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Back to Form 8-K [form_8-k.htm]
 
Exhibit 10.1
 

Contract No. FA615

STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STANDARD CONTRACT

THIS CONTRACT is entered into between the State of Florida, AGENCY FOR HEALTH
CARE ADMINISTRATION, hereinafter referred to as the “Agency”, whose address is
2727 Mahan Drive, Tallahassee, Florida 32308, and WELLCARE OF FLORIDA, INC.
D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the “Vendor”
or “Health Plan”, whose address is 8735 Henderson Road, Renaissance 1, Tampa,
Florida 33634, a Florida For-Profit Corporation, to provide Health Care Services
to Medicaid Beneficiaries.

I.  
THE VENDOR HEREBY AGREES:

A. General Provisions

   
1.
To provide services according to the terms and conditions set forth in this
Contract, Attachment I, Scope of Services, and Attachment II, Medicaid Prepaid
Health Plan Model Contract and all other attachments named herein which are
attached hereto and incorporated by reference.

2.  
To perform as an independent vendor and not as an agent, representative, or
employee of the Agency.

3.  
To recognize that the State of Florida, by virtue of its sovereignty, is not
required to pay any taxes on the services or goods purchased under the terms of
this Contract.

B.  
Federal Laws and Regulations

   
1.
If this Contract contains federal funds, the Vendor shall comply with the
provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other applicable
regulations as specified in Attachments I and II.

   
2.
If this Contract contains federal funding in excess of $100,000, the Vendor
must, upon Contract execution, complete the Certification Regarding Lobbying
form, Attachment IV. If a Disclosure of Lobbying Activities form, Standard Form
LLL, is required, it may be obtained from the Agency’s Contract Manager. All
disclosure forms as required by the Certification Regarding Lobbying form must
be completed and returned to the Agency’s Contract Manager.

   
3.
Pursuant to 45 CFR, Part 76, if this Contract contains federal funding in excess
of $25,000, the Vendor must, upon Contract execution, complete the Certification
Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
Contracts/Subcontracts, Attachment V.

C.  
Audits and Records

 
1.
To maintain books, records, and documents (including electronic storage media)
pertinent to performance under this Contract in accordance with generally
accepted accounting procedures and practices which sufficiently and properly
reflect all revenues and expenditures of funds provided by the Agency under this
Contract.

 
2.
To assure that these records shall be subject at all reasonable times to
inspection, review, or audit by state personnel and other personnel duly
authorized by the Agency, as well as by federal personnel.

 
3.
To maintain and file with the Agency such progress, fiscal and inventory reports
as specified in Attachment II, and other reports as the Agency may require
within the period of this Contract. In addition, access to relevant computer
data and applications which generated such reports should be made available upon
request.

 
4.
To ensure that all related party transactions are disclosed to the Agency
Contract Manager. Additional audit requirements are specified in Attachment II,
Special Provisions, Section XII.

   
5.
To include these aforementioned audit and record keeping requirements in all
approved subcontracts and assignments.

D.  
Retention of Records

   
1.
To retain all financial records, supporting documents, statistical records, and
any other documents (including electronic storage media) pertinent to
performance under this Contract for a period of five (5) years after termination
of this Contract, or if an audit has been initiated and audit findings have not
been resolved at the end of five (5) years, the records shall be retained until
resolution of the audit findings.

2.Persons duly authorized by the Agency and federal auditors, pursuant to 45
CFR, Part 74 and/or 45 CFR, Part 92, shall have full access to and the right to
examine any of said records and documents.

3.The rights of access in this section must not be limited to the required
retention period but shall last as long as the records are retained.

E.  
Monitoring

   
1.
To provide reports as specified in Attachment II. These reports will be used for
monitoring progress or performance of the contractual services as specified in
Attachments I and II.

   
2.
To permit persons duly authorized by the Agency to inspect any records, papers,
documents, facilities, goods and services of the Vendor which are relevant to
this Contract.

F.  
Indemnification

The Vendor shall save and hold harmless and indemnify the State of Florida and
the Agency against any and all liability, claims, suits, judgments, damages or
costs of whatsoever kind and nature resulting from the use, service, operation
or performance of work under the terms of this Contract, resulting from any act,
or failure to act, by the Vendor, his subcontractor, or any of the employees,
agents or representatives of the Vendor or subcontractor.

G. Insurance

   
1.
To the extent required by law, the Vendor will be self-insured against, or will
secure and maintain during the life of the Contract, Worker’s Compensation
Insurance for all his employees connected with the work of this project and, in
case any work is subcontracted, the Vendor shall require the subcontractor
similarly to provide Worker’s Compensation Insurance for all of the latter’s
employees unless such employees engaged in work under this Contract are covered
by the Vendor’s self insurance program. Such self insurance or insurance
coverage shall comply with the Florida Worker’s Compensation law. In the event
hazardous work is being performed by the Vendor under this Contract and any
class of employees performing the hazardous work is not protected under Worker’s
Compensation statutes, the Vendor shall provide, and cause each subcontractor to
provide, adequate insurance satisfactory to the Agency, for the protection of
his employees not otherwise protected.

