturer unless
the RFP clearly specifies that used, reconditioned, or remanufactured equipment
and supplies may be offered.   g.   Prices shall include all packing, handling
and shipping charges FOB destination, freight prepaid and allowed unless
otherwise specified in the RFP.   h.   Prices offered shall remain valid for
90 days from proposal opening unless otherwise indicated. If the proposal is
accepted, prices shall be firm for the specified contract period.   i.   Any
foreign offeror not having an Employer Identification Number assigned by the
United States Internal Revenue Service (IRS) must submit a completed IRS Form
W-8 prior to or with the submission of their proposal in order to be considered
for award.

5. SUBMISSION OF PROPOSALS

a.   Proposals may be submitted by delivery of a hard copy to the DPMM office.
Electronic submission of proposals by Premium registered offerors through the
State of Missouri’s On-Line Bidding/Vendor Registration System website is not
available unless stipulated in the RFP. Delivered proposals must be sealed in an
envelope or container, and received in the DPMM office located at 301 West High
St, Rm 630 in Jefferson City, MO no later than the exact opening time and date
specified in the RFP. All proposals must (1) be submitted by a duly authorized
representative of the offeror’s organization, (2) contain all information
required by the RFP, and (3) be priced as required. Hard copy proposals may be
mailed to the DPMM post office box address. However, it shall be the
responsibility of the offeror to ensure their proposal is in the DPMM office
(address listed above) no later than the exact opening time and date specified
in the RFP.   b.   The sealed envelope or container containing a proposal should
be clearly marked on the outside with (1) the official RFP number and (2) the
official opening date and time. Different proposals should not be placed in the
same envelope, although copies of the same proposal may be placed in the same
envelope.   c.   A proposal submitted electronically by a Premium registered
offeror may be modified on-line prior to the official opening date and time. A
proposal which has been delivered to the DPMM office, may be modified by signed,
written notice which has been received by the DPMM prior to the official opening
date and time specified. A proposal may also be modified in person by the
offeror or its authorized representative, provided proper identification is
presented before the official opening date and time. Telephone or telegraphic
requests to modify a proposal shall not be honored.   d.   A proposal submitted
electronically by a Premium registered offeror may be canceled on-line prior to
the official opening date and time. A proposal which has been delivered to the
DPMM office, may only be withdrawn by a signed, written notice or facsimile
which has been received by the DPMM prior to the official opening date and time
specified. A proposal may also be withdrawn in person by the offeror or its
authorized representative, provided proper identification is presented before
the official opening date and time. Telephone, e-mail, or telegraphic requests
to withdraw a proposal shall not be honored.   e.   When submitting a proposal
electronically, the Premium registered offeror indicates acceptance of all RFP
terms and conditions by clicking on the “Submit” button on the Electronic Bid
Response Entry form. Offerors delivering a hard copy proposal to DPMM must sign
and return the RFP cover page or, if applicable, the cover page of the last
amendment thereto in order to constitute acceptance by the offeror of all RFP
terms and conditions. Failure to do so may result in rejection of the proposal
unless the offeror’s full compliance with those documents is indicated elsewhere
within the offeror’s response.

6. PROPOSAL OPENING

a.   Proposal openings are public on the opening date and at the opening time
specified on the RFP document. Only the names of the respondents shall be read
at the proposal opening. Premium registered vendors may view the same proposal
response information on the state’s On-Line Bidding/Vendor Registration System
website. The contents of the responses shall not be disclosed at this time.   b.
  Proposals which are not received in the DPMM office prior to the official
opening date and time shall be considered late, regardless of the degree of
lateness, and normally will not be opened. Late proposals may only be opened
under extraordinary circumstances in accordance with 1 CSR 40-1.050.

7. PREFERENCES

a.   In the evaluation of proposals, preferences shall be applied in accordance
with Chapter 34 RSMo. Contractors should apply the same preferences in selecting
subcontractors.   b.   By virtue of statutory authority, a preference will be
given to materials, products, supplies, provisions and all other articles
produced, manufactured, made or grown within the State of Missouri and to all
firms, corporations or individuals doing business as Missouri firms,
corporations or individuals. Such preference shall be given when quality is
equal or better and delivered price is the same or less.   c.   In accordance
with Executive Order 05-30, contractors are encouraged to utilize certified
minority and women-owned businesses in selecting subcontractors.

8. EVALUATION/AWARD

a.   Any clerical error, apparent on its face, may be corrected by the buyer
before contract award. Upon discovering an apparent clerical error, the buyer
shall contact the offeror and request clarification of the intended proposal.
The correction shall be incorporated in the notice of award. Examples of
apparent clerical errors are: 1) misplacement of a decimal point; and 2) obvious
mistake in designation of unit.   b.   Any pricing information submitted by an
offeror shall be subject to evaluation if deemed by the DPMM to be in the best
interest of the State of Missouri.   c.   The offeror is encouraged to propose
price discounts for prompt payment or propose other price discounts that would
benefit the State of Missouri. However, unless otherwise specified in the RFP,
pricing shall be evaluated at the maximum potential financial liability to the
State of Missouri.   d.   Awards shall be made to the offeror whose proposal
(1) complies with all mandatory specifications and requirements of the RFP and
(2) is the lowest and best proposal, considering price, responsibility of the
offeror, and all other evaluation criteria specified in the RFP and any
subsequent negotiations and (3) complies with Sections 34.010 and 34.070 RSMo
and Executive Order 04-09.   e.   In the event all offerors fail to meet the
same mandatory requirement in an RFP, DPMM reserves the right, at its sole
discretion, to waive that requirement for all offerors and to proceed with the
evaluation. In addition, the DPMM reserves the right to waive any minor
irregularity or technicality found in any individual proposal.   f.   The DPMM
reserves the right to reject any and all proposals.   g.   When evaluating a
proposal, the State of Missouri reserves the right to consider relevant
information and fact, whether gained from a proposal, from a offeror, from
offeror’s references, or from any other source.   h.   Any information submitted
with the proposal, regardless of the format or placement of such information,
may be considered in making decisions related to the responsiveness and merit of
a proposal and the award of a contract.   i.   Negotiations may be conducted
with those offerors who submit potentially acceptable proposals. Proposal
revisions may be permitted for the purpose of obtaining best and final offers.
In conducting negotiations, there shall be no disclosure of any information
submitted by competing offerors.

 

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j.   Any award of a contract shall be made by notification from the DPMM to the
successful offeror. The DPMM reserves the right to make awards by item, group of
items, or an all or none basis. The grouping of items awarded shall be
determined by DPMM based upon factors such as item similarity, location,
administrative efficiency, or other considerations in the best interest of the
State of Missouri.   k.   Pursuant to Section 610.021 RSMo, proposals and
related documents shall not be available for public review until after a
contract is executed or all proposals are rejected.   l.   The DPMM posts all
proposal results on the On-line Bidding/Vendor Registration System website for
Premium registered offerors to view for a reasonable period after proposal award
and maintains images of all proposal file material for review. Offerors who
include an e-mail address with their proposal will be notified of the award
results via e-mail.   m.   The DPMM reserves the right to request clarification
of any portion of the offeror’s response in order to verify the intent of the
offeror. The offeror is cautioned, however, that its response may be subject to
acceptance or rejection without further clarification.   n.   Any proposal award
protest must be received within ten (10) calendar days after the date of award
in accordance with the requirements of 1 CSR 40-1.050 (10).   o.   The final
determination of contract(s) award shall be made by DPMM.

9. CONTRACT/PURCHASE ORDER

a.   By submitting a proposal, the offeror agrees to furnish any and all
equipment, supplies and/or services specified in the RFP, at the prices quoted,
pursuant to all requirements and specifications contained therein.   b.   A
binding contract shall consist of: (1) the RFP, amendments thereto, and/or Best
and Final Offer (BAFO) request(s) with RFP changes/additions, (2) the
contractor’s proposal including the contractor’s BAFO, and (3) DPMM’s acceptance
of the proposal by “notice of award” or by “purchase order.”   c.   A notice of
award issued by the State of Missouri does not constitute an authorization for
shipment of equipment or supplies or a directive to proceed with services.
Before providing equipment, supplies and/or services for the State of Missouri,
the contractor must receive a properly authorized purchase order unless the
purchase is equal to or less than $3,000. State purchases equal to or less than
$3,000 may be processed with a purchase order or other form of authorization
given to the contractor at the discretion of the state agency.   d.   The
contract expresses the complete agreement of the parties and performance shall
be governed solely by the specifications and requirements contained therein. Any
change, whether by modification and/or supplementation, must be accomplished by
a formal contract amendment signed and approved by and between the duly
authorized representative of the contractor and the DPMM or by a modified
purchase order prior to the effective date of such modification. The contractor
expressly and explicitly understands and agrees that no other method and/or no
other document, including correspondence, acts, and oral communications by or
from any person, shall be used or construed as an amendment or modification.

10. INVOICING AND PAYMENT

a.   The State of Missouri does not pay state or federal taxes unless otherwise
required under law or regulation.   b.   The statewide financial management
system has been designed to capture certain receipt and payment information. For
each purchase order received, an invoice must be submitted that references the
purchase order number and must be itemized in accordance with items listed on
the purchase order. Failure to comply with this requirement may delay processing
of invoices for payment.   c.   The contractor shall not transfer any interest
in the contract, whether by assignment or otherwise, without the prior written
consent of the DPMM.   d.   Payment for all equipment, supplies, and/or services
required herein shall be made in arrears unless otherwise indicated in the RFP.
  e.   The State of Missouri assumes no obligation for equipment, supplies,
and/or services shipped or provided in excess of the quantity ordered. Any
unauthorized quantity is subject to the state’s rejection and shall be returned
at the contractor’s expense.   f.   All invoices for equipment, supplies, and/or
services purchased by the State of Missouri shall be subject to late payment
charges as provided in Section 34.055 RSMo.   g.   The State of Missouri
reserves the right to purchase goods and services using the state purchasing
card.

11. DELIVERY

    Time is of the essence. Deliveries of equipment, supplies, and/or services
must be made no later than the time stated in the contract or within a
reasonable period of time, if a specific time is not stated.

12. INSPECTION AND ACCEPTANCE

a.   No equipment, supplies, and/or services received by an agency of the state
pursuant to a contract shall be deemed accepted until the agency has had
reasonable opportunity to inspect said equipment, supplies, and/or services.  
b.   All equipment, supplies, and/or services which do not comply with the
specifications and/or requirements or which are otherwise unacceptable or
defective may be rejected. In addition, all equipment, supplies, and/or services
which are discovered to be defective or which do not conform to any warranty of
the contractor upon inspection (or at any later time if the defects contained
were not reasonably ascertainable upon the initial inspection) may be rejected.
  c.   The State of Missouri reserves the right to return any such rejected
shipment at the contractor’s expense for full credit or replacement and to
specify a reasonable date by which replacements must be received.   d.   The
State of Missouri’s right to reject any unacceptable equipment, supplies, and/or
services shall not exclude any other legal, equitable or contractual remedies
the state may have.

13. WARRANTY

a.   The contractor expressly warrants that all equipment, supplies, and/or
services provided shall: (1) conform to each and every specification, drawing,
sample or other description which was furnished to or adopted by the DPMM,
(2) be fit and sufficient for the purpose expressed in the RFP, (3) be
merchantable, (4) be of good materials and workmanship, and (5) be free from
defect.   b.   Such warranty shall survive delivery and shall not be deemed
waived either by reason of the state’s acceptance of or payment for said
equipment, supplies, and/or services.

14. CONFLICT OF INTEREST

a.   Officials and employees of the state agency, its governing body, or any
other public officials of the State of Missouri must comply with
Sections 105.452 and 105.454 RSMo regarding conflict of interest.   b.   The
contractor hereby covenants that at the time of the submission of the proposal
the contractor has no other contractual relationships which would create any
actual or perceived conflict of interest. The contractor further agrees that
during the term of the contract neither the contractor nor any of its employees
shall acquire any other contractual relationships which create such a conflict.

15. REMEDIES AND RIGHTS

 

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B3Z06118   Page 125

a.   No provision in the contract shall be construed, expressly or implied, as a
waiver by the State of Missouri of any existing or future right and/or remedy
available by law in the event of any claim by the State of Missouri of the
contractor’s default or breach of contract.   b.   The contractor agrees and
understands that the contract shall constitute an assignment by the contractor
to the State of Missouri of all rights, title and interest in and to all causes
of action that the contractor may have under the antitrust laws of the United
States or the State of Missouri for which causes of action have accrued or will
accrue as the result of or in relation to the particular equipment, supplies,
and/or services purchased or procured by the contractor in the fulfillment of
the contract with the State of Missouri.

16. CANCELLATION OF CONTRACT

a.   In the event of material breach of the contractual obligations by the
contractor, the DPMM may cancel the contract. At its sole discretion, the DPMM
may give the contractor an opportunity to cure the breach or to explain how the
breach will be cured. The actual cure must be completed within no more than 10
working days from notification, or at a minimum the contractor must provide DPMM
within 10 working days from notification a written plan detailing how the
contractor intends to cure the breach.   b.   If the contractor fails to cure
the breach or if circumstances demand immediate action, the DPMM will issue a
notice of cancellation terminating the contract immediately.   c.   If the DPMM
cancels the contract for breach, the DPMM reserves the right to obtain the
equipment, supplies, and/or services to be provided pursuant to the contract
from other sources and upon such terms and in such manner as the DPMM deems
appropriate and charge the contractor for any additional costs incurred thereby.
  d.   The contractor understands and agrees that funds required to fund the
contract must be appropriated by the General Assembly of the State of Missouri
for each fiscal year included within the contract period. The contract shall not
be binding upon the state for any period in which funds have not been
appropriated, and the state shall not be liable for any costs associated with
termination caused by lack of appropriations.

17. COMMUNICATIONS AND NOTICES

    Any notice to the contractor shall be deemed sufficient when deposited in
the United States mail postage prepaid, transmitted by facsimile, transmitted by
e-mail or hand-carried and presented to an authorized employee of the
contractor.

18. BANKRUPTCY OR INSOLVENCY

a.   Upon filing for any bankruptcy or insolvency proceeding by or against the
contractor, whether voluntary or involuntary, or upon the appointment of a
receiver, trustee, or assignee for the benefit of creditors, the contractor must
notify the DPMM immediately.   b.   Upon learning of any such actions, the DPMM
reserves the right, at its sole discretion, to either cancel the contract or
affirm the contract and hold the contractor responsible for damages.

19. INVENTIONS, PATENTS AND COPYRIGHTS

    The contractor shall defend, protect, and hold harmless the State of
Missouri, its officers, agents, and employees against all suits of law or in
equity resulting from patent and copyright infringement concerning the
contractor’s performance or products produced under the terms of the contract.