 
2.
The Vendor shall secure and maintain Commercial General Liability insurance
including bodily injury, property damage, personal & advertising injury and
products and completed operations. This insurance will provide coverage for all
claims that may arise from the services and/or operations completed under this
Contract, whether such services and/or operations are by the Vendor or anyone
directly, or indirectly employed by him. Such insurance shall include a Hold
Harmless Agreement in favor of the State of Florida and also include the State
of Florida as an Additional Named Insured for the entire length of the Contract.
The Vendor is responsible for determining the minimum limits of liability
necessary to provide reasonable financial protections to the Vendor and the
State of Florida under this Contract.

 
3.
All insurance policies shall be with insurers licensed or eligible to transact
business in the State of Florida. The Vendor’s current certificate of insurance
shall contain a provision that the insurance will not be canceled for any reason
except after thirty (30) days written notice to the Agency’s Contract Manager.

H. Assignments and Subcontracts

To neither assign the responsibility of this Contract to another party nor
subcontract for any of the work contemplated under this Contract without prior
written approval of the Agency. No such approval by the Agency of any assignment
or subcontract shall be deemed in any event or in any manner to provide for the
incurrence of any obligation of the Agency in addition to the total dollar
amount agreed upon in this Contract. All such assignments or subcontracts shall
be subject to the conditions of this Contract and to any conditions of approval
that the Agency shall deem necessary.

I. Financial Reports

To provide financial reports to the Agency as specified in Attachment II.

J. Return of Funds

To return to the Agency any overpayments due to unearned funds or funds
disallowed pursuant to the terms of this Contract that were disbursed to the
Vendor by the Agency. The Vendor shall return any overpayment to the Agency
within forty (40) calendar days after either discovery by the Vendor, its
independent auditor, or notification by the Agency, of the overpayment.

K. Purchasing

1. P.R.I.D.E.

It is expressly understood and agreed that any articles which are the subject
of, or required to carry out this Contract shall be purchased from the
corporation identified under Chapter 946, Florida Statutes, if available, in the
same manner and under the same procedures set forth in Section 946.515(2), (4),
Florida Statutes; and for purposes of this Contract the person, firm or other
business entity carrying out the provisions of this Contract shall be deemed to
be substituted for this agency insofar as dealings with such corporation are
concerned.

The “Corporation identified” is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED
ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:

P.R.I.D.E.
2720-G Blair Stone Road
Tallahassee, Florida 32301
(850) 487-3774
Toll Free: 1-800-643-8459
Website: www.pridefl.com

 
2.
RESPECT of Florida

It is expressly understood and agreed that any articles that are the subject of,
or required to carry out, this Contract shall be purchased from a nonprofit
agency for the blind or for the severely handicapped that is qualified pursuant
to Chapter 413, Florida Statutes, in the same manner and under the same
procedures set forth in Section 413.036(1) and (2), Florida Statutes; and for
purposes of this Contract the person, firm, or other business entity carrying
out the provisions of this Contract shall be deemed to be substituted for the
state agency insofar as dealings with such qualified nonprofit agency are
concerned.

The "nonprofit agency” identified is RESPECT of Florida which may be contacted
at:

RESPECT of Florida.
2475 Apalachee Parkway, Suite 205
Tallahassee, Florida 32301-4946
(850) 487-1471
Website: www.respectofflorida.org

3. 
Procurement of Products or Materials with Recycled Content

It is expressly understood and agreed that any products which are required to
carry out this Contract shall be procured in accordance with the provisions of
Section 403.7065, Florida Statutes.

L. Civil Rights Requirements/Vendor Assurance

The Vendor assures that it will comply with:

   
1.
Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et seq.,
which prohibits discrimination on the basis of race, color, or national origin.

   
2.
Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 794, which
prohibits discrimination on the basis of handicap.

   
3.
Title IX of the Education Amendments of 1972, as amended, 20 U.S.C. 1681 et
seq., which prohibits discrimination on the basis of sex.

   
4.
The Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq., which
prohibits discrimination on the basis of age.

   
5.
Section 654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
42 U.S.C. 9849, which prohibits discrimination on the basis of race, creed,
color, national origin, sex, handicap, political affiliation or beliefs.

   
6.
The Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
discrimination on the basis of disability and requires reasonable accommodation
for persons with disabilities.

   
7.
All regulations, guidelines, and standards as are now or may be lawfully adopted
under the above statutes.

The Vendor agrees that compliance with this assurance constitutes a condition of
continued receipt of or benefit from funds provided through this Contract, and
that it is binding upon the Vendor, its successors, transferees, and assignees
for the period during which services are provided. The Vendor further assures
that all contractors, subcontractors, subgrantees, or others with whom it
arranges to provide services or benefits to participants or employees in
connection with any of its programs and activities are not discriminating
against those participants or employees in violation of the above statutes,
regulations, guidelines, and standards.

M. Discrimination

An entity or affiliate who has been placed on the discriminatory vendor list may
not submit a bid, proposal, or reply on a contract to provide any goods or
services to a public entity; may not submit a bid, proposal, or reply on a
contract with a public entity for the construction or repair of a public
building or public work; may not submit bids, proposals, or replies on leases of
real property to a public entity; may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any
public entity; and may not transact business with any public entity. The Florida
Department of Management Services is responsible for maintaining the
discriminatory vendor list and intends to post the list on its website.
Questions regarding the discriminatory vendor list may be directed to the
Florida Department of Management Services, Office of Supplier Diversity at (850)
487-0915.

N. Requirements of Section 287.058, Florida Statutes

 
1.
To submit bills for fees or other compensation for services or expenses in
sufficient detail for a proper pre-audit and post-audit thereof.

   
2.
Where applicable, to submit bills for any travel expenses in accordance with
Section 112.061, Florida Statutes.

 
3.
To provide units of deliverables, including reports, findings, and drafts, in
writing and/or in an electronic format agreeable to both parties, as specified
in Attachment I and Attachment II, to be received and accepted by the Contract
Manager prior to payment.

 
4.
To comply with the criteria and final date by which such criteria must be met
for completion of this Contract as specified in Section III, Paragraph A. of
this Contract.

 
5.
To allow public access to all documents, papers, letters, or other material made
or received by the Vendor in conjunction with this Contract, unless the records
are exempt from Section 24(a) of Article I of the State Constitution and Section
119.07(1), Florida Statutes. It is expressly understood that substantial
evidence of the Vendor's refusal to comply with this provision shall constitute
a breach of Contract.

O. Sponsorship

As required by Section 286.25, Florida Statutes, if the Vendor is a
nongovernmental organization which sponsors a program financed wholly or in part
by state funds, including any funds obtained through this Contract, it shall, in
publicizing, advertising or describing the sponsorship of the program, state:

"Sponsored by WELLCARE OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF
FLORIDA and the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION".

If the sponsorship reference is in written material, the words "State of
Florida, AGENCY FOR HEALTH CARE ADMINISTRATION" shall appear in the same size
letters or type as the name of the organization.

P. Final Invoice

The Vendor must submit the final invoice for payment to the Agency no more than
90 days after the Contract ends or is terminated. If the Vendor fails to do so,
all right to payment is forfeited and the Agency will not honor any requests
submitted after the aforesaid time period. Any payment due under the terms of
this Contract may be withheld until all reports due from the Vendor and
necessary adjustments thereto have been approved by the Agency.

 
Q.
Use Of Funds For Lobbying Prohibited

To comply with the provisions of Section 216.347, Florida Statutes, which
prohibits the expenditure of Contract funds for the purpose of lobbying the
Legislature, the judicial branch or a state agency.

R. Public Entity Crime

A person or affiliate who has been placed on the convicted vendor list following
a conviction for a public entity crime may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any
public entity, and may not transact business with any public entity in excess of
the threshold amount provided in Section 287.017, Florida Statutes, for category
two, for a period of 36 months from the date of being placed on the convicted
vendor list.

S. Health Insurance Portability and Accountability Act
 
To comply with the Department of Health and Human Services Privacy Regulations
in the Code of Federal Regulations, Title 45, Sections 160 and 164, regarding
disclosure of protected health information as specified in Attachment III.

T. Confidentiality of Information

Not to use or disclose any confidential information, including social security
numbers that may be supplied under this Contract pursuant to law, and also
including the identity or identifying information concerning a Medicaid
recipient or services under this Contract for any purpose not in conformity with
state and federal laws, except upon written consent of the recipient, or his/her
guardian.

U. Employment

To comply with Section 274A (e) of the Immigration and Nationality Act. The
Agency shall consider the employment by any contractor of unauthorized aliens a
violation of this Act. If the Vendor knowingly employs unauthorized aliens, such
violation shall be cause for unilateral cancellation of this Contract. The
Vendor shall be responsible for including this provision in all subcontracts
with private organizations issued as a result of this Contract.

V. Vendor Performance

Penalties or sanctions for unsatisfactory performance under this Contract are
specified in Attachment I and Attachment II, if applicable.

II. THE AGENCY HEREBY AGREES:

A. Contract Amount

To pay for contracted services according to the conditions of Attachment I in an
amount not to exceed $1,218,028,875.00, subject to the availability of funds.
The State of Florida's performance and obligation to pay under this Contract is
contingent upon an annual appropriation by the Legislature.