20. NON-DISCRIMINATION AND AFFIRMATIVE ACTION

    In connection with the furnishing of equipment, supplies, and/or services
under the contract, the contractor and all subcontractors shall agree not to
discriminate against recipients of services or employees or applicants for
employment on the basis of race, color, religion, national origin, sex, age,
disability, or veteran status. If the contractor or subcontractor employs at
least 50 persons, they shall have and maintain an affirmative action program
which shall include:

a.   A written policy statement committing the organization to affirmative
action and assigning management responsibilities and procedures for evaluation
and dissemination;   b.   The identification of a person designated to handle
affirmative action;   c.   The establishment of non-discriminatory selection
standards, objective measures to analyze recruitment, an upward mobility system,
a wage and salary structure, and standards applicable to layoff, recall,
discharge, demotion, and discipline;   d.   The exclusion of discrimination from
all collective bargaining agreements; and   e.   Performance of an internal
audit of the reporting system to monitor execution and to provide for future
planning.       If discrimination by a contractor is found to exist, the DPMM
shall take appropriate enforcement action which may include, but not necessarily
be limited to, cancellation of the contract, suspension, or debarment by the
DPMM until corrective action by the contractor is made and ensured, and referral
to the Attorney General’s Office, whichever enforcement action may be deemed
most appropriate.

21. AMERICANS WITH DISABILITIES ACT

    In connection with the furnishing of equipment, supplies, and/or services
under the contract, the contractor and all subcontractors shall comply with all
applicable requirements and provisions of the Americans with Disabilities Act
(ADA).

22. FILING AND PAYMENT OF TAXES

    The commissioner of administration and other agencies to which the state
purchasing law applies shall not contract for goods or services with a vendor if
the vendor or an affiliate of the vendor makes sales at retail of tangible
personal property or for the purpose of storage, use, or consumption in this
state but fails to collect and properly pay the tax as provided in chapter 144,
RSMo. For the purposes of this section, “affiliate of the vendor” shall mean any
person or entity that is controlled by or is under common control with the
vendor, whether through stock ownership or otherwise. Therefore offeror’s
failure to maintain compliance with chapter 144, RSMo may eliminate their
proposal from consideration for award.

23. TITLES

    Titles of paragraphs used herein are for the purpose of facilitating
reference only and shall not be construed to infer a contractual construction of
language.

Revised 01/03/06

 

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    (SEAL) [a38671a3867115.gif]   (STAMP) [a38671a3867116.gif]

NOTICE OF AWARD
State Of Missouri
Office Of Administration
Division Of Purchasing And Materials Management
PO Box 809
Jefferson City, MO 65102
http://www.oa.mo.gov/purch

     
CONTRACT NUMBER
  CONTRACT TITLE
 
   
C306118003
  Medicaid Managed Care – Central, Eastern, and
 
  Western Regions
 
   
AMENDMENT NUMBER
  CONTRACT PERIOD
 
   
Amendment #001
  July 1, 2006 through June 30, 2007
 
   
REQUISITION NUMBER
  VENDOR NUMBER
 
   
NR 886 25757001820
  4317439020 2
 
   
CONTRACTOR NAME AND ADDRESS
  STATE AGENCY’S NAME AND ADDRESS
 
   
Mercy CarePlus
  Department of Social Services
10123 Corporate Square Drive
  Division of Medical Services
St. Louis MO 63132
  PO Box 6500
 
  Jefferson City MO 65102-6500
 
    ACCEPTED BY THE STATE OF MISSOURI AS FOLLOWS:
 
    Contract C306118003 is hereby amended pursuant to the attached Amendment
#001 dated 07/31/06.
 
   
BUYER
  BUYER CONTACT INFORMATION
 
  E-Mail: laura.ortmeyer@oa.mo.gov
Laura Ortmeyer
  Phone: (573) 751-4579 Fax: (573) 526-9817
 
   
SIGNATURE OF BUYER
  DATE
 
   
/s/ Laura Ortmeyer
  8/10/06
 
   
DIRECTOR OF PURCHASING AND MATERIALS MANAGEMENT
   
/s/ James Miluski
   

 

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(STAMP) [a38671a3867115.gif]
  STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT AMENDMENT
 
 

     
AMENDMENT NO.: 001
  REQ NO.: NR 886 25757001820
CONTRACT NO.: C306118003
  BUYER: Laura Ortmeyer
TITLE: Medicaid Managed Care — Central, Eastern, & Western Regions
  PHONE NO.: (573) 751-4579
ISSUE DATE: 07/24/06
  E-MAIL: Laura.Ortmeyer@oa.mo.gov

TO: Alliance for Community Health
RETURN AMENDMENT NO LATER THAN: August 4, 2006 AT 5:00 PM CENTRAL TIME
RETURN AMENDMENT TO:

              (U.S. Mail)       (Courier Service) Div of Purchasing & Matls Mgt
(DPMM)   OR   Div of Purchasing & Matls Mgt (DPMM)
 
            PO BOX 809       301 WEST HIGH STREET, ROOM 630 JEFFERSON CITY MO
65102-0809       JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)
DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING
ADDRESS:

         
 
  Department of Social Service    
 
  Division of Medical Services    
 
  P.O. Box 6500    
 
  Jefferson City, MO 65102-6500   RCVD AUG 1’06 AM 9:44 OA-DPMM
 
       
 
  SIGNATURE REQUIRED    

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
   
Mercy CarePlus
  Alliance for Community Health
 
   
MAILING ADDRESS
  IRS FORM 1099 MAILING ADDRESS
 
   
10123 Corporate Square DR.
  10123 Corporate Square DR.
 
   
CITY, STATE, ZIP CODE
  CITY, STATE, ZIP CODE
 
   
St. Louis, MO 63132
  St. Louis, MO 63132

     
CONTACT PERSON
  EMAIL ADDRESS
 
   
Jerry Linder/Marcia Albridge
  Malbridge@mercycareplus.com
jlinder@mercycareplus.com
 
   
PHONE NUMBER
  FAX NUMBER
 
   
314- 432-9300
  314-994-9398

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
   
43-1743902
  þ FEIN       o SSN   43-17439020 2

                      VENDOR TAX FILING TYPE WITH IBS (CHECK ONE)   (NOTE: LLC
IS NOT A VALID TAX FILING TYPE.)
 
þ Corporation
  o Individual   o State/Local Government   o Partnership   o Sole Proprietor  
o Other                      

     
AUTHORIZED SIGNATURE
  DATE  
/s/ Jerry Linder
  7/31/06
 
   
PRINTED NAME
  TITLE  
Jerry Linder
  CEO

 

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Contract C306118003   Page 2

AMENDMENT #001 TO CONTRACT C306118003

     
CONTRACT TITLE:
  Medicaid Managed Care — Central, Eastern, & Western Regions  
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007

In accordance with the attached Agreement and Consent document and effective
July 1, 2006, the State of Missouri hereby assigns the above-referenced contract
from Alliance for Community Health LLC d/b/a Community CarePlus (4317439020 1)
to Mercy CarePlus. All references to Community CarePlus or CCP shall be replaced
with Mercy CarePlus.
As a result of such assignment, the response to section 4.4.2 a. is replaced
with the following:
The name and address of each person with an ownership or controlling interest of
5% or more in Mercy CarePlus is as follows:

  •   CCP Acquisition Limited, a MO Corporation (“CAL”) has a 40.050 % direct
ownership interest. CCP Acquisition Limited is located at 101 S. Hanley,
Suite 1250, Clayton, MO 63105     •   Mercy Health Plans, Inc. (MHP), a Delaware
corporation, has a 50% direct ownership interest. MHP is located at 14528 South
Outer 40 Drive, Chesterfield MO 63017.

The above documents those entities with ownership of 5% or greater.
Missouri Physicians Associates, a MO Domestic Insurance Company (“MPA”) owns all
of the capital stock of CAL; therefore, for purposes of this response, MPA is
deemed to own an indirect interest of ownership or control in Mercy CarePlus.
The address for MPA is 101 S. Hanley, Suite 1250, Clayton, MO 63105.
Also, the attached documentation from the Missouri Department of Insurance dated
June 23, 2006 is included as an addition to Attachment 1 (reference the response
to 4.5.1).
Additionally, the response to section 4.4.2 e and the originally submitted
Attachment 10 is replaced with the Revised Attachment 10 attached hereto.
All other terms, conditions and provisions of the contract, including all
prices, shall remain the same and apply hereto.
The contractor shall sign and return this document, on or before the date
indicated, signifying acceptance of the amendment.

 

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Contract C306118003   Page 3

AGREEMENT AND CONSENT
TO ASSIGNMENT OF CONTRACT

         
ALLIANCE FOR COMMUNITY HEALTH
  Alliance for community Health    
dba COMMUNITY CAREPLUS
  dba : Mercy CarePlus    
10123 CORPORATE SQUARE DRIVE
       
ST LOUIS, MO 63132
 
 
       
 
       
(Assignor)
  (Assignee)    

RE:       Contract C306118003
The Assignor, as named above, assigns the contract in its entirety to the
Assignee, as named above.
The Assignee shall honor and comply with all terms and conditions, requirements
and specifications of the contract, and hereby entitles the State of Missouri to
performance by Assignee of all obligations under the contract. This assignment
does not entitle the Assignee to receive payment in any amount above that which
the Assignor would otherwise receive. In addition, the Assignee releases the
State of Missouri from all responsibilities for payment made previously to the
Assignor pursuant to the contract.
The Assignee agrees that any payments made by the State of Missouri pursuant to
the contract, including all payments assigned to the Assignee, shall be
contingent upon the performance of the Assignee in accordance with all terms and
conditions, requirements and specifications of the contract, and the approval
and acceptance of such performance by the State of Missouri.
This Agreement and Consent shall not be final until it is incorporated into the
subject contract by formal amendment subject to approval and acceptance by the
State of Missouri, Division of Purchasing and Materials Management.
IN WITNESS THEREOF, the parties hereto have executed this Agreement and Consent
on the date as stated below.

                      (ASSIGNOR)       (ASSIGNEE)                          
BY:
          BY:   /s/ Jerry Linder    
NAME:
 
 
      NAME:  
 
Jerry Linder    
 
                   
TITLE:
          TITLE:   CEO    
 
                   
DATE:
          DATE:   7/31/06    
 
                   
 
          FEIN:   43-1743902    

 

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(LOGO) [a38671a3867115.gif]
 
STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT AMENDMENT
  (LOGO) [a38671a3867117.gif]

     
AMENDMENT NO.: 002
  REQ NO.: NR 886 25757002046
CONTRACT NO.: C306118003
  BUYER: Laura Ortmeyer TITLE: Medicaid Managed Care — Central, Eastern, and
Western Regions   PHONE NO.: (573)751-4579
ISSUE DATE: 07/27/06
  E-MAIL: Laura.Ortmeyer@oa.mo.gov

TO: MERCY CARE PLUS
RETURN AMENDMENT NO LATER THAN: August 14, 2006 AT 5:00 PM CENTRAL TIME
RETURN AMENDMENT TO:

          (U.S. Mail)       (Courier Service)
Div of Purchasing & Matls Mgt (DPMM)
  OR   Div of Purchasing & Matls Mgt (DPMM)
PO BOX 809
      301 WEST HIGH STREET, ROOM 630
JEFFERSON CITY MO 65102-0809
      JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)
DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Service
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
SIGNATURE REQUIRED

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
   
MAILING ADDRESS
  IRS FORM 1099 MAILING ADDRESS
 
   
CITY, STATE, ZIP CODE
  CITY, STATE, ZIP CODE

     
CONTACT PERSON
  EMAIL ADDRESS
 
   
PHONE NUMBER
  FAX NUMBER

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)
 
  o FEIN      o SSN    

(VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)   (NOTE: LLC IS NOT A VALID TAX
FILING TYPE.)

o Corporation     o Individual     o State/Local Government     o
Partnership     o Sole Proprietor      o Other                    

     
AUTHORIZED SIGNATURE
  DATE
 
   
PRINTED NAME
  TITLE

 

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Contract C306118003 Page 2

AMENDMENT #002 TO CONTRACT C306118003

          
CONTRACT TITLE:
  Medicaid Managed Care — Central, Eastern, and Western Regions
 
   
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007

The State of Missouri hereby desires to amend the above-referenced contract, as
follows, effective July 1,2006:

  1.   Paragraph 2.4.9 is hereby amended as follows:

    2.4.9   The health plan shall maintain the fee schedule for office visit
services and dental services located in Attachment 14 at no lower than the
Medicaid fee-for-service fee schedule in effect at the time of service.

  2.   Paragraph 2.7.l 1. is hereby amended as follows:

    2.7.1 l.   Optical services include one comprehensive or one limited eye
examination every two years for refractive error, services related to trauma or
treatment of disease/medical condition (including eye prosthetics), and one pair
eyeglasses following cataract surgery.

  3.   Paragraphs 2.7.1 r. is hereby amended as follows:

    2.7.1 r.   Durable medical equipment limited to: prosthetic devices (with
the exception of artificial larynx), respiratory equipment and oxygen (with the
exception of CPAP, BiPAP, and nebulizers), wheelchairs (including accessories
and batteries), diabetic supplies and equipment, and ostomy supplies. Members
with Home Health Plan of Care receive all medically necessary durable medical
equipment services during the plan of care coverage period.

  4.   Paragraph 2.7.2 is hereby amended as follows:

    2.7.2   The health plan shall include all the services specified in the
comprehensive benefit package with the exception of non-emergency medical
transportation (NEMT) for uninsured children in ME Codes 71-75 (Refer to
Attachment 1, COA 5) and children in state custody with the following ME Codes
08, 52, 57, and 64 (Refer to Attachment 1, COA 4).

  5.   Paragraph 2.7.3 c is hereby amended as follows:

    2.7.3 c.   Optical services for children under age 21 include one
comprehensive or one limited eye examination per year for refractive error,
eyeglasses, and HCY/EPSDT optical screens and services. Optical services for
pregnant women age 21 and over with ME codes 18, 43, 44, 45, or 61 include one
comprehensive or one limited eye examination per year for refractive error.
Eyeglasses (except the one pair following cataract surgery covered by the health
plan) for these pregnant women are covered through the Fee for Service program.

  6.   Paragraph 2.7.3 e. is hereby amended as follows

    2.7.3 e.   Durable medical equipment (including but not limited to: orthotic
devices, artificial larynx, enteral and parenteral nutrition, walkers, CPAP,
BiPAP, and nebulizers);

  7.   Paragraph 2.12.7 is hereby amended as follows:

 

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Contract C306118003   Page 3

    2.12.7   Pharmacy Services: Pharmacy services (including physician
injections) not included in the health plan’s awarded proposal shall be
reimbursed by the state agency on a fee-for-service basis according to the terms
and conditions of the Medicaid program.

  8.   Attachment 3 is hereby revised.     9.   Attachment 6 is hereby revised.
    10.   Attachment 12 is hereby revised.     11.   Attachment 14 is hereby
revised.

The contractor shall indicate in Column 2 on the attached Pricing page, any
changes to the firm fixed prices of the contract for performing the required
services in accordance with the terms, conditions, and provisions of the
contract, including the above stated changes. The contractor’s firm, fixed PMPM
Net Capitation Rate for Each Category of Aid (COA) Rate subgroup must not exceed
the State’s Maximum Net Capitation Rate Listed in Column 1.
All other terms, conditions and provisions of the contract shall remain the same
and apply hereto.
The contractor shall sign and return this document, on or before the date
indicated, signifying acceptance of the amendment.