B. Contract Payment

Section 215.422, Florida Statutes, provides that agencies have 5 working days to
inspect and approve goods and services, unless bid specifications, Contract or
purchase order specifies otherwise. With the exception of payments to health
care providers for hospital, medical, or other health care services, if payment
is not available within forty (40) days, measured from the latter of the date
the invoice is received or the goods or services are received, inspected and
approved, a separate interest penalty set by the Comptroller pursuant to Section
55.03, F. S., will be due and payable in addition to the invoice amount. To
obtain the applicable interest rate, please contact the Agency’s Fiscal Section
at (850) 488-5869, or utilize the Department of Financial Services website at
www.dfs.state.fl.us/interest.html. Payments to health care providers for
hospitals, medical or other health care services, shall be made not more than 35
days from the date of eligibility for payment is determined, and the daily
interest rate is .0003333%. Invoices returned to a vendor due to preparation
errors will result in a payment delay. Invoice payment requirements do not start
until a properly completed invoice is provided to the Agency. A Vendor
Ombudsman, whose duties include acting as an advocate for vendors who may be
experiencing problems in obtaining timely payment(s) from a State agency, may be
contacted at (850) 410-9724 or by calling the State Comptroller’s Hotline,
1-800-848-3792.

III. THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

A. Effective/End Date

This Contract shall begin upon execution by both parties or September 1, 2006,
(whichever is later) and end August 31, 2009, inclusive.

B. Termination

1. Termination at Will

This Contract may be terminated by either party upon no less than thirty (30)
calendar days written notice, without cause, unless a lesser time is mutually
agreed upon by both parties. Said notice shall be delivered by certified mail,
return receipt requested, or in person with proof of delivery.

2. Termination Due To Lack of Funds

In the event funds to finance this Contract become unavailable, the Agency may
terminate the Contract upon no less than twenty-four (24) hours written notice
to the Vendor. Said notice shall be delivered by certified mail, return receipt
requested, or in person with proof of delivery. The Agency shall be the final
authority as to the availability of funds.

3. Termination for Breach

Unless the Vendor's breach is waived by the Agency in writing, the Agency may,
by written notice to the Vendor, terminate this Contract upon no less than
twenty-four (24) hours written notice. Said notice shall be delivered by
certified mail, return receipt requested, or in person with proof of delivery.
If applicable, the Agency may employ the default provisions in
Chapter 60A-1.006(4), Florida Administrative Code.

Waiver of breach of any provisions of this Contract shall not be deemed to be a
waiver of any other breach and shall not be construed to be a modification of
the terms of this Contract. The provisions herein do not limit the Agency's
right to remedies at law or to damages.

C. Contract Managers

   
1.
The Agency’s Contract Manager’s name, address and telephone number for this
Contract is as follows:

G. Douglas Harper
Agency for Health Care Administration
2727 Mahan Drive, MS# 50
Tallahassee, FL 32308
(850) 487-2355
 

2.  
The Vendor’s Contract Manager’s name, address and telephone number for this
Contract is as follows:

Imtiaz "MT" Sattaur
WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida
8735 Henderson Road, Renaissance 1
Tampa, FL 33634
(813) 290-6279

   
3.
All matters shall be directed to the Contract Managers for appropriate action or
disposition. A change in Contract Manager by either party shall be reduced to
writing through an amendment to this Contract by the Agency.

D. Renegotiation or Modification

   
1.
Modifications of provisions of this Contract shall only be valid when they have
been reduced to writing and duly signed during the term of the Contract. The
parties agree to renegotiate this Contract if federal and/or state revisions of
any applicable laws, or regulations make changes in this Contract necessary.

     
2.
The rate of payment and the total dollar amount may be adjusted retroactively to
reflect price level increases and changes in the rate of payment when these have
been established through the appropriations process and subsequently identified
in the Agency's operating budget.

E. Name, Mailing and Street Address of Payee

   
1.
The name (Vendor name as shown on Page 1 of this Contract) and mailing address
of the official payee to whom the payment shall be made:

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida
8735 Henderson Road, Renaissance 1
Tampa, FL 33634

 
2.
The name of the contact person and street address where financial and
administrative records are maintained:

Paul L. Behrens
8735 Henderson Road, Renaissance 1
Tampa, FL 33634

F. All Terms and Conditions

     
This Contract and its attachments as referenced herein contain all the terms and
conditions agreed upon by the parties.

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IN WITNESS THEREOF, the parties hereto have caused this three-hundred twelve
(312) page Contract, which includes any referenced attachments, to be executed
by their undersigned officials as duly authorized. This Contract is not valid
until signed and dated by both parties.

WELLCARE OF FLORIDA, INC.
D/B/A STAYWELL HEALTH PLAN 
OF FLORIDA
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
         
SIGNED BY:
 /s/  Paul Behrens        
SIGNED BY:
   /s/  Christa Calamas                    
NAME:
   Paul Behrens
NAME:
  Christa Calamas
           
TITLE:
  SVP and Chief Financial Officer
TITLE:
   Secretary
           
DATE:
  8/31/06
DATE:
  9/1/06            

FEDERAL ID NUMBER (or SS Number for an individual): 59-2583622

VENDOR FISCAL YEAR ENDING DATE: 12/31

List of attachments/exhibits included as part of this Contract:
 
Attachment I Scope of Services (9 Pages)
Attachment II Medicaid Prepaid Health Plan Model Contract (288) Pages
Attachment III Business Associate Agreement (3 Pages)
Attachment IV Lobbying Certification (1 Page)
Attachment V Debarment Certification (1 Page)

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ATTACHMENT I
SCOPE OF SERVICES

A.
Manner of Service (s) Provision:

Policies and Procedures

The Health Plan shall comply with all provisions of this Contract and any
subsequent amendments, and shall act in good faith in the performance of the
Contract's provisions. The Health Plan shall develop, maintain and implement
written policies and procedures covering all provisions of this Contract. All
policies and procedures shall be prior-approved by the Agency in writing. The
Health Plan agrees that failure to comply with all provisions of this Contract
shall result in the assessment of penalties and/or termination of this Contract,
in whole or in part, as set forth in this Contract.

B. Method of Payment:

1. General

Notwithstanding the payment amounts which may be computed with the rate tables
specified in Exhibit III, the sum of total capitation payments under this
Contract shall not exceed the total Contract amount of $1,218,028,875.00.

 
a.
The Health Plan shall be paid capitation payments for each Agency Service Area,
based upon Exhibit II, Table 4, attached hereto.

 
c.
All payments made to the Health Plan shall be in accordance with this section
(Section B, Method of Payment) and Attachment II, Section XIII, Method of
Payment.

2. Enrollment Levels

The Agency assigns the Health Plan an authorized maximum Enrollment level for
each operational county. The authorized maximum Enrollment level is in effect on
September 1, 2006, or upon Contract execution, whichever is later.

a.  
The Agency must approve, in writing, any increase in the Health Plan’s maximum
Enrollment level for each operational county and subpopulation to be served, as
applicable. Such approval shall not be unreasonably withheld, and shall be based
upon the Health Plan’s satisfactory performance of terms of the Contract and
upon the Agency’s approval of the Health Plan’s administrative and service
resources, as specified in this Contract, in support of each Enrollment level. 

b.  
Exhibit I, Table 1, attached hereto, indicates the Health Plan’s maximum
authorized Enrollment levels for each Medicaid Reform county and each applicable
authorized eligibility category.

3. Health Plan Capitation Rate

Exhibit II, Table 4 provides the capitation rates respective to the authorized
areas of operation, as identified in subsection B, Method of Payment, Item 2,
above. The Capitation Rate payment shall be in accordance with Attachment II,
Section XIII, Payment Methodology.

4. Capitation Rate Tables

Exhibit III lists the Capitation Rates for the Health Plan’s authorized Service
Areas.

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EXHIBIT 1

MAXIMUM ENROLLMENT LEVELS

TABLE 1
ENROLLMENT LEVELS

County
Maximum Enrollment Level
Brevard
14,000
Broward
25,000
Dade
25,000
Hernando
15,000
Hillsborough
28,000
Lee
15,000
Manatee
12,000
Palm Beach
15,000
Pasco
7,000
Pinellas
15,000
Polk
25,000
Orange
38,000
Osceola
12,000
Sarasota
6,000
Seminole
6,000

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EXHIBIT II
CAPITATION RATES

A. Table 4 - General Capitation Rates plus Mental Health Rates plus
Transportation:

Area 3 Counties: 

County
Provider Number
Hernando
015016901

Area 5 Counties: 

County
Provider Number
Pasco
015016903
Pinellas
015016904

Area 6 Counties:

County
Provider Number
Hillsborough
015016902
Polk
015016905
Manatee
015016912

Area 7 Counties:

County
Provider Number
Orange
015016906
Seminole
015016908
Osceola
015016907
Brevard
015016913

Area 8 Counties:

County
Provider Number
Lee
015016911
Sarasota
015016914

Area 9 Counties:

County
Provider Number
Palm Beach
015016910

Area 10 Counties:

County
Provider Number
Broward
015016900

Area 11 Counties:

County
Provider Number
Miami-Dade
015016909

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EXHIBIT III
 
September 1, 2006- August 31, 2007 HMO RATES
(MEDICAID Non-Reform HMO CAPITATION RATES)
By Area , Age and Eligibility Category
Effective from September 1, 2006 thru August 31, 2007
                                         
TABLE 1
                             
General Rates:
                                     
 
 
 
 
 
 TANF
 
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
 (6-13)
AGE
(14-20)
AGE
(21-54)
AGE
(55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
 
 
 
 
 
 
   
 
                                       
 
   
01
984.41
187.77
94.20
59.28
124.19
65.47
240.45
153.59
321.77
9,105.00
1,514.90
418.36
193.71
221.49
689.79
663.38
224.43
81.78
72.80
 
02
984.41
187.77
94.20
59.28
124.19
65.47
240.45
153.59
321.77
9,105.00
1,514.90
418.36
193.71
221.49
689.79
663.38
224.43
81.78
72.80
 
03
1,119.04
215.12
108.14
68.68
142.53
75.76
277.34
177.97
374.11
9,838.59
1,650.55
455.86
214.24
243.93
761.80
733.75
222.99
76.64
68.22
 