 

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REVISED ATTACHMENT 3
MANAGED CARE POLICIES GOVERNING MC+ SERVICES
The following are brief descriptions of the services included in the standard
benefit package and the various programs and policies governing the delivery of
services for the MC+ Managed Care Program, These policies follow the amount,
duration, and scope of services covered under the Missouri Medicaid State Plan.
For those services included in the MC+ Managed Care benefit package, the MC+
Managed Care health plan must offer, at a minimum, the amount, duration, and
scope of that service included in the Medicaid State Plan. The state agency
produces and up dates MC+ Managed Care policy statements governing the delivery
of services under MC+ managed care. The MC+ Managed Care health plan shall
comply with such policies governing the delivery of services and as amended by
the state agency. Detailed information regarding MC+ fee-for-service services is
contained in the fee-for-service provider manuals and bulletins, and the deluxe
pricing file.
ADULT DAY HEALTH CARE

Adult Day Health Care is a covered benefit for members.
Adult Day Health Care is a program of organized therapeutic, medical,
rehabilitative, and social activities provided outside of the home. MC-t+
fee-for-service eligible persons are assessed to be eligible for the program by
the Missouri Department of Health and Senior Services (DHSS). They must have
functional impairments requiring nursing home level of cafe, but with the
provision of this service and perhaps other supports, they may safely remain in
their home. Adult Day Health Care must be provided in a DHSS licensed facility
or be exempt from licensure by way of regulation.
AMBULATORY SURGICAL CENTERS (INCLUDING BIRTHING CENTERS)
Ambulatory Surgical Center services are a covered benefit. MC+ Managed Care
health plans may utilize Ambulatory Surgical Centers as an alternative to
outpatient hospital services. The Ambulatory Surgical Center provides a place
for operative procedures to be accomplished that can be safely performed in an
outpatient setting and be able to be completed within 90 minutes. This is the
maximum length of time that a person may be placed under anesthetic in an
Ambulatory Surgical Center.
Birthing Centers are also licensed as Ambulatory Surgical Centers and are
appropriate settings for the delivery of services provided by a physician,
advanced practice nurse, or certified nurse midwife. MC+ Managed Care health
plans are responsible for Birthing Center services.
ANESTHESIA SERVICES
Anesthesia services are a covered benefit. Anesthesia services are covered when
performed by an Anesthesiologist or Certified Registered Nurse Anesthetist
(CRNA). Medical direction of anesthetists by an anesthesiologist is also a
covered service.
CASE MANAGEMENT
Case management is a clinical system that focuses on the accountability of an
identified individual or group for coordinating a patient’s care (or group of
patients) across an episode or continuum of care; negotiating, procuring, and
coordinating services and resources needed by patients/families with complex
issues; insuring and facilitating the achievement of quality, clinical, and cost
outcomes; intervening at key points for individual patients; addressing and
resolving patterns of issues that have a negative quality cost impact; and
creating opportunities and systems to enhance outcomes. (Definition used with
permission of The Center for Case Management, 6 Pleasant Street, South Natick,
MA 01760.) Case management is understood as including, but not limited to the
development of individualized treatment plans and ongoing communication and
coordination with other systems of care. The treatment plans must be:

  •   Developed by the member’s primary care provider with member participation,
and in consultation with any specialists caring for the member;     •   Approved
by the MC+ Managed Care health plan in a timely manner, if this approval is
required; and     •   In accord with any applicable State quality assurance and
utilization review standards.

 

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MC+ Managed Care health plans shall provide case management to members with
special health care needs and maintain a detailed case management record on each
member. Members with special health care needs are those members who have
ongoing special conditions that require a course of treatment or regular care
monitoring. The Case Management MC+ Managed Care Policy Statement shall include
a list of diagnoses for children and adults that, at a minimum, the MC+ Managed
Care health plan shall use for identification of members with special health
care needs requiring case management and criteria for maintaining a detailed
case management record. The following groups of individuals are at high risk of
having a special health care need:

  •   Individuals eligible for Supplemental Security Income (SSI);     •  
Individuals in foster care or other out-of-home placement;     •   Individuals
receiving foster care or adoption subsidy; and     •   Individuals receiving
services through a family-centered community-based coordinated care system that
receives grant funds under Section 501(a)(l)(D) of Title V, as defined by the
state agency in terms of either program participant or special health care
needs.

At the time of enrollment, the MC+ Managed Care health plan shall perform an
initial health assessment of members with special health care needs and members
who are at high risk of having a special health care need and implement
appropriate case management based upon that assessment appropriate to the
member’s needs.
The MC+ Managed Care health plan shall be responsible for providing members with
special health care needs all services covered under the contract beginning with
the effective date of enrollment. All services authorized prior to enrollment in
an MC+ Managed Care health plan shall be terminated only after a case-specific,
clinical decision has been made by an MC- Managed Care health plan provider. The
MC+ Managed Care health plan shall have a mechanism in place to allow members
direct access to a specialist as appropriate for the member’s condition and
identified needs.
HCY CASE MANAGEMENT: MC+ Managed Care health plans are required to provide
medically necessary HCY case management services for members under the age of
21. Healthy Children and Youth (HCY) Case Management is an activity under which
responsibility for locating, coordinating, and monitoring necessary and
appropriate services for members under age 21, rests with an MC+ Managed Care
Health Plan or an organization or individual that the MC+ Managed Care Health
Plan has contracted with. HCY Case Management is the process of collecting
information on the health needs of the child, making (and following up on)
referrals as needed, maintaining a health history, activating the Early Periodic
Screening and Diagnostic Treatment (EPSDT) program and ensuring collaboration
between providers.
LEAD CASE MANAGEMENT: The MC+ Managed Care health plan is responsible for the
provision of lead case management for those children with elevated blood lead
levels. The MC+ Managed Care health plan must screen children for elevated blood
lead levels as part of the requirement for the EPSDT/HCY program. When a child
is identified with an elevated blood lead level, the MC+ Managed Care health
plan is responsible for providing medically necessary services including case
management for the child.
CASE MANAGEMENT — PREGNANT WOMEN
MC+ Managed Care health plans are required to provide prenatal case management
services for at risk pregnant women enrolled in their MC+ Managed Care health
plan. Based on the prenatal risk assessment, the case manager will formulate an
individualized plan of management designed to accomplish the intended
objectives.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
Children with special health care needs are likely to require the services of
the MC+ Managed Care health plan’s special programs coordinator. These children
may also be served by the Departments of Health and Senior Services, Mental
Health, or Elementary and Secondary Education in early intervention programs
(Individuals with Disabilities Education Act — Part C), school-based services,
etc.
Without services such as private duty nursing, personal care, home health,
durable medical equipment/supplies, and case management these children may
require hospitalization or institutionalization. Nursing homes are not usually
an option for children due to their intense needs as well as their age. Some
examples of children with

 

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special health care needs include: children with special needs due to physical
and/or mental illnesses, foster care children, homeless children, children with
serious and persistent mental illness and/or substance abuse, and children who
are disabled or chronically ill with developmental or physical disabilities. The
following information identifies some of the special health care needs of this
population.

  X   Requires vital functions to be sustained through unusual support such as
oxygen, respirator support, total parenteral nutrition, inhalation therapy, and
postural drainage.     X   Requires continuous nursing attention as the result
of a surgical or medical procedure such as tracheostomy, ileostomy, colostomy,
gastrostomy, nephrotomy, cast, or shunt.     X   Requires continuous maintenance
because of gavage feedings, frequent oral suctioning, elimination care, and
positioning needs.     X   Requires therapy such as physical, occupational,
and/or speech therapy to reach their greatest potential and to minimize
progression of disability as in children with cerebral palsy, rheumatoid
arthritis, and spinabifida.     X   Require continuous medical monitoring of
underlying disease and its therapy.     X   Requires monitoring of indicators of
vital functions such as heart rate, respiration, blood sugar, oxygen levels,
blood pressure, and urine output.     X   Requires assistance in bathing,
toileting, eating, or other activities of daily living because of a medical
condition.

COMPREHENSIVE DAY REHABILITATION
Comprehensive Day Rehabilitation services are a covered benefit for children
under the age of 21 and pregnant women with ME codes 18, 43, 44, 45, and 61.
Coverage for comprehensive day rehabilitation services is required for certain
persons with disabling impairments as the result of a traumatic head injury.
Comprehensive day rehabilitation services are services beginning early post
trauma as part of a coordinated system of care. Rehabilitation services must be
based on an individualized, goal-oriented, comprehensive and coordinated
treatment plan. The treatment plan must be developed, implemented, and monitored
through an interdisciplinary assessment designed to restore an individual to
optimal level of physical, cognitive, and behavioral function (See RSMo
208.152). MC+ Managed Care health plans are responsible for providing
rehabilitation services to survivors of a Traumatic Brain Injury (TBI).
DENTAL
All MC+ Managed Care members receive dental care related to trauma to the mouth,
jaw, teeth or other contiguous sites as a result of injury. Adults age 21 and
over receive treatment of a disease/medical condition without which the health
of the recipient would be adversely affected through the fee for service
program. Medically necessary covered dental services provided by a dentist,
doctor of medicine, osteopathy or dentistry are the responsibility of the MC+
Managed Care health plan. Medications prescribed by a dentist for MC+ Managed
Care health plan members are the responsibility of the MC+ Managed Care health
plan. The MC+ Managed Care health plan is not responsible for dental services
which are exclusively for cosmetic reasons.
DENTAL — CHILDREN UNDER AGE 21
Dental screens, dental services, and orthodontic services are covered for
members under age 21.
It is recommended that preventive dental services and oral treatment for
children begin at age 6-12 months and be repeated every six months or as
medically indicated.
DENTAL — PREGNANT WOMEN AGE 21 AND OVER WITH ME CODES 18, 43, 44, 45, AND 61:
Dental services for pregnant women age 21 and over with ME codes 18, 43, 44, 45,
and 61 shall be limited to dentures and services related to trauma to the mouth,
jaw, teeth or other contiguous sites as a result of injury. Services to prepare
the mouth for dentures, such as examinations, X-rays, or extractions will not be
covered by the health plan. Ancillary denture services such as relining,
rebasing, and repairs will not be covered by the health plan. All other Medicaid
State Plan dental services for this population is covered through the fee for
service program and is not the responsibility of the MC+ Managed Care health
plan.

 

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DIABETES SELF-MANAGEMENT TRAINING
Coverage of self management training must be provided to all children under age
21 and pregnant women in ME Codes 18, 43, 44, 45, and 61 used in the management
and treatment of gestational, Type I, and Type II diabetes as prescribed by a
health care provider licensed by law to prescribe such services.
DURABLE MEDICAL EQUIPMENT (DME)
MC+ Managed Care health plans are required to provide medically necessary DME
items to children under the age of 21, pregnant women with ME codes 18,43, 44,
45, and 61, and members with a Home Health Plan of Care. MC+ Managed Care health
plans are required to provide limited medically necessary DME items to all other
MC+ Managed Care members.
CHILDREN UNDER THE AGE OF 21 AND PREGNANT WOMEN WITH ME CODES 18, 43, 44, 45,
AND 61 AND THOSE WITH A HOME HEALTH PLAN OF CARE REGARDLESS OF AGE: Medically
necessary equipment such as hospital beds, walkers, commodes, decubitus care
equipment, hoyer lifts, augmentative communication devices when prior authorized
by the MC+ Managed Care health plan, trapeze equipment, canes, and crutches,
etc. will be provided to children under the age of 21 and pregnant women with ME
codes 18, 43, 44, 45, and 61 and those with a home health plan of care
regardless of age. The recipient must be MC+ eligible on the date the equipment
is delivered or dispensed. Equipment that is purchased becomes the property of
the recipient. Those with a home health plan of care receive covered DME items
during the plan of care coverage period.
In addition to the above-mentioned DME items, the MC+ Managed Care health plans
are required to provide the following:

  X   HCY DME items and services to members under the age of 21. This includes
medically necessary items such as diapers, medical supplies, enteral nutrition,
PKU nutrition, and positioning equipment. MC+ Managed Care health plans must
arrange for continuation of coverage of HCY equipment and supplies presently
being reimbursed under the HCY program.     X   All medically necessary Total
Parenteral Nutrition (TPN) items and services. This includes TPN pumps,
nutritional solutions, and supplies.     X   All medically necessary non-sterile
ostomy supplies.     X   All medically necessary orthotic and prosthetic
devices.     X   All medically necessary diabetic supplies and equipment.     X
  All medically necessary oxygen and respiratory equipment. This includes oxygen
and oxygen delivery systems, ventilators, nebulizers, Apnea monitors, suction
pumps, etc. A summary of oxygen and respiratory equipment benefits and
limitations may be found in the MC+ Durable Medical Equipment Policy Statement.
    X   Augmentative communication evaluations, devices, and training. Medically
necessary communication devices prescribed as a result of the augmentative
evaluation are covered as a Durable Medical Equipment (DME) benefit when the
augmentative communication device is prior authorized by the MC+ Managed Care
health plan.

LIMITED DURABLE MEDICAL EQUIPMENT FOR MC+ MANAGED CARE ELIGIBLE INDIVIDUALS WHO
ARE NOT CHILDREN UNDER THE AGE OF 21. PREGNANT WOMEN WITH ME CODES 18, 43, 44,
45, AND 61, OR THOSE WITH A HOME HEALTH PLAN OF CARE INCLUDES:

  •   Diabetic supplies and equipment (insulin and needles are considered
Pharmaceuticals),     •   Manual and power wheelchairs including wheelchair
accessories and batteries,     •   Prosthetic devices (artificial larynx is not
covered),     •   Respiratory equipment and oxygen. (Nebulizers, CPAP and BiPAP
are not covered services unless medical necessity is determined through the MC+
Managed Care health plan’s exception process. If services are currently
authorized, the MC+ Managed Care health plan may only discontinue or reduce
these services after a determination of medical necessity is made through the
MC+ Managed Care health plan’s exception process.)     •   Ostomy supplies.