04
977.46
188.43
94.81
60.52
124.94
66.54
243.67
156.49
329.66
9,496.04
1,594.91
440.11
207.52
236.40
737.11
710.51
281.10
80.69
71.81
 
05
1,067.14
205.69
103.55
66.12
136.51
72.78
266.02
170.99
360.08
10,493.86
1,761.79
486.26
229.33
261.00
813.88
784.20
227.89
75.00
66.73
 
06
952.19
184.52
93.11
59.80
122.69
65.63
239.77
154.53
326.30
9,506.98
1,600.98
441.82
209.34
238.56
743.00
716.54
266.50
71.11
63.33
 
07
995.57
192.16
96.69
61.72
127.53
68.03
248.61
159.82
336.93
9,869.04
1,664.31
459.14
218.22
247.85
773.41
746.36
258.48
74.69
66.44
 
08
891.16
172.27
86.81
55.56
114.42
61.12
223.35
143.81
303.33
8,573.17
1,440.41
397.64
187.66
213.40
665.88
641.84
199.48
70.72
62.90
 
09
959.78
184.64
92.88
59.08
122.41
65.01
238.25
152.88
321.72
9,678.19
1,630.65
450.09
213.75
242.41
757.35
730.08
187.44
75.59
67.24
 
10
949.98
183.45
92.43
59.18
121.83
65.12
237.80
153.08
322.61
12,128.14
2,049.58
566.06
269.77
306.61
956.09
922.33
227.28
85.14
75.76
 
11
1,250.56
239.79
120.51
76.32
158.78
84.09
308.55
197.83
415.51
13,040.05
2,192.54
605.29
286.46
325.12
1,014.84
978.59
283.70
121.23
107.80
                                           
TABLE 2
                               
General + Mental Health Rates:
                                 
 
 
 
 
 
TANF
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
(14-20)
AGE
(21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
 
 
 
 
                                                       
01
984.43
187.79
95.93
71.39
136.48
77.76
244.40
157.54
325.26
9,105.08
1,514.98
430.15
264.67
289.33
793.42
700.39
227.58
94.88
85.90
 
02
984.43
187.79
96.79
78.05
138.03
79.31
243.59
156.73
324.95
9,105.09
1,514.99
432.97
271.86
269.95
740.56
685.53
246.33
96.76
87.78
 
03
1,119.05
215.13
109.27
76.84
148.55
81.78
278.71
179.34
375.49
9,838.63
1,650.59
462.53
249.94
266.07
784.99
743.87
230.86
84.31
75.89
 
04
977.47
188.44
96.10
69.88
131.84
73.44
245.24
158.06
331.24
9,496.10
1,594.97
450.87
265.05
272.08
774.49
726.81
300.20
98.57
89.69
 
05
1,067.15
205.70
104.70
74.42
142.63
78.90
267.41
172.38
361.49
10,493.90
1,761.83
492.59
263.20
282.00
835.88
793.80
232.83
83.72
75.45
 
06
952.21
184.54
95.20
74.40
137.52
80.46
244.53
159.29
330.50
9,507.04
1,601.04
451.42
267.12
293.80
827.38
746.67
267.56
74.98
67.20
 
07
995.59
192.18
98.58
75.44
137.65
78.15
250.91
162.12
339.25
9,869.10
1,664.37
468.64
269.01
279.35
806.41
760.75
264.02
87.29
79.04
 
08
891.17
172.28
87.87
63.26
120.10
66.80
224.64
145.10
304.63
8,573.21
1,440.45
403.68
219.96
233.43
686.87
650.99
205.52
83.04
75.22
 
09
959.79
184.65
94.38
69.92
130.40
73.00
240.06
154.69
323.55
9,678.23
1,630.69
457.28
252.19
266.25
782.32
740.97
192.43
85.84
77.49
 
10
950.00
183.47
94.50
74.19
132.90
76.19
240.31
155.59
325.15
12,128.19
2,049.63
574.97
317.41
336.15
987.04
935.83
232.19
91.90
82.52
 
11
1,250.58
239.81
122.43
90.20
169.02
94.33
310.87
200.15
417.86
13,040.10
2,192.59
613.63
331.07
352.78
1,043.82
991.23
291.36
127.80
114.37
 
                                         
TABLE 3
                               
General + MH + Dental Rates:
                                                                               
 
 
 
 
TANF 
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
(14-20)
AGE
 (21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
 
 
 
 
 
                                                     
01
984.43
187.80
98.41
76.67
142.09
82.41
245.26
158.28
326.24
9,105.08
1,515.00
432.51
268.70
292.89
795.68
702.46
227.77
96.63
86.76
 
02
984.43
187.80
99.27
83.33
143.64
83.96
244.45
157.47
325.93
9,105.09
1,515.01
435.33
275.89
273.51
742.82
687.60
246.52
98.51
88.64
 
03
1,119.05
215.14
112.34
83.37
155.49
87.52
281.35
181.61
378.51
9,838.63
1,650.61
465.60
255.18
270.70
788.49
747.08
231.90
87.26
77.34
 