 

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EPSDT/HCY
The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MC+
fee-for-service provide medically necessary services to children from birth
through age 20 which are necessary to treat or ameliorate detects, physical or
mental illness, or conditions identified by an Early Periodic Screening,
Diagnosis, and Treatment (EPSDT) well child visit (screen) regardless of whether
or not the services are covered under the MC+ fee-for-service state plan. This
program is referred to nationally as the EPSDT Program. In Missouri this program
is referred to as the Healthy Children and Youth (HCY) Program. Services must be
sufficient in amount, duration, and scope to reasonably achieve their purpose
and may only be limited by medical necessity. The MG+ Managed Care health plans
are responsible for providing EPSDT/HCY services for all members. If a problem
is detected during a well child visit (screening examination), the child must be
evaluated as necessary for further diagnosis and treatment services. The MC+
Managed Care health plan is responsible for the treatment services.
EPSDT/HCY WELL CHILD (SCREENING) SERVICES: MC+ Managed Care health plans are
responsible for ensuring that HCY well child visits (screens) are performed on
all members under the age of 21. Missouri has adopted the American Academy of
Pediatrics’ (AAP) Schedule for Preventive Pediatric Health Care as a minimum
standard for frequency of providing full HCY well child visits. Immunizations
are recommended in accordance with the Advisory Committee on Immunization
Practices (ACIP) guidelines. MC+ Managed Care health plans are required to keep
immunizations and well child visits current according to schedules as specified
by the state agency. The current schedules are as follows:
Children should receive HCY/EPSDT well child visits regularly, at the ages
listed below.

         
o Newborn
  o 15-17 months   o 8-9 years
o By age one month
  o 18-23 months   o 10-11 years
o 2-3 months
  o 24 months   o 12-13 years
o 4-5 months
  o 3 years   o 14-15 years
o 6-8 months
  o 4 years   o 16-17 years
o 9-11 months
  o 5 years   o 18-19 years
o 12- 14 months
  o 6-7 years   o 20 years

EPSDT/HCY LEAD SCREENING SERVICES: All children from 6 to 72 months of age are
considered at risk and must be assessed for lead poisoning. A verbal risk
assessment must be completed at each HCY visit and if at high risk, the child
must have a blood lead test. A blood lead test is required at 12 and 24 months,
regardless of risk or annually if residing in a high-risk area of Missouri as
defined by Department of Health and Senior Services regulation 19 CSR 20-8.030.
The Division of Medical Services requires the use of the Lead Screening Guide
(MO 886-2998) when providing services to MC+ eligible children.
Childhood Immunization Schedule: Children should receive childhood immunizations
regularly, at the ages listed on the Recommended Childhood Immunization
Schedule, as a mended. The current schedule appears in the Missouri Medicaid
Provider Manuals that may be found on the Internet at the Division of Medical
Services website, http://www.medicaid.state.irio.us/indexl.html (Look under
Missouri Medicaid Provider Manuals, List of Forms, Recommended Childhood
Immunization Schedule.)
FAMILY PLANNING/STERILIZATIONS
Family planning services are a covered benefit. MC+ Managed Care health plans
are required to provide freedom of choice for family planning and reproductive
health services which may be accessed out-of-network. Examples of reproductive
health services are: contraception management, insertion of Norplant,
intrauterine devices, Depo-Provera injections, pap test, pelvic exams, sexually
transmitted disease testing, and family planning counseling/education on various
methods of birth control. For family planning purposes, sterilizations shall
only be those elective sterilization procedures performed for the purpose of
rendering an individual permanently incapable of reproducing and must always be
reported as family planning services in accordance with mandated federal
regulations 42 CFR 441.250-441.259.

 

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HEARING AID - Limited to Children under the age of 21 and Pregnant Women with ME
codes 18, 43, 44, 45, and 61
MC+ Managed Care health plans are required to provide medically necessary
hearing aids and related services. This includes medically necessary audiometric
and hearing aid services for all MC+ Managed Care members under the age of 21
including but not limited to hearing aid batteries, FM system, diagnostic
testing, post cochlear implant training, aural habilitation, auditory trainers,
etc.
HOME HEALTH
MC+ Managed Care health plans are responsible for covering medically necessary,
physician ordered home health benefits. M C+ Managed C are health plans shall
not terminate such services without a case-specific, clinical decision made by a
provider. Home health services provide primarily medically oriented treatment or
supervision to members with an acute illness, or an exacerbation of a chronic or
long term illness which can be therapeutically managed at home. The delivered
care should follow a written plan of treatment established and periodically
reviewed by a physician.
The home health program is divided into two distinct segments based on the age
of the member. Members who are 21 years of age and older are defined as adults
within the home health program. Members 20 and under are classified as children
and are eligible to receive expanded home health services as part of the EPSDT
federal mandate. Services include skilled nursing, aide visits, psychiatric
nursing, physical, occupational, and speech therapy and supplies.
HOSPICE
MC+ Managed Care health plans are required to provide hospice services when a
terminally ill member elects those services. The hospice benefit is designed to
meet the needs of members with life-limiting illnesses and to help their
families cope with related problems and feelings. To be eligible to elect
hospice care, members must be certified by a physician as being terminally ill
with a life expectancy of six months or less. Hospice care cannot be prescribed
or ordered by a physician. The member must elect hospice care and agree to seek
only palliative care for the duration of the hospice election.
HYSTERECTOMY SERVICES
In order to be in compliance with 42 CFR 441.256, the MC+ Managed Care health
plan must require a completed copy of the “Acknowledgement of Receipt of
Hysterectomy Information” form from the performing provider. The MC+ Managed
Care health plan must assure that the “Acknowledgement of Receipt of
Hysterectomy Information” form meets all of the criteria required by HCFA in 42
CFR 441.250 through 441.259.
INPATIENT/OUTPATIENT HOSPITAL including MENTAL HEALTH
Inpatient hospitalization and outpatient services for physical health needs are
the responsibility of the MC+ Managed Care health plan for all members, based on
medical necessity. This includes charges for the pretransplant and post
discharge follow-up for transplant recipients (see Transplants).
MATERNITY PRE-NATAL CARE AND DELIVERY
MC+ Managed Care health plans are required to cover maternity pre-natal care and
delivery.
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
MC+ Managed Care health plans are responsible for all medically necessary mental
health and substance abuse services available in the fee-for-service program for
members. Mental health and substance abuse services shall include court ordered,
96 hour detentions and involuntary commitments. Mental health and substance
abuse services may be provided by an acute care hospital (for a psychiatric
stay), private or state psychiatric hospital, community mental health or
substance abuse treatment program certified or licensed by the joint commission,
Commission for Accreditation of Rehabilitation Facilities (CARF), or the
Missouri Department of Mental Health including qualified mental health
professionals, licensed and provisionally licensed psychologists, licensed and
provisionally licensed clinical social workers, licensed and provisionally
licensed professional counselors, psychiatrist, psychiatric advance practice
nurse or home health psychiatric nurse.
Mental health and substance abuse services (including inpatient and outpatient)
for children in Category of Aid 4 (primarily children in state custody) are not
the financial responsibility of the MC+ Managed Care health plan and

 

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will be reimbursed to MC+ fee-for-service enrolled providers on a
fee-for-service basis. For inpatients with dual diagnoses (physical and mental)
identified at admission or during the stay, the MC+ Managed Care health plans
will be financially responsible for all inpatient hospital days if the primary,
secondary, or tertiary diagnosis is a combination of physical and mental health.
OPTICAL
MC+ Managed Care health plans are required to provide medically necessary
optical services for members as described herein.
Optical services include one comprehensive or one limited eye examination every
two years for refractive error, services related to trauma or treatment of
disease/medical condition (including eye prosthetics), and one pair eyeglasses
following cataract surgery. Additionally:

§   Children under age 21 services include one comprehensive or one limited eye
examination per year for refractive error, eyeglasses, HCY/EPSDT optical screens
and services.   §   Pregnant women age 21 and over with ME codes 18, 43, 44, 45,
and 61 services include one comprehensive or one limited eye examination per
year for refractive error. Eyeglasses (except the one pair following cataract
surgery covered by the health plan) for these pregnant women are covered through
the Fee for Service program.

When it is medically necessary for an optical procedure to be performed in an
inpatient or outpatient hospital facility, emergency room, or ambulatory
surgical center, the facility charges and ancillary services associated with the
optical procedure are the responsibility of the MC+ Managed Care health plan.
If the MC+ Managed Care health plan approves optical items which are delivered
or placed after enrollment in the MC+ Managed Care health plan ends, the MC+
Managed Care health plan that approves the optical item(s) is responsible for
payment.
PERSONAL CARE
Personal care services are covered benefits for all members. Personal care
services are medically oriented tasks that may be reviewed by a physician.
Personal care services are not physician driven. Personal care services are
tasks which assist an individual in activities of daily living due to a stable,
chronic condition. Personal care services are provided as a cost effective
alternative to nursing home placement.
Basic personal care services are services related to an MC+ enrollee’s physical
requirements, such as assistance with eating, bathing, dressing, personal
hygiene, and activities of daily living. They also include services essential to
the health and welfare of the MC+ enrollee, such as housekeeping chores like
preparing meals, bedmaking, dusting, and vacuuming.
Advanced personal care tasks are maintenance services provided to assist MC+
enrollees with stable, chronic conditions when such assistance requires devices
and procedures related to altered body functions.
Nurse visits provided by an RN or LPN in the personal care program are
authorized to provide increased supervision of the aid, assessment of the MC+
enrollee’s health and the suitability of the care plan to meet the patient’s
needs as well as referral and/or follow-up action. In addition, nurse visits may
be authorized for skilled tasks that must be performed by a nurse, such as
filling insulin syringes, setting up oral medications, monitoring skin
conditions, providing nail care for diabetic patients, etc.
If personal care services have been authorized prior to a member enrolling in an
MC+ Managed Care health plan, the MC+ Managed Care health plan may only
discontinue or reduce these services based on an assessment performed by the
Department of Health and Senior Services.
PERSONAL CARE (HCY): Children, ages 0 through 20, are determined to be in need
of personal care by medical necessity. Personal care needs (including advanced
personal care needs) for children are demonstrated by

 

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their need for extra assistance in bathing, toileting, eating, or other
activities of daily living because of a medical condition. The fact that a child
has a caretaker does not make him or her ineligible for personal care services.
The primary caretaker may not be present to deliver the required services or may
lack the time or ability to deliver the essential care. A family member may not
be reimbursed for the delivery of personal care services.
PHARMACY
MC+ Managed Care health plans are required to provide pharmacy services if the
health plan included pharmacy benefits in its proposal. Under the current
Missouri MC+ Fee-For-Service Pharmacy Program, nearly all products of
manufacturers participating in the national rebate program are reimbursable,
including many over-the-counter preparations. Insulin syringes are also
reimbursable under this program.
Some products have been excluded from coverage under the current Missouri MC+
Fee-For-Service Pharmacy Program. MC+ Managed Care health plans may elect to
exclude these, but may not exclude from coverage any product not excluded from
the current Fee-For-Service Pharmacy Program (see the MC+ Pharmacy Policy
Statement for a list of products excluded from coverage). Protease inhibitors
will be reimbursed by the state agency on a fee-for-service basis.
It is not essential that MC+ Managed Care health plans cover pharmaceutical
products without restriction to the same extent that current fee-for-service
policy dictates. However, any product that is reimbursable by the current
Fee-For-Service Pharmacy Program must be made available to members, regardless
of whether or not the prescriber is in the MC+ Managed Care health plan’s
network. MC+ Managed Care health plans may elect to have a restricted formulary;
however, products not included on that formulary that are covered or allowed
through prior authorization by the current Fee-For-Service Pharmacy Program must
be made available to members when medically necessary. MC+ Managed Care health
plans may also require that prior authorization be obtained for prescriptions
generated by an out-of-network prescriber. MC+ Managed Care health plans may
have a more extensive list of products requiring prior authorization, but MC+
Managed Care health plans may not exclude from coverage any products not
excluded under the current Fee-For-Service Pharmacy Program.
It is acceptable for MC+ Managed Care health plans to implement a drug
authorization program in order to provide this access. Any drug prior
authorization program implemented by an MC+ Managed Care health plan must meet
the following criteria:

  X   MC+ Managed Care health plans must provide response by telephone or other
telecommunication device within 24 hours of a request for prior authorization.  
  X   MC+ Managed Care health plans must provide for the dispensing of at least
a 72-hour supply of a drug product that requires prior authorization in an
emergency situation.     X   Approvals must be granted for any medically
accepted use. Medically accepted use is defined as any use for an FDA approved
drug product which appears in peer-reviewed literature or which is accepted by
one or more of the following compendia: the American Hospital Formulary Service
— Drug Information and the United States Pharmacopeia — Drug Information and
DRUGDEX.

In addition, MC+ Managed Care health plans must have a mechanism whereby drugs
can be prior-authorized if a member is out of the MC+ Managed Care health plans’
service area and during the time lag between the date of a members’ effective
enrollment and that members’ assignment to a primary care provider.
PHARMACY DISPENSING FEES: The recipient portion of the pharmacy dispensing fee
is to be collected according to current fee-for-service policy. Unlike
traditional copayment requirements, the current Fee-For-Service Pharmacy fee
requirement is considered a portion of the professional dispensing fee and is
not deducted from reimbursement to providers. Therefore, the recipient portion
of the dispensing fees is required to be collected for pharmacy services
provided by MC+ Managed Care health plans. Providers of service may not deny or
reduce services to MC+ members solely on the basis of the member’s inability to
pay the fee when charged, A member’s inability to pay a required amount as due
and charged when a service is delivered, shall in no way extinguish the member’s
liability to pay the amount due. Fee responsibility and amounts collectible
shall be as follows:

 

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      MC+ Fee-For-Service Maximum Allowable   Beneficiary Participation in
Professional Ingredient Cost for Each Prescription   Dispensing Fee $10.00 or
less   $0.50 $10.01 to $25.00   $1.00 $25.01 or greater   $2.00

Under the current pharmacy dispensing fee policy all Missouri eligible
beneficiaries are subject to the fee requirement when provided covered pharmacy
services, with the exception of the following which are excluded:

  X   Beneficiaries under age 19;     X   Services related to Early Periodic
Screening, Diagnosis and Treatment (EPSDT);     X   Institutionalized
beneficiaries who are residing in a skilled nursing facility, a psychiatric
hospital, a residential care facility, or an adult boarding home;     X   Foster
Care children up to 21 years of age;     X   All Medicare/MC+ Fee-For-Service
crossover claims as primary coverage is afforded by the Medicare Program;     X
  Those services specifically identified as relating to Family Planning
services;     X   Emergency services; and     X   Services provided to pregnant
women which are directly related to the pregnancy or a complication of the
pregnancy.

Participation in each MC+ Managed Care health plan’s pharmacy network shall be
limited to providers who accept, as payment in full, the amounts paid by the MC+
Managed Care health plan plus any fee amount required of the member and
collected by the provider.
PHARMACY — GENERIC DRUG REIMBURSEMENT OVERRIDE POLICY: The current MC+
Fee-For-Service Pharmacy Program reimbursement methodology limits payment at a
generic level for many drugs that are available generically from multiple
sources. The majority of these reimbursement limitations are established as
federal upper limits by the Centers for Medicare and Medicaid Services (CMS).
Other such limitations have been established by the state agency (Missouri
Maximum Allowable Cost or MAC).
Both CMS and the Missouri Division of Medical Services recognize that there are
situations in which trade name products are necessary for patient’s treatment.
There is currently a generic reimbursement override procedure. If the MC+
Managed Care health plan intends to implement similar generic reimbursement
limitations on multiple source products, a mechanism must exist so that trade
name reimbursement is available when it is medically necessary. This mechanism
may not be more restrictive than current fee-for-service policy.
PHYSICIAN INJECTIONS: Under the current Fee-For-Service Pharmacy Program, all
FDA approved injectable products are reimbursable when billed by National Drug
Code (NDC) on a pharmacy claim form by a private physician for administration in
his/her office. MC+ Managed Care health plans are required to provide pharmacy
services (including physician injections) if the health plan included pharmacy
benefits in it’s proposal. In addition, certain non-injectable products are also
reimbursable when billed by a private physician. These products include Norplant
and irrigation solutions. Every product that is reimbursable by the current
Fee-For-Service Pharmacy Program either without restriction or through prior
authorization, must be covered by the MC+ Managed Care health plans either
without restriction or through prior authorization except for protease
inhibitors which are excluded from MC+ Managed Care. However, it is not
essential that health plans cover injectable pharmaceutical products without
restriction to the same extent that current policy dictates. Coverage must be
granted for any medically accepted use.
PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY FOR ADULT PREGNANT WOMEN WITH ME CODES
18, 43,44, 45, AND 61
MC+ Managed Care health plans are required to provide physical therapy (PT),
occupational therapy (OT), and speech therapy (ST) services for adult pregnant
women with ME codes 18, 43, 44, 45, and 61 as follows.

 

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Medically necessary physical therapy (PT) benefits are covered in the outpatient
hospital setting and as part of home health when the patient is medically
homebound. PT is covered in a rehabilitation center if the services are for
adaptive training for a prosthetic or orthotic device.
Occupational therapy (OT) is covered in a rehabilitation center for adaptive
training for a prosthetic or orthotic device. Medically necessary OT is covered
as part of home health if the patient is medically homebound.
Speech therapy (ST) is covered in a rehabilitation center for adaptive training
for an artificial larynx. Medically necessary ST is covered in as part of home
health if the patient is medically homebound.
PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY (HCY)
MC+ Managed Care health plans are required to provide medically necessary
physical (PT), occupational (OT), and speech (ST) therapy and supplies used for
casting and splinting to children age 20 and under. Physical, occupational, and
speech therapy services identified in a child’s Individual Education Plan
(IEP) or Individualized Family Service Plan (IFSP) will not be the
responsibility of the MC+ Managed Care health plan. These services will be paid
fee-for-service by the state agency. Medically necessary PT, OT, and ST services
beyond the scope identified in a child’s IEP or IFSP are the responsibility of
the MC+ Managed Care health plan. This includes developmental as well as
maintenance therapy.
Medically necessary equipment and supplies used in connection with PT, OT, and
ST services are the responsibility of the MC+ Managed Care health plan.
PHYSICIAN/ADVANCED PRACTICE NURSE SERVICES
MC+ Managed Care health plans are required to provide medically necessary
physician/advanced practice nurse services within their scope of practice.
FEDERALLY QUALIFIED HEALTH CENTER (PQHC): Federally Qualified Health Center
(FQHC) services are the responsibility of the MC+ Managed Care health plans.
FQHC core services that must be performed in an FQHC setting are listed in
Attachment 2. To receive FQHC provider status, a health center must be certified
by the Public Health Services, be certified for participation in MC+
Fee-For-Service and enrolled with Missouri MC+ Fee-For-Service as an FQHC. FQHCs
are entitled to cost-based reimbursement from the state agency for FQHC services
provided to MC+ enrollees. The cost settlement will be performed by the state
agency through an FQHC MC+ Fee-For-Service cost report.
PODIATRY SERVICES
MC+ Managed Care health plans are required to provide medically necessary
podiatry services that are within the scope of practice of the podiatrist for
children under the age of 21 or pregnant women with ME codes 18, 43, 44, 45, and
61. All other MC+ Managed Care enrollees are eligible for podiatry services with
the exception of trimming of nondystrophic nails, any number; debridement of
nail(s) by any method(s), one to five; debridement of nail(s) by any method(s),
six or more; excision of nail and nail matrix, partial or complete; and
strapping of ankle and/or foot.
PRIVATE DUTY NURSING (HCY)
Private Duty Nursing services are covered under the Healthy Children and Youth
(HCY) program. The HCY program serves children age 20 and under. Private duty
nursing is shift care delivered either by an R.N. or an L.P.N acting within the
scope of the Missouri Nurse Practice Act according to an individualized plan of
care approved by a physician. The duration of care can extend up to twenty-four
(24) hours per day. The duration and frequency of care is dependent upon the
child’s need and physician orders. Children receiving private duty nursing care
are high risk children that are medically fragile. The MC+ Managed Care health
plans shall only terminate such services after a case-specific, clinical
decision has been reached by a provider.
RADIOLOGY AND LABORATORY SERVICES
MC+ Managed Care health plans are required to provide medically necessary
radiology and laboratory services. The MC+ Managed Care health plan must assure
that the criteria required by CMS defined under the CLIA Act of 1988 as defined
in 42 CFR 493.2 and Section 2303 of the Deficit Reduction Act of 1984 (P.L.
98-369) for Clinical Diagnostic Laboratory Procedures are met.

 

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TRANSPLANTS
MC+ Managed Care health plans are responsible for the pre-surgery
assessment/evaluation, care (excluding the solid organ procurement or bone
marrow/stem cell harvest), post-transplant discharge follow-up care, and
immuno-suppressive pharmacy products prescribed after the inpatient transplant
discharge.
The transplant must be prior authorized by the Division of Medical Services
(DMS) and must be performed at a DMS approved transplant facility. DMS will
continue to cover the solid organ/stem cell/bone marrow procurement costs, the
inpatient stay for the transplant from the date of the transplant through the
date of discharge and the transplant surgeon’s fee, all physician, lab etc.
charges incurred during the transplant stay (date of transplant through the date
of discharge).
TRANSPORTATION
The MC+ Managed Care health plan must provide emergency (ground or air) medical
transportation.
The MC+ Managed Care health plan must provide necessary non-emergency medical
transportation (NEMT) for members accessing health care services included in the
comprehensive benefit package as well as health care services that are carved
out of the MC+ Managed Care contract. The MC+ Managed Care health plan must
arrange the least expensive and most appropriate mode of transportation based on
the MC+ Managed Care member’s medical needs.
MC+ Managed Care health plans are not required to provide transportation to MC+
Managed Care members with access to free transportation at no cost to them,
however, such members may be eligible for ancillary services. Also, MC+ Managed
Care health plans are not required to provide NEMT services to Durable Medical
Equipment providers that provide free delivery or mail order services nor to a
pharmacy.
An offer of transportation assistance must be made to all children prior to
periodic screenings required under EPSDT/HCY. Parents/guardians must be informed
of this transportation benefit.
NEMT services are not covered for those MC+ enrollees with ME Codes 71 through
75.
VACCINE FOR CHILDREN (VFC)
VFC services are a covered benefit. Under the provision of the Omnibus Budget
Reconciliation Act (OBRA) of 1993, vaccines are available free to providers who
enroll with the VFC Program. MC+ Managed Care health plans and their
subcontractors must enroll in the VFC Program administered by the Missouri
Department of Health and Senior Services and must use the free vaccines when
administering vaccines to members. A separate administration fee will not be
paid to the MC+ Managed Care health plans as the reimbursement is included in
the capitation payment. If a vaccine is medically necessary and not covered
through the VFC program, the MC+ Managed Care health plan is responsible for the
vaccine and the administration costs.

 

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Revised Attachment 6
The following is the state agency’s Quality Improvement (QI) Strategy. The state
agency produces and updates the MC+ Managed Care Quality Improvement
(QI) Strategy, MC+ Managed Care contract and the MC+ Managed Care policy
statements. The MC+ Managed Care health plan shall comply with the Quality
Improvement (QI) Strategy, MC+ Managed Care policy statements and the MC+
Managed Care contract.
MISSOURI DEPARTMENT OF SOCIAL SERVICES
DIVISION OF MEDICAL SERVICES
QUALITY IMPROVEMENT
(Q I) STRATEGY
1. DEPARTMENT OF SOCIAL SERVICES MISSION STATEMENT
To maintain or improve the quality of life for people in the state of Missouri
by providing the best possible services to the public, with respect,
responsiveness and accountability which will enable individuals and families to
better fulfill their potential.
Purpose
The Department of Social Services (DSS), Division of Medical Services
(DMS) seeks to assure access and availability of quality health care services
for MC+ Managed Care members through a Managed Care delivery system, standards
setting and enforcement, and education of providers and members. This QI
strategy supports the following DMS objectives:

  o   Assessment of the quality and appropriateness of care and services
furnished to members,including those with special health care needs, centered on
evidenced based practice;     o   Use of care management with emphasis on the
individual member to ensure that members have a medical home which focuses
attention on the wellness of the member and includes personal responsibility and
investment on the part of the member;     o   Use of data regarding the race,
ethnicity, and primary language spoken of each member to improve care delivery;
    o   Use of national performance measures and levels when identified and
developed by CMS in consultation with states and other relevant stakeholders;  
  o   An effective information system that supports initial and ongoing
operation and review of the quality strategy;     o   A process for public input
that provides for the integration of various perspectives and priorities and
will facilitate improvements in member health status;     o   Appropriate use of
sanctions, including intermediate sanctions, to assure appropriate delivery of
care to members; and     o   Compliance with regulatory and contractual
requirements.

 

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Goal
The goal is to ensure that:

  o   Quality health care services are provided to MO Managed Care members;    
o   MC+ Managed Care health plans are in compliance with Federal, State, and
contract requirements; and     o   A collaborative process is maintained to
collegially work with the MC+ Managed Care health plans to improve care.

Overview
This strategy will be annually evaluated for effectiveness. This process
includes obtaining input from stakeholders, the State Quality Assessment &
Improvement Advisory Group, Consumer Advisory Committee, and approval from CMS
prior to implementation. In the instance there is significant change in outcome
or indicator status that is not self-limiting and impacts on more than one area
of the population’s health status, modifications will be made to the strategy
reporting process. These modifications may include changes to the monthly,
quarterly and annual MC+ Managed Care health plan reports, on-site review
topics, and MC+ Managed Care performance measures.
Each MC+ Managed Care health plan must meet program standards for monitoring and
evaluation of systems as outlined in the MC+Managed Care contract to meet
Federal and State regulations. Each MC+ Managed Care health plan must implement
a QI strategy that addresses the standards as noted but is not limited to the
requirements within the MC+ Managed Care Quality Improvement (QI) Strategy or
the MC+ Managed Care contract. The MC+ Managed Care health plan’s strategy shall
include components to monitor, evaluate, and implement the contract standards
and processes to improve:

  o   Quality management;     o   Utilization management;     o   Records
management;     o   Information management;     o   Care management;     o  
Member services;     o   Provider services;     o   Organizational structure;  
  o   Credentialing;     o   Network Performance;     o   Fraud and abuse
detection and prevention;     o   Access and availability; and     o   Data
collection, analysis and reporting.

1.1 Program Components
I. MC+ Managed Care Health Plans Reports of Quality Assessment and Improvement
The MC+ Managed Care health plans will provide the DMS with regular reports of
utilization and quality assessment. These reports will be provided in accordance
with the:

  o   MC+ Managed Care Policy Statements;     o   MC+ Managed Care contract;    
o   MC+ Managed Care Performance Measures (Exhibit 1); and     o   MC+ Managed
Care QA & I Program, Reporting Period Schedule, (Exhibit 2).

The frequency and types of reports include:

 

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  A.   Monthly Reports: Monthly reports regarding special needs and lead
poisoning prevention will be submitted to DMS in a format specified by the state
agency. Monthly reports will be due the last working day of each month.     B.  
Quarterly Reports: Quarterly reports of member grievances and appeals, provider
complaints, grievances, and appeals, and fraud and abuse detection will be
submitted to DMS in a format specified by the state agency.     C.   Annual
Evaluation: An annual evaluation of the MC+ Managed Care health plan’s quality
assessment and improvement program specific to the Missouri MC+ Managed Care
Program is to be submitted in the format specified by the state agency
(Exhibit 4). The evaluation shall contain information concerning the
effectiveness and impact of the health plan’s MC+ Managed Care quality
assessment and improvement strategy. The annual evaluation report must provide
information that indicates that data is collected, analyzed and reported, and
health operations are in compliance with State, federal and MC+ Managed Care
contractual requirements. The annual evaluation of the health plan’s QA &I
program must incorporate multiple year outcomes and trends. The evaluation must
show the health plan’s QA & I program is ongoing, continuous and based upon
evaluation of past outcomes. The evaluation will, at a minimum, contain
information from subcontractors and internal processes including:

  a.   An analysis and evaluation of member grievances and appeals and provider
complaints, grievances and appeals;     b.   An analysis and evaluation of how
the health plan incorporates race, ethnicity, and primary language into the
health plan’s quality strategy. The DSS asks each potential enrollee their race,
ethnicity and primary language at the time of application in accordance with
Medicaid eligibility rules. DSS uses the federally recognized categories for
race, ethnicity and language. The state agency shall electronically provide
race, ethnicity and language to the health plan upon member enrollment.     c.  
An analysis and evaluation of utilization and clinical performance data that
supports use of evidenced based practice;     d.   An analysis and evaluation of
24 access/after hours availability, appointment availability and open/closed
panels;     e.   An analysis and evaluation of the MC+ Managed Care health
plan’s provider network including provider/enrollee ratios;     f.   An analysis
and evaluation of all MC+ Managed Care quality indicators:

  1.   Trends in Missouri Medicaid Quality Indicators provided by the Department
of Health and Senior Services (DHSS) (Exhibit 3);     2.   HEDIS Indicators by
Missouri MC+ Managed Care Health Plans Within Regions, Live Births provided by
the Department of Health and Senior Services (DHSS) (Exhibit 3); and     3.  
MC+ Managed Care Performance Measures (Exhibit 1).

  h.   An analysis and evaluation of quality is sues and actions identified
through the quality strategy and how these efforts were used to improve systems
of care and health outcomes;     i.   An analysis and evaluation of action items
documented in the meeting minutes of the MC+ Managed Care health plan’s quality
and compliance committee(s) including:

  1.   Trends identified for focused study; results of focused studies;
corrective action taken; evaluation of the effectiveness of the actions and
outcomes.

  j.   An analysis and evaluation of Performance Improvement Projects (PIP) that
addresses clinical and non-clinical PIPs and the requirement for on-going
interventions and improvement;     k.   An analysis and evaluation of
subcontractor relationships that addresses integration with the health plan’s
QA&I program. This analysis and evaluation is not a replication of the
Subcontractor Oversight Annual Evaluation report;     l.   An analysis and
evaluation of the health plan’s fraud and abuse program;

 

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  m.   An analysis and evaluation of care management that includes case
management, disease management and care coordination for both medical and mental
health services; and     n.   An analysis and evaluation of the health plan’s
claims processing and Management Information System.

  D.   Periodic Reports of Quality and Utilization: The MC+ Managed Care health
plan will provide periodic reports regarding case management, quality
initiatives, and other quality analysis reports per DMS request.     E.   An
annual report regarding multilingual services for members who speak a language
other than English and the MC+ Managed Care health plan’s methods for
communicating with members with visual and hearing impairments and accommodating
for the physically disabled. The health plan’s report shall include but not be
limited to the following:

  1.   A count by language of how many members declared a language other than
English as their primary language.     2.   A summary by language of translation
services provided to members (oral and in-person).     3.   A count of members
identified as needing communication accommodations due to visual or hearing
impairments or a physical .disability.     4.   A summary of services provided
to members with visual or hearing impairments or members who are physically
disabled (Braille, large print, cassette, sign interpreters-, etc.).     5.   An
inventory by language of member material translated.     6.   An inventory of
member materials available in alternative formats.     7.   A summarization of
grievances regarding multilingual issues and dispositions.

  F.   Annual subcontractor oversight reports that reflect the health plan’s
monitoring activities in the previous year for each health care service
subcontractor and any corrective actions implemented as a result of its
monitoring activities. The annual subcontractor oversight reports shall be
submitted in the format specified by the state agency (Exhibit 5).