04
977.47
188.45
98.28
74.52
136.78
77.53
247.57
160.06
333.90
9,496.10
1,594.99
453.16
268.97
275.55
777.64
729.71
301.57
101.51
91.14
 
05
1,067.16
205.72
108.38
82.24
150.94
85.79
275.45
179.28
370.68
10,493.91
1,761.87
497.23
271.12
289.01
842.94
800.28
237.48
92.44
79.75
 
06
952.21
184.55
97.98
80.32
143.81
85.67
248.64
162.82
335.19
9,507.05
1,601.07
454.57
272.52
298.58
832.70
751.55
270.73
80.85
70.09
 
07
995.59
192.19
100.95
80.49
143.01
82.60
253.93
164.71
342.70
9,869.10
1,664.39
471.63
274.11
283.87
810.02
764.07
266.03
90.77
80.76
 
08
891.17
172.29
90.51
68.89
126.08
71.75
227.84
147.84
308.28
8,573.21
1,440.47
406.25
224.35
237.32
691.37
655.12
207.65
87.12
77.23
 
09
959.79
184.66
97.52
76.58
137.48
78.87
242.05
156.40
325.82
9,678.23
1,630.71
460.05
256.93
270.44
784.62
743.09
193.17
88.23
78.67
 
10
950.00
183.48
97.54
80.65
139.77
81.87
242.34
157.32
327.46
12,128.20
2,049.66
578.71
323.81
341.82
989.96
938.51
234.27
94.95
84.02
 
11
1,250.59
239.83
126.08
97.97
177.28
101.17
312.69
201.72
419.94
13,040.11
2,192.62
617.59
337.84
358.76
1,047.74
994.82
294.22
131.90
116.39
                                           
TABLE 4
                               
General + MH + Transportation Rates:
                                 
 
 
 
 
 
 TANF
 
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
 (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
(14-20)
AGE
(21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
                                                                 
01
989.41
189.41
97.06
72.23
138.71
79.17
248.03
159.83
329.39
9,129.34
1,535.05
440.25
267.63
294.48
813.36
714.87
239.52
112.65
93.54
 
02
989.41
189.41
97.92
78.89
140.26
80.72
247.22
159.02
329.08
9,129.35
1,535.06
443.07
274.82
275.10
760.50
700.01
258.27
114.53
95.42
 
03
1,124.90
217.03
110.60
77.82
151.16
83.44
282.97
182.02
380.34
9,868.98
1,675.69
475.17
253.66
272.53
809.95
761.99
241.15
110.17
87.01
 
04
981.69
189.81
97.06
70.59
133.73
74.63
248.31
160.00
334.75
9,525.59
1,619.35
463.16
268.67
278.36
798.72
744.42
307.55
122.56
100.01
 
05
1,070.82
206.90
105.54
75.03
144.28
79.94
270.09
174.06
364.54
10,513.00
1,777.63
500.55
265.53
286.05
851.58
805.21
239.28
100.41
82.63
 
06
956.09
185.80
96.08
75.05
139.25
81.56
247.35
161.07
333.72
9,527.20
1,617.71
459.82
269.59
298.08
843.95
758.71
273.49
90.97
74.07
 
07
998.64
193.18
99.28
75.95
139.01
79.01
253.13
163.52
341.78
9,889.65
1,681.36
477.19
271.52
283.71
823.30
773.02
269.96
103.51
86.01
 
08
896.29
173.95
89.03
64.12
122.39
68.25
228.37
147.45
308.88
8,596.82
1,459.97
413.52
222.85
238.44
706.27
665.08
214.93
101.16
83.01
 
09
964.64
186.23
95.47
70.73
132.56
74.37
243.58
156.91
327.57
9,702.53
1,650.78
467.40
255.16
271.41
802.29
755.47
198.62
107.13
86.64
 
10
953.74
184.69
95.35
74.82
134.57
77.25
243.04
157.31
328.25
12,156.21
2,072.80
586.63
320.83
342.12
1,010.07
952.55
239.40
118.00
93.74
 
11
1,253.13
240.64
123.00
90.63
170.16
95.05
312.73
201.33
419.99
13,058.07
2,207.46
621.12
333.27
356.60
1,058.59
1,001.97
296.79
144.07
121.37
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
       
TABLE 5
                                 
General + Transportation Rates:
                                   
 
 
 
 
TANF
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
 (1-5)
AGE
(6-13)
AGE  (14-20)
AGE  (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
(14-20)
AGE
(21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
                                                               
01
989.39
189.39
95.33
60.12
126.42
66.88
244.08
155.88
325.90
9,129.26
1,534.97
428.46
196.67
226.64
709.73
677.86
236.37
99.55
80.44
 
02
989.39
189.39
95.33
60.12
126.42
66.88
244.08
155.88
325.90
9,129.26
1,534.97
428.46
196.67
226.64
709.73
677.86
236.37
99.55
80.44
 