II. DMS Analysis and Evaluation
DMS will analyze and evaluate data from a variety of sources including the state
agency’s Medicaid Management Information System (MMIS) to assess the quality and
appropriateness of care delivery to the MC+ Managed Care population. The DMS
will analyze and evaluate the following:

  •   Monthly reports, quarterly reports, periodic reports, annual reports, and
the annual evaluations submitted by MC+ Managed Care health plans.     •  
Encounter data.     •   Performance measures.     •   Performance improvement
projects.     •   Compliance with the MC+ Managed Care contract.     •  
Enrollment, transfer and disenrollment activity.

Results from the analysis and evaluation activities will be compiled and
presented through regularly scheduled meetings of the State Quality Assessment &
Improvement Advisory Group. The QA & I Advisory Group will review these results
to identify opportunities for improvement.

 

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III. External Quality Review
An external quality review of the MC+ Managed Care health plans will be
conducted annually in accordance with the “Medicaid Program; External Quality
Review of Medicaid Managed Care Organizations; Final Rule, 42 CFR Part 438,
Subpart E”. External quality review means the analysis and evaluation by an
External Quality Review Organization (EQRO) of aggregated information on
quality, timeliness, and access to health care services. The EQRO will provide
an annual evaluation report to the QA & I Advisory Group regarding, but not
limited to, the following:

  1.   Validation of two (2) performance improvement projects that were underway
during the preceding 12 months for each MC+ Managed Care health plan.     2.  
Validation of three (3) performance measures reported during the preceding 12
months.     3.   A review every three years to determine the MC+ Managed Care
health plan’s compliance with standards as listed within the MC+ Managed Care
contract.     4.   Validation of encounter data.

IV. Compliance

  A.   Intermediate Sanctions. The DMS may establish and specify intermediate
sanctions that may be imposed when a MC+ Managed Care health plan acts or fails
to act as specified below. The DMS may require a corrective action plan, as
referenced in section 2.28.5, to be developed and approved by the DMS in
situations where intermediate sanctions may be imposed. The DMS shall approve
and monitor implementation of such a plan and set appropriate timelines to bring
activities of the MC+ Managed Care health plan into compliance with state and
federal regulations. The DMS may monitor via required reporting on a specified
basis and/or through on-site evaluations, the effectiveness of the plan. Before
imposing intermediate sanctions, the DMS shall give the MC+ Managed Care health
plan timely written notice that explains the basis and nature of the sanction
and any other due process protections that the DMS elects to provide.

  1.   Fails substantially to provide medically necessary services that the MC+
Managed Care health plan is required to provide, under law or under this
contract, to a member covered under the contract.     2.   Imposes on members
premiums or charges that are in excess of the premiums or charges permitted
under the Medicaid program.     3.   Acts to discriminate among members on the
basis of their health status or need for health care services.     4.  
Misrepresents or falsifies information that it furnishes to CMS or to the DMS.  
  5.   Misrepresents or falsifies information that it furnishes to a member,
potential member, or a health care provider.     6.   Fails to comply with the
requirements for physician incentive plans, as set forth (for Medicare) in 42
CFR 422.208 and 422.210.     7.   Distributes directly, or indirectly through
any agent or independent contractor, marketing materials that have not been
approved by the DMS or that contain false or materially misleading information.
    8.   Violates any of the other applicable requirements of sections 1903(m)
or 1932 of the Act and any implementing regulations.     9.   Violates any of
the other applicable requirements of sections 1932 or 1905(t)(3) of the Act and
any implementing regulations.

  B.   Intermediate Sanctions: Types. The types of intermediate sanctions that
the DMS may impose include:

 

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  1.   Civil monetary penalties in the following specified amounts:

  a.   A maximum of $25,000 for each determination of failure to provide
services; misrepresentation or falsification of statements to members, potential
members or health care providers; failure to comply with physician incentive
plan requirements; or marketing violations.     b.   A maximum of $100,000 for
each determination of discrimination among members on the basis of their health
status or need for services; or misrepresentation or falsification to CMS or the
DMS.     c.   A maximum of $15,000 for each member the DMS determines was
discriminated against based on the member’s health status or need for services
(subject to the $100,000 limit above).     d.   A maximum of $25,000 or double
the amount of the excess charges (whichever is greater), for charging premiums
or charges in excess of the amounts permitted under the Medicaid program. The
DMS shall return the amount of overcharge to the affected member(s).

  2.   Appointment of temporary management for a health plan as provided in 42
CFR 438.706.     3.   Granting members the right to terminate enrollment without
cause and notifying the affected members of their right to disenroll.     4.  
Suspension of all new enrollment, including default enrollment, after the
effective date of the sanction.     5.   Suspension of payment for members
enrolled after the effective date of the sanction and until CMS or the DMS is
satisfied that the reason for imposition of the sanction no longer exists and is
not likely to recur.     6.   Additional sanctions allowed under state statutes
or regulations that address areas of noncompliance described above.

 

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

 

Exhibit 1
MC+ MANAGED CARE PERFORMANCE MEASURES
a.    EFFECTIVENESS OF CARE

1.   (H) Childhood Immunization Status (CIS)*   2.   (H) Adolescent Immunization
Status (AIS)*   3.   (H) Cervical Cancer Screening (CCS)*   4.   (H) Chlamydia
Screening in Women (CHL)*   5.   (H) Follow-up After Hospitalization For Mental
Health Disorders (FUH)   6.   (H) Use of Appropriate Medications for People with
Asthma (ASM)*

1) ACCESS/AVAILABILITY OF CARE

7.   (H) Prenatal and Postpartum Care (PPC)   8.   (H) Annual dental visit
(ADV)*

2) SATISFACTION WITH THE EXPERIENCE OF CARE

9.   (H) CAHPS 3.OH Child/Adult Survey*

3) USE OF SERVICES

10.   (H) Well child Visits in the First 15 Months of Life (W15)   11.  
(H) Well Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life (W34)
  12.   (H) Adolescent Well-Care Visits (AWC)*   13.   (H) Ambulatory Care (AMB)

14.   (H) Mental Health Utilization — Percentage of Members Receiving Inpatient,
Intermediate Care and Ambulatory Services (MPT)

15.   (H) Identification of Alcohol and Other Drug Services (IAD)

(H) = HEDIS Measure
 
* DHSS required measure. Follow the instructions provided within 19 CSR
10-5.010.
Note: The measures shall be collected and reported in accordance with HEDIS
specifications. In the event that NCQA retires a DMS required measure, the
Division will inform the health plan whether the DMS will require the health
plan to collect and report using HEDIS specifications in effect prior to the
measurement’s retirement or whether the Division will follow NCQA’a retirement
of the measure. NCQA rotates certain measures every year. As approved by DMS,
rotated measures shall be reported in accordance with current HEDIS technical
specifications for reporting rotated measures. DMS shall not approve rotation of
CAHPS. DHSS measures shall be reported according to DHSS specifications as
provided in 19 CSR 100-5.010. MC+ Managed Care health plans contracted for more
than one region shall submit region specific data. All MC+ Managed Care health
plans shall submit the measures in an electronic format utilizing tables
provided by the DMS and DHSS.

 

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

 

Exhibit 2
MC+ Managed Care Quality Assessment and Improvement
Reporting Periods
The following reporting periods have been defined for reporting of monthly,
quarterly and annual reports by MC+ Managed Care health plans participating in
the MC+ Managed Care Program.
MONTHLY REPORTING

      Time Period   Due Date
Calendar month
  Last working day of the month

QUARTERLY REPORTING

      Time Period   Due Date
1st Quarter (July thru September)
  December 1st of each year
2nd Quarter (October thru December)
  March 1st of each year
3rd Quarter (January thru March)
  June 1st of each year
4th Quarter (April thru June)
  September 1st of each year

ANNUAL REPORTS — ANNUAL EVALUATION, MULTILINGUAL SERVICES,
SUBCONTRACTOR OVERSIGHT

      Time Period   Due Date
July 1 thru June 30
  November 30, 2007 and on November 30 of each subsequent year

PERFORMANCE MEASURES

      Time Period   Due Date
January 1 thru December 31
  June 30 of each year

 

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

 

Exhibit 3
Trends in Missouri Medicaid Quality Indicators
(Secondary-Source Reporting)

1.   Trimester Prenatal Care Began:

  a.   First     b.   Second     c.   Third     d.   None     e.   Total

2.   Inadequate Prenatal Care   3.   Birth weight (grams) — total number of
births by weight category For each live birth.

  a.   <500Gms.     b.   500-1499 Gms.     c.   1500-1999 Gms.     d.  
2000-2499 Gms.     e.   .2500 Gms.     f.   Stillborn fetuses

4.   Low Birth Weight (<2500 grams)   5.   Method of Delivery

  a.   C-Section     b.   VBAC     c.   Repeat C-Section

6.   Smoking During Pregnancy   7.   Spacing <18 months since last birth   8.  
Births to mothers <18 years of age   9.   Repeat teen births   10.   Fetal
Deaths (20+weeks)*   11.   Total live birth or stillbirth fetuses 500 grams or
more**   12.   Percent of pregnant women on Women’s Infants and Children Program
(WIC)   13.   Percent of prenatals on WIC   14.   VLBW not delivered in level
111 hospitals   15.   Average maternal length of stay (days), Inpatient
admissions   16.   Average behavioral health length of stay (days), Inpatient
admissions   17.   Asthma inpatient admissions ages 4-17**   18.   Asthma
emergency room visits ages 4-17**   19.   Asthma admissions under age 16,
Inpatient admissions**   20.   Asthma admissions ages 18 — 64, Inpatient
admissions**   21.   Emergency room visits under age 18**   22.   Emergency room
visits ages 18 — 64**   23.   Hysterectomies**   24.   Vaginal hysterectomies  
25.   Preventable hospitalization under age 18**

 

*   Rate per 1000 live births   **   Rate per 1000 population

 

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

 

Exhibit 3
HEDIS Indicators by Missouri MC+ Managed Care Health Plans Within Regions, Live
Births
(Secondary-Source Reporting)

1.   C-Sections   2.   VBACs   3.   Adequacy of Prenatal Care   4.   Early
Prenatal Care   5.   Low Birth Weight   6.   Low Birth Weight Delivered in Level
II/III Hospitals   7.   Very Low Birth Weight Delivered in Level II/III
Hospitals   8.   Smoking During Pregnancy   9.   Spacing Less Than 18 Months  
10.   Births to Mothers Less Than 18   11.   Repeat Births to Teen Mothers   12.
  Prenatal WIC Participants

 

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

 

Exhibit 4
MC+ MANAGED CARE ANNUAL EVALUATION REPORT FORMAT
TABLE OF CONTENTS
EXECUTIVE SUMMARY
     Overview of the Quality Improvement Program
     Overview of the Effectiveness of the Quality Improvement Program
DEVELOPMENT, APPROVAL AND MONITORING OF THE QI PROGRAM
     Quality and Compliance Committee
     Analysis of Quality Improvement Process
     Overall Effectiveness of the Quality Improvement Program
          Strengths and Accomplishments
          Opportunities for Improvement
POPULATION CHARACTERISTICS
     Race/Ethnicity
     Special Needs
     Languages Identified
     Opt Outs
QUALITY INDICATORS
     Performance Measures
     Trends in Missouri Medicaid Quality Indicators
     HEDIS Indicators by Missouri MC+ Managed Care Health Plans Within Regions,
Live Births
ACCESSIBILITY OF SERVICES
     Average Speed of Answer
     Call Abandonment Rate
     Non-Routine Needs Appointments
     Routine Needs Appointments
     Access to Emergent and Urgent Care
     Network Adequacy — Provider/Enrollee Ratios
     24 Hour Access/After Hours Availability
     Open/Closed Panels
     Cultural Competency
     Requests to Change Practitioners
FRAUD AND ABUSE
     Prevention, Detection, Investigation
     Training and Education
INFORMATION MANAGEMENT
     Claims Processing — Timeliness of Claims Payment
     Membership
     Providers
QUALITY MANAGEMENT
     Provider Satisfaction
     Care Coordination
     Case Management
     Disease Management Program
     Mental Health Care Management including Case Management
     Clinical Practice Guidelines
     Credentialing and Re-Credentialing
     Medical Record Review
     Subcontractor Monitoring
RIGHTS AND RESPONSIBILITIES

 

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

 

     Provider Complaint, Grievance and Appeal Management
     Member Grievance and Appeal Management
     Confidentiality
UTILIZATION MANAGEMENT
     Utilization Improvement Program Scope
     Discharges Per Year*
     Inpatient Visits*
     Average Length of Stay
     Re-Admissions*
     Emergency Department Utilization*
     Outpatient Visits* .
     Over/Under Utilization
     Inter-Rater Reliability
     Timeliness of Care Delivery
     Timeliness of Prior Authorization/Certification Decision Making
*Per 1000 members
PERFORMANCE IMPROVEMENT PROJECTS (PIP)
     Clinical
     Non- Clinical
     On-going Interventions and Improvements
     Effect on Health Outcomes and Member Satisfaction
WORKPLAN FOR NEXT YEAR
APPENDICES

 

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

 

Exhibit 5
SUBCONTRACTOR OVERSIGHT ANNUAL EVALUATION REPORT TEMPLATE
(Complete for each subcontractor- 2-5pages)
Subcontractor Name

A.   Overview of subcontractor including contract effective dates   B.  
Description of delegated services/products/activities   C.   Description of MC+
Managed Care health plan’s oversight process (must include, but shall not be
limited to, the following:)

  1)   Review of subcontractor contract documents compliance with requirements
included in the MC+ Managed Care contract with state (Refer to Section 3.8.3 of
MC+ Managed Care contract)     2)   Subcontractor policies and procedures comply
with subcontractor/MC+ Managed Care health plan’s/state contract requirements  
  3)   Implementation of policies/procedures/contract requirements

D.   Oversight outcomes/findings (must include, but shall not be limited to, the
following:)

  1)   Access/availability     2)   Fraud and abuse     3)   Grievances and
appeals     4)   Performance projects and measures     5)   Encounter data    
6)   Prior authorization denials     7)   Timely payment

E.   Work plan for next year

 

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

 

Revised Attachment 14
Page 1 of 5
OFFICE VISIT SERVICES

                  Allowable Fee for         Dates of Service         July 1,
2006 and Procedure Code   Program Type   after
99201
  Medical Services   $21.52
99201 GE
  Medical Services   $21.52
99201 GT
  Medical Services   $21.52
99201
  Nurse Midwife   $21.52
99201
  Podiatry   $21.52
99201 GE
  Podiatry   $21.52
99201 W2
  Podiatry   $21.52
99201
  Other Medical   $21.52
99201 GE
  Other Medical   $21.52
99202
  Medical Services   $38.23
99202 EP
  Medical Services   $38.23
99202 GT
  Medical Services   $38.23
99202 GT EP
  Medical Services   $38.23
99202 GE
  Medical Services   $38.23
99202 GE EP
  Medical Services   $38.23
99202
  Nurse Midwife   $38.23
99202 EP
  Nurse Midwife   $38.23
99202
  Podiatry   $38.23
99202 W2
  Podiatry   $38.23
99202 GE
  Podiatry   $38.23
99202
  Other Medical   $38.23
99202 EP
  Other Medical   $38.23
99202 GE
  Other Medical   $38.23
99202 GE EP
  Other Medical   $38.23
99203
  Medical Services   $56.93
99203 EP
  Medical Services   $56.93
99203 GE
  Medical Services   $56.93
99203 GE EP
  Medical Services   $56.93
99203 GT
  Medical Services   $56.93
99203 GT EP
  Medical Services   $56.93
99203
  Nurse Midwife   $56.93
99203 EP
  Medical Services   $56.93
99203
  Podiatry   $56.93
99203 W2
  Podiatry   $56.93
99203
  Other Medical   $56.93
99203 EP
  Other Medical   $56.93
99203 GE
  Other Medical   $56.93

 

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

 

Revised Attachment 14
Page 2 of 5
OFFICE VISIT SERVICES

                          Allowable Fee for                 Dates of Service    
            July 1, 2006 and         Procedure Code   Program Type   after      
 
99203 GE EP
  Other Medical   $56.93        
99204
  Medical Services   $80.62        
99204 EP
  Medical Services   $80.62        
99204 GT
  Medical Services   $80.62        
99204 GT EP
  Medical Services   $80.62        
99204
  Nurse Midwife   $80.62        
99204 EP
  Nurse Midwife   $80.62        
99204
  Podiatry   $80.62        
99204 W2
  Podiatry   $80.62        
99204
  Other Medical   $80.62        
99204 EP
  Other Medical   $80.62        
99205
  Medical Services   $102.58        
99205 EP
  Medical Services   $102.58        
99205 GT
  Medical Services   $102.58        
99205 GT EP
  Medical Services   $102.58        
99205
  Nurse Midwife   $102.58        
99205 EP
  Nurse Midwife   $102.58        
99205
  Podiatry   $102.58        
99205 W2
  Podiatry   $102.58        
99205
  Other Medical   $102.58        
99205 EP
  Other Medical   $102.58        
99211
  Medical Services   $12.55        
99211 GE
  Medical Services   $12.55        
99211 GT
  Medical Services   $12.55        
99211
  Nurse Midwife   $12.55        
99211
  Podiatry   $12.55        
99211 W2
  Podiatry   $12.55        
99211 GE
  Podiatry   $12.55        
99211
  Other Medical   $12.55        
99211 GE
  Other Medical   $12.55        
99212
  Medical Services   $22.60        
99212 GT
  Medical Services   $22.60        
99212 GE
  Medical Services   $22.60        
99212
  Nurse Midwife   $22.60        
99212
  Podiatry   $22.60        
99212 W2
  Podiatry   $22.60     •  
99212 GE
  Podiatry   $22.60        

 

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

 

Revised Attachment 14
Page 3 of 5
OFFICE VISIT SERVICES

                  Allowable Fee for         Dates of Service         July 1,
2006 and Procedure Code   Program Type   after
99212
  Other Medical   $22.60
99212 GE
  Other Medical   $22.60
99213
  Medical Services   $30.86
99213 GE
  Medical Services   $30.86
99213 GT
  Medical Services   $30.86
99213
  Nurse Midwife   $30.86
99213
  Podiatry   $30.86
99213 W2
  Podiatry   $30.86
99213 GE
  Podiatry   $30.86
99213
  Other Medical .   $30.86
99213 GE
  Other Medical   $30.86
99214
  Medical Services   $48.45
99214 EP
  Medical Services   $48.45
99214 GT
  Medical Services   $48.45
99214 GT EP
  Medical Services   $48.45
99214
  Nurse Midwife   $48.45
99214 EP
  Nurse Midwife   $48.45
99214
  Podiatry   $48.45
99214 W2
  Podiatry   $48.45
99214
  Other Medical   $48.45
99214 EP
  Other Medical   $48.45
99215
  Medical Services   $70.63
99215 EP
  Medical Services   $70.63
99215 GT
  Medical Services   $70.63
99215 GT EP
  Medical Services   $70.63
99215
  Nurse Midwife   $70.63
99215 EP
  Nurse Midwife   $70.63
99215
  Podiatry   $70.63
99215 W2
  Podiatry   $70.63
99215
  Other Medical   $70.63
99215 EP
  Other Medical   $70.63

 

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

 

Revised Attachment 14
Page 4 of5
DENTAL SERVICES

      Procedure Code   Age
D0210
  0-125
D0270
  0-125
D0272
  0-125
D0330
  0-125
D0340
  0-20
D0350
  0-20
D1110
  13-125
D1203
  0-20
D1204
  21-125
D1351
  0-20
D2140
  0-125
D2150
  0-125
D2160
  0-125
D2161
  0-125
D2330
  0-125
D2331
  0-125
D2332
  0-125
D2335
  0-125
D2910
  0-125
D2920
  0-125
D2930
  0-125
D2931
  0-125
D2932
  0-125
D2940
  0-125
D3220
  0-125
D3310
  0-125
D3320
  0-125
D3330
  0-125
D3346
  0-125
D3347
  0-125
D3348
  0-125
D3410
  0-125
D3421
  0-125
D3425
  0-125
D4210
  0-125
D5510
  0-125
D5520
  0-125
D5610
  0-125
D5630
  0-125
D5640
  0-125

 

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

 

Revised Attachment 14
Page 5 of 5
DENTAL SERVICES

      Procedure Code   Age
D5650
  0-125
D5660
  0-125
D5710
  0-125
D5711
  0-125
D5721
  0-125
D5730
  0-125
D5731
  0-125
D5740
  0-125
D5741
  0-125
D5750
  0-125
D5751
  0-125
D5760
  0-125
D5761
  0-125
D5820
  0-125
D5821
  0-125
D6930
  0-125
D7220
  0-125
D7230
  0-125
D7240
  0-125
D7241
  0-125
D7960
  0-125
D7970
  0-125
D9110
  0-125
D9241
  0-125
D9910
  0-125
D9951
  0-125

NOTE: The health plan shall review provider bulletins posted on the DMS website
for future code changes due to HCPCS and HIPAA.

 

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

 

5.2 West Region — Firm Fixed Net Capitation Pricing Page

                  Category           State’s Maximum Net   Firm Fixed Net of    
      Capitation Rate   Capitation Rate Aid   Age   Sex   (Per Member Per Month)
  (Per Member Per Month)
1
  Newborn < 01   Male and Female   $677.81   $
 
               
1
  01 - 06   Male and Female   $125.63   $
 
               
1
  07 - 13   Male and Female   $107.39   $
 
               
1
  14 - 20   Female   $265.58   $
 
               
1
  14 - 20   Male   $121.43   $
 
               
1
  21 - 44   Female   $353.42   $
 
               
1
  21 - 44   Male   $196.90   $
 
               
1
  45 - 99   Male and Female   $402.91   $
 
               
4
  00 - 20 JC   Male and Female   $206.11   $
 
               
4
  00 - 20 OSJC   Male and Female   $249.74   $
 
               
5
  00 - 06   Male and Female   $159.62   $
 
               
5
  07 - 13   Male and Female   $128.99   $
 
               
5
  14 - 18   Male and Female   $172.28   $
 
               

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

 

5.3 East Region — Firm Fixed Net Capitation Pricing Page

                  Category           State’s Maximum Net   Firm Fixed Net of    
      Capitation Rate   Capitation Rate Aid   Age   Sex   (Per Member Per Month)
  (Per Member Per Month)
1
  Newborn < 01   Male and Female   $777.07   $
 
               
1
  01 - 06   Male and Female   $113.59   $
 
               
1
  07 - 13   Male and Female   $90.07   $
 
               
1
  14 - 20   Female   $240.17   $
 
               
1
  14 - 20   Male   $114.66   $
 
               
1
  21 - 44   Female   $333.06   $
 
               
1
  21 - 44   Male   $172.85   $
 
               
1
  45 - 99   Male and Female   $399.40   $
 
               
4
  00 - 20   Male and Female   $207.76   $
 
               
5
  00 - 06   Male and Female   $ 140.03   $
 
               
5
  07 - 13   Male and Female   $ 108.12   $
 
               
5
  14 - 18   Male and Female   $158.18   $
 
               

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

 

5.4 Central Region — Firm Fixed Net Capitation Pricing Page

                  Category           State’s Maximum Net   Firm Fixed Net of    
      Capitation Rate   Capitation Rate Aid   Age   Sex   (Per Member Per Month)
  (Per Member Per Month)
1
  Newborn < 01   Male and Female   $581.95   $
 
               
1
  01 - 06   Male and Female   $126.99   $
 
               
1
  07 - 13   Male and Female   $103.08   $
 
               
1
  14 - 20   Female   $301.80   $
 
               
1
  14 - 20   Male   $123.65   $
 
               
1
  21 - 44   Female   $405.35   $
 
               
1
  21 - 44   Male   $ 194.98   $
 
               
1
  45 - 99   Male and Female   $416.76   $
 
               
4
  00 - 20   Male and Female   $207.15   $
 
               
5
  00 - 06   Male and Female   $162.54   $
 
               
5
  07 - 13   Male and Female   $124.27   $
 
               
5
  14 - 18   Male and Female   $178.45   $
 
               

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

 

REVISED ATTACHMENT 12

                                  Policies and Procedures Requiring Prior
Approval       Contract         Contract         Contract Required Policy    
Reference   Required Policy     Reference   Required Policy     Reference
Non-Discrimination in Hiring and Provisions of Services
    2.2.6     24-Hour Coverage     2.14.1     Provider C, G & A     2.16  
Linking Members to PCPs
    2.3.2     Prior Authorization     2.14.2     QA&I     2.17.1  
Marketing Guidelines
    2.6.1 a.18)     Appointment Standards Edu.     2.14.4 d.1)     Utilization
Management     2.17.5 b  
Member Rights
    2.6.2 j.2)     Referral to non-network provider     2.14.5     Provider
Credentialing     2. 17.5 c  
Assignment of PCP
    2.6.2 k.     Standing Referral to Specialist     2.14.6     Monitoring
Providers     2.17.5 c.  
Assignment of PCP
    2.6.2 k.4)     Referral to Specialty Care Cntr.     2.14.7     Records
Retention     2.26.4  
Transfers Between Health Plans
    2.6.2 r.     Transitioning of Care     2.14.10     Medical Records    
2.26.5  
Disenrollment Effective Dates
    2.6.2 u.     Care Management     2.14.11 c.     Fraud & Abuse     2.31  
Provider Listing Updates
    2.9.1 g.     Certification Review     2.14.12     Subcontractor Oversight  
  3.8.3  
Second Opinion
    2.13     Member Grievance System     2.15              

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(STAMP) [a38671a3867115.gif]
  STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT AMENDMENT

     
AMENDMENT NO.: 003
  REQ NO.: NR 886 25757007159
CONTRACT NO.: C306118003
  BUYER: Laura Ortmeyer TITLE: Medicaid Managed Care — Central, Eastern, and
Western Regions   PHONE NO.: (573) 751-4579
ISSUE DATE: 02/23/07
  E-MAIL: laura.ortmeyer@oa.mo.gov

TO:   MERCY CAREPLUS
10123 CORPORATE SQUARE DR
ST LOUIS, MO 63132

RETURN AMENDMENT NO LATER THAN: March 7, 2007 AT 5:00 PM CENTRAL TIME
RETURN AMENDMENT TO:

          (U.S. Mail)       (Courier Service)
Div of Purchasing & Matls Mgt (DPMM)
  OR   Div of Purchasing & Matls Mgt (DPMM)
 
       
PO BOX 809
      301 WEST HIGH STREET, ROOM 630
JEFFERSON CITY MO 65102-0809
      JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)
DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Missouri Department of Social Service
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
SIGNATURE REQUIRED

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
   
Mercy CarePlus
  Alliance for Community Health, LLC
MAILING ADDRESS
  IRS FORM 1099 MAILING ADDRESS
 
   
10123 Corporate Square Drive
  10123 Corporate Square Drive
CITY, STATE, ZIP CODE
  CITY, STATE, ZIP CODE
 
   
St. Louis, MO 63132
  St. Louis, MO 63132

     
CONTACT PERSON
  EMAIL ADDRESS
 
   
Jerry Linder
  jlinder@mercycareplus.com
PHONE NUMBER
  FAX NUMBER
 
   
(314) 432-9300 Ext. 202
  (314) 432-9203 or (314) 994-9398

          TAXPAYER ID NUMBER (TIN)   TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR
NUMBER (IF KNOWN)           43-1743902   þ FEIN      o SSN   4317439020 2

      VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)   (NOTE: LLC IS NOT A VALID
TAX FILING TYPE.)

                      þ Corporation   o Individual   o State/Local Government  
o Partnership   o Sole Proprietor   o Other                  

     
AUTHORIZED SIGNATURE
  DATE
 
   
/s/ Jerry Linder
  February 27, 2007
PRINTED NAME
  Chief Executive Officer - President
 
   
Jerry Linder
   

 

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

 

Contract C306118003   Page 2

AMENDMENT #003 TO CONTRACT C306118003

     
CONTRACT TITLE:
  Medicaid Managed Care - Central, Eastern, and Western Regions
 
   
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007

The State of Missouri hereby desires to amend the above-referenced contract, as
follows, effective July 1, 2006:
In order to determine the impact of the eligibility changes implemented
effective with fiscal year 2007 on the overall birth rate, the state agency’s
actuary consultant conducted an analysis specific to the female child bearing
rate cells in order to ensure the actuarially soundness of the rates. The
attached Pricing Page reflects the actuarially sound rates determined as a
result of the analysis.
The contractor shall indicate in Column 2 on the attached Pricing Page, any
changes to the firm fixed prices of the contract for performing the required
services in accordance with the terms, conditions, and provisions of the
contract. The contractor’s firm, fixed PMPM Net Capitation Rate for Each
Category of Aid (COA) Rate subgroup must not exceed the State’s Maximum Net
Capitation Rate Listed in Column 1.
All other terms, conditions and provisions of the contract, including all
prices, shall remain the same and apply hereto.
The contractor shall sign and return this document, on or before the date
indicated, signifying acceptance of the amendment.

 

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

 

5.2 West Region — Firm Fixed Net Capitation Pricing Page

                                                Category               State’s
Maximum Net   Firm Fixed Net of               Capitation Rate   Capitation Rate
Aid   Age   Sex   (Per Member Per Month)   (Per Member Per Month)   1    
Newborn < 01
  Male and Female   $ 677.81     $ 677.81     1    
01 - 06
  Male and Female   $ 125.63     $ 125.63     1    
07 - 13
  Male and Female   $ 107.39     $ 107.39     1    
14 - 20
  Female   $ 270.37     $ 270.37     1    
14 - 20
  Male   $ 121.43     $ 121.43     1    
21 - 44
  Female   $ 368.58     $ 368.58     1    
21 - 44
  Male   $ 196.90     $ 196.90     1    
45 - 99
  Male and Female   $ 402.91     $ 402.91     4    
00 - 20 JC
  Male and Female   $ 249.74     $ 249.74     4    
00 - 20 OSJC
  Male and Female   $ 206.11     $ 206.11          
 
                          5    
00 - 06
  Male and Female   $ 159.62     $ 159.62     5    
07 - 13
  Male and Female   $ 128.99     $ 128.99     5    
14 - 18
  Male and Female   $ 172.28     $ 172.28  

 

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

 

5.3 East Region — Firm Fixed Net Capitation Pricing Page

                                                Category               State’s
Maximum Net   Firm Fixed Net of               Capitation Rate   Capitation Rate
Aid   Age   Sex   (Per Member Per Month)   (Per Member Per Month)   1    
Newborn < 01
  Male and Female   $ 777.07     $ 777.07     1    
01 - 06
  Male and Female   $ 113.59     $ 113.59     1    
07 - 13
  Male and Female   $ 90.07     $ 90.07     1    
14 - 20
  Female   $ 269.72     $ 269.72     1    
14 - 20
  Male   $ 114.66     $ 114.66     1    
21 - 44
  Female   $ 368.27     $ 368.27     1    
21 - 44
  Male   $ 172.85     $ 172.85     1    
45 - 99
  Male and Female   $ 399.40     $ 399.40     4    
00 - 20
  Male and Female   $ 207.76     $ 207.76          
 
                          5    
00 - 06
  Male and Female   $ 140.03     $ 140.03     5    
07 - 13
  Male and Female   $ 108.12     $ 108.12     5    
14 - 18
  Male and Female   $ 158.18     $ 158.18  

 

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

 

5.4 Central Region — Firm Fixed Net Capitation Pricing Page

                                                  Category               State’s
Maximum Net   Firm Fixed Net of               Capitation Rate   Capitation Rate
Aid   Age   Sex   (Per Member Per Month)   (Per Member Per Month)   1    
Newborn < 01
  Male and Female   $ 581.95     $ 581.95     1    
01 - 06
  Male and Female   $ 126.99     $ 126.99     1    
07 - 13
  Male and Female   $ 103.08     $ 103.08     1    
14 - 20
  Female   $ 314.36     $ 314.36     1    
14 - 20
  Male   $ 123.65     $ 123.65     1    
21 - 44
  Female   $ 427.42     $ 427.42     1    
21 - 44
  Male   $ 194.98     $ 194.98     1    
45 - 99
  Male and Female   $ 416.76     $ 416.76     4    
00 - 20
  Male and Female   $ 207.15     $ 207.15          
 
                          5    
00 - 06
  Male and Female   $ 162.54     $ 162.54     5    
07 - 13
  Male and Female   $ 124.27     $ 124.27     5    
14 - 18
  Male and Female   $ 178.45     $ 178.45  

 

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

 

     
(LOGO) [a38671a3867115.gif]
  STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT AMENDMENT

     
AMENDMENT NO.: 004
  REQ NO.: NR 886 25757006928
CONTRACT NO.: C306118003
  BUYER: Laura Ortmeyer TITLE: Medicaid Managed Care — Central, Eastern, and
Western Regions   PHONE NO.: (573) 751-4579
ISSUE DATE: 02/23/07
  E-MAIL: laura.ortmeyer@oa.mo.gov

TO:   MERCY CAREPLUS
10123 CORPORATE SQUARE DR
ST LOUIS, MO 63132

RETURN AMENDMENT NO LATER THAN: March 7, 2007 AT 5:00 PM CENTRAL TIME
RETURN AMENDMENT TO:

          (U.S. Mail)       (Courier Service)
Div of Purchasing & Matls Mgt (DPMM)
  OR   Div of Purchasing & Matls Mgt (DPMM)
PO BOX 809
      301 WEST HIGH STREET, ROOM 630
JEFFERSON CITY MO 65102-0809
      JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)
DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Missouri Department of Social Service
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
SIGNATURE REQUIRED

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
 
   
Mercy CarePlus
MAILING ADDRESS
  Alliance for Community Health, LLC
IRS FORM 1099 MAILING ADDRESS
 
   
10123 Corporate Square Drive
CITY, STATE, ZIP CODE
  10123 Corporate Square Drive
CITY, STATE, ZIP CODE
 
   
St. Louis, MO 63132
  St. Louis, MO 63132

     
CONTACT PERSON
  EMAIL ADDRESS
 
   
Jerry Linder
PHONE NUMBER
  jlinder@mercycareplus.com
FAX NUMBER
 
   
(314) 432-9300 Ext. 202
  (314)432-9203 or (314) 994-9398

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER(IF- KNOWN)
 
       
43-1743902
  þ FEIN    o SSN   4317439020 2

VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)   (NOTE: LLC IS NOT A VALID TAX
FILING TYPE.)

þ Corporation            o Individual           o State/Local
Government           o Partnership           o Sole Proprietor           o
Other          

     
AUTHORIZED SIGNATURE
  DATE
 
   
/s/ Jerry Linder
PRINTED NAME
  February 27, 2007
TITLE
 
   
Jerry Linder
  Chief Executive Officer — President

 

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

 

Contract C306118003   Page 2

AMENDMENT #004 TO CONTRACT C306118003

     
CONTRACT TITLE:
  Medicaid Managed Care — Central, Eastern, and Western Regions
 
   
CONTRACT PERIOD:
  July 1, 2006 through June 30, 2007

The State of Missouri hereby desires to amend the above-referenced contract in
accordance with the following:

1.   Paragraph 2.4.8 a. 2) is hereby amended effective January 1, 2007:

  2)   The health plan shall pay out-of-network providers for emergency services
at the current Missouri Medicaid program rates in effect at the time of service.

2.   Paragraph 2.28.1 b. is hereby amended effective July 1, 2006:

  b.   If the health plan is new to a MC+ managed care region, the health plan
shall agree that its capitation rate shall reflect the average participant ratio
of the MC+ managed care health plans that are not new to the region by rate cell
and category of assistance for the applicable measurement period reflected in
Attachment 11. Beginning January 2008, the new health plan shall agree that
their future capitation rates shall be adjusted by the health plan’s actual
12-month HCY/EPSDT participant ratio.

All other terms, conditions and provisions of the contract, including all
prices, shall remain the same and apply hereto.
The contractor shall sign and return this document, on or before the date
indicated, signifying acceptance of the amendment.

 

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

 

(SEAL)
NOTICE OF AWARD
State Of Missouri
Office Of Administration
Division Of Purchasing And Materials Management
PO Box 809
Jefferson City, MO 65102
http://www.oa.mo.gov/purch

     
CONTRACT NUMBER
  CONTRACT TITLE
 
   
C306118003
  Medicaid Managed Care-Central, Eastern, and Western Regions
 
   
AMENDMENT NUMBER
  CONTRACT PERIOD
 
   
005
  July 1, 2007 through June 30, 2008
 
   
REQUISITION NUMBER
  VENDOR NUMBER
 
   
MR 886 25757008216
  4317439020 2
 
   
CONTRACTOR NAME AND ADDRESS
  STATE AGENCY’S NAME AND ADDRESS
 
   
Mercy Careplus
  Department of Social Services
10123 Corporate Square Dr
  Division of Medical Services
St. Louis, MO 63132
  Jefferson City, MO 65102-6500 PO Box 6500
 
    ACCEPTED BY THE STATE OF MISSOURI AS FOLLOWS:
 
    Contract C306118003 is hereby amended pursuant to the attached Amendment
#005 dated April 16, 1007.
 
   
 
   
BUYER
  BUYER CONTACT INFORMATION
 
   
Laura Ortmeyer
  Email: laura.ortmeyer@oa.mo.gov
 
  Phone: (573) 751-4579
 
  Fax: (573)526-9817
SIGNATURE OF BUYER
  DATE
 
   
/s/ Laura Ortmeyer
  April 24, 2007
 
   
DIRECTOR OF PURCHASING AND MATERIALS MANAGEMENT
 
   
/s/ James Milvsk
   

 

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

 

     
(SEAL)
  STATE OF MISSOURI
 
  OFFICE OF ADMINISTRATION
 
  DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
 
  CONTRACT RENEWAL

     
AMENDMENT NO.: 005
  REQ NO.: NR 886 25757008216
CONTRACT NO.: C306118003
  BUYER: Laura Ortmeyer
TITLE: Medicaid Managed Care — Central, Eastern, and Western Regions  
  PHONE NO.: (573) 751-4579
ISSUE DATE: 04/10/07
  E-MAIL: laura.ortmeyer@oa.mo.gov

     
TO:
  MERCY CAREPLUS
 
  10123 CORPORATE SQUARE DR
 
  ST LOUIS MO 63132

RETURN AMENDMENT NO LATER THAN: 04/24/07 AT 5:00 PM CENTRAL TIME
RETURN AMENDMENT TO:

          (U.S. Mail)       (Courier Service)
Div of Purchasing & Matls Mgt (DPMM)
  OR   Div of Purchasing & Matls Mgt (DPMM)
PO BOX 809
      301 WEST HIGH STREET, ROOM 630
JEFFERSON CITY MO 65102-0809
      JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)
DELIVER SUPPLIES/SERVICES FOR (Free On Board) DESTINATION TO THE FOLLOWING
ADDRESS:
Department of Social Services
Division of Medical Services
PO Box 6500
Jefferson City MO 65102-6500
SIGNATURE REQUIRED

     
DOING BUSINESS AS (DBA) NAME
  LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.  
Mercy CarePlus
  Alliance for Community Health, LLC dba Mercy CarePlus  
MAILING ADDRESS
  IRS FORM 1099 MAILING ADDRESS  
10123 Corporate Square Drive
  10123 Corporate Square Drive
CITY, STATE, ZIP CODE
  CITY, STATE, ZIP CODE  
St. Louis, MO 63132
  St. Louis, MO 63132
CONTACT PERSON
  EMAIL ADDRESS  
Jerry Linder
  jlinder@mercycareplus. com
PHONE NUMBER
  FAX NUMBER  
(314) 432-9300 ext. 202
  (314) 994-9389

         
TAXPAYER ID NUMBER (TIN)
  TAXPAYER ID (TIN) TYPE (CHECK ONE)   VENDOR NUMBER (IF KNOWN)  
43-1743902
  þ FEIN      o SSN   4317439020 2

                      VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)       (NOTE:
LLC IS NOT A VALID TAX FILING TYPE.)
 
                   
þ  Corporation
  o  Individual   o  State/Local Government   o  Partnership   o  Sole
Proprietor   o  Other               

     
AUTHORIZED SIGNATURE
  DATE  
/s/ Jerry Linder
  4-16-07
PRINTED NAME
  TITLE  
Jerry Linder
  CEO

 

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

 

 
Contract C306118003    Page 2

AMENDMENT #005 TO CONTRACT C306118003

     
CONTRACT TITLE:
  Medicaid Managed Care — Central, Eastern, and Western Regions  
CONTRACT PERIOD:
  July 1, 2007 through June 30, 2008

The State of Missouri hereby exercises its option to renew the above-referenced
contract.
The contractor shall indicate in Column 2 on the attached Pricing page, any
changes to the firm, fixed prices of the contract for performing the required
services in accordance with the terms, conditions, and provisions of the
contract. The contractor’s firm, fixed PMPM Net Capitation Rate for Each
Category of Aid (COA) Rate subgroup must not exceed the State’s Maximum Net
Capitation Rate listed in Column 1.
The contractor must furnish a performance security deposit in accordance with
the terms and conditions stated in the original contract in the amount of
$1,000,000.00 for each region. The performance security deposit must specify the
contract number and contract period.
All other terms, conditions and provisions of the previous contract period shall
remain and apply hereto. The contractor shall sign and return this document,
along with completed pricing and the applicable bond, on or before the date
indicated.

NOTE:   The contractor’s failure to complete and return this document shall not
stop the action specified herein. If the contractor fails to complete and return
this document prior to the return date specified or the effective date of the
contract period stated above, whichever is later, the state may renew the
contract at the same price(s) as the previous contract period or at the price(s)
allowed by the contract, whichever is lower.

 

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

 

C306118003
5.3 East Region — Firm Fixed Net Capitation Pricing Page

                                      Column 1   Column 2 Category          
State’s Maximum Net   Firm Fixed Net of           Capitation Rate   Capitation
Rate Aid   Age   Sex   (Per Member Per Month)   (Per Member Per Month)
1
  Newborn < 01   Male and Female   $ 863.53     $ 863.53  
1
  01 - 06   Male and Female   $ 125.55     $ 125.55  
1
  07 - 13   Male and Female   $ 98.44     $ 98.44  
1
  14 - 20   Female   $ 306.93     $ 306.93  
1
  14 - 20   Male   $ 126.73     $ 126.73  
1
  21 - 44   Female   $ 418.80     $ 418.80  
1
  21 - 44   Male   $ 191.64     $ 191.64  
1
  45 - 99   Male and Female   $ 436.77     $ 436.77  
4
  00 - 20   Male and Female   $ 233.97     $ 233.97  
 
                       
5
  00 - 06   Male and Female   $ 152.68     $ 152.68  
5
  07 - 13   Male and Female   $ 117.88     $ 117.88  
5
  14 - 18   Male and Female   $ 175.38     $ 175.38  

 

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

 

C306118003
5.2 West Region — Firm Fixed Net Capitation Pricing Page

                                      Column 1   Column 2 Category          
State’s Maximum Net   Firm Fixed Net of           Capitation Rate   Capitation
Rate Aid   Age   Sex   (Per Member Per Month)   (Per Member Per Month)
1
  Newborn < 01   Male and Female   $ 758.67     $ 758.67  
1
  01 - 06   Male and Female   $ 147.55     $ 147.55  
1
  07 - 13   Male and Female   $ 119.08     $ 119.08  
1
  14 - 20   Female   $ 312.64     $ 312.64  
1
  14 - 20   Male   $ 149.02     $ 149.02  
1
  21 - 44   Female   $ 469.35     $ 469.35  
1
  21 - 44   Male   $ 229.66     $ 229.66  
1
  45 - 99   Male and Female   $ 447.06     $ 447.06  
4
  00 - 20 JC       $ 284.16     $ 284.16  
4
  00 - 20 OSJC   Male and Female   $ 230.99     $ 230.99  
 
                       
5
  00 - 06   Male and Female   $ 177.17     $ 177.17  
5
  07 - 13   Male and Female   $ 142.71     $ 142.71  
5
  14 - 18   Male and Female   $ 191.75     $ 191.75  

 

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

 

C306118003
5.4 Central Region — Firm Fixed Net Capitation Pricing Page

                                      Column 1   Column 2 Category          
State’s Maximum Net   Firm Fixed Net of           Capitation Rate   Capitation
Rate Aid   Age   Sex   (Per Member Per Month)   (Per Member Per Month)
1
  Newborn < 01   Male and Female   $ 687.17     $ 687.17  
1
  01 - 06   Male and Female   $ 143.61     $ 143.61  
1
  07 - 13   Male and Female   $ 116.00     $ 116.00  
1
  14 - 20   Female   $ 340.24     $ 340.24  
1
  14 - 20   Male   $ 144.98     $ 144.98  
1
  21 - 44   Female   $ 483.82     $ 483.82  
1
  21 - 44   Male   $ 230.15     $ 230.15  
1
  45 - 99   Male and Female   $ 470.57     $ 470.57  
4
  00 - 20   Male and Female   $ 227.94     $ 227.94  
 
                       
5
  00 - 06   Male and Female   $ 175.25     $ 175.25  
5
  07 - 13   Male and Female   $ 134.72     $ 134.72  
5
  14 - 18   Male and Female   $ 193.45     $ 193.45