03
1,124.89
217.02
109.47
69.66
145.14
77.42
281.60
180.65
378.96
9,868.94
1,675.65
468.50
217.96
250.39
786.76
751.87
233.28
102.50
79.34
 
04
981.68
189.80
95.77
61.23
126.83
67.73
246.74
158.43
333.17
9,525.53
1,619.29
452.40
211.14
242.68
761.34
728.12
288.45
104.68
82.13
 
05
1,070.81
206.89
104.39
66.73
138.16
73.82
268.70
172.67
363.13
10,512.96
1,777.59
494.22
231.66
265.05
829.58
795.61
234.34
91.69
73.91
 
06
956.07
185.78
93.99
60.45
124.42
66.73
242.59
156.31
329.52
9,527.14
1,617.65
450.22
211.81
242.84
759.57
728.58
272.43
87.10
70.20
 
07
998.62
193.16
97.39
62.23
128.89
68.89
250.83
161.22
339.46
9,889.59
1,681.30
467.69
220.73
252.21
790.30
758.63
264.42
90.91
73.41
 
08
896.28
173.94
87.97
56.42
116.71
62.57
227.08
146.16
307.58
8,596.78
1,459.93
407.48
190.55
218.41
685.28
655.93
208.89
88.84
70.69
 
09
964.63
186.22
93.97
59.89
124.57
66.38
241.77
155.10
325.74
9,702.49
1,650.74
460.21
216.72
247.57
777.32
744.58
193.63
96.88
76.39
 
10
953.72
184.67
93.28
59.81
123.50
66.18
240.53
154.80
325.71
12,156.16
2,072.75
577.72
273.19
312.58
979.12
939.05
234.49
111.24
86.98
 
11
1,253.11
240.62
121.08
76.75
159.92
84.81
310.41
199.01
417.64
13,058.02
2,207.41
612.78
288.66
328.94
1,029.61
989.33
289.13
137.50
114.80
                                           
TABLE 6
                                 
General + Dental Rates:
                                   
 
 
 
 
TANF
 
 
 
 

 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
(14-20)
AGE
(21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
 
 
 
 
 
 
                                                   
01
984.41
187.78
96.68
64.56
129.80
70.12
241.31
154.33
322.75
9,105.00
1,514.92
420.72
197.74
225.05
692.05
665.45
224.62
83.53
73.66
 
02
984.41
187.78
96.68
64.56
129.80
70.12
241.31
154.33
322.75
9,105.00
1,514.92
420.72
197.74
225.05
692.05
665.45
224.62
83.53
73.66
 
03
1,119.04
215.13
111.21
75.21
149.47
81.50
279.98
180.24
377.13
9,838.59
1,650.57
458.93
219.48
248.56
765.30
736.96
224.03
79.59
69.67
 
04
977.46
188.44
96.99
65.16
129.88
70.63
246.00
158.49
332.32
9,496.04
1,594.93
442.40
211.44
239.87
740.26
713.41
282.47
83.63
73.26
 
05
1,067.15
205.71
107.23
73.94
144.82
79.67
274.06
177.89
369.27
10,493.87
1,761.83
490.90
237.25
268.01
820.94
790.68
232.54
83.72
71.03
 
06
952.19
184.53
95.89
65.72
128.98
70.84
243.88
158.06
330.99
9,506.99
1,601.01
444.97
214.74
243.34
748.32
721.42
269.67
76.98
66.22
 
07
995.57
192.17
99.06
66.77
132.89
72.48
251.63
162.41
340.38
9,869.04
1,664.33
462.13
223.32
252.37
777.02
749.68
260.49
78.17
68.16
 
08
891.16
172.28
89.45
61.19
120.40
66.07
226.55
146.55
306.98
8,573.17
1,440.43
400.21
192.05
217.29
670.38
645.97
201.61
74.80
64.91
 
09
959.78
184.65
96.02
65.74
129.49
70.88
240.24
154.59
323.99
9,678.19
1,630.67
452.86
218.49
246.60
759.65
732.20
188.18
77.98
68.42
 
10
949.98
183.46
95.47
65.64
128.70
70.80
239.83
154.81
324.92
12,128.15
2,049.61
569.80
276.17
312.28
959.01
925.01
229.36
88.19
77.26
 
11
1,250.57
239.81
124.16
84.09
167.04
90.93
310.37
199.40
417.59
13,040.06
2,192.57
609.25
293.23
331.10
1,018.76
982.18
286.56
125.33
109.82
                                           
TABLE 7
                                     
General + Dental + Transportation Rates:
                             
 

 
 
 
 TANF
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE  (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
(14-20)
AGE
(21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
 
 
 
 
                                                       
01
989.39
189.40
97.81
65.40
132.03
71.53
244.94
156.62
326.88
9,129.26
1,534.99
430.82
200.70
230.20
711.99
679.93
236.56
101.30
81.30
 
02
989.39
189.40
97.81
65.40
132.03
71.53
244.94
156.62
326.88
9,129.26
1,534.99
430.82
200.70
230.20
711.99
679.93
236.56
101.30
81.30
 
03
1,124.89
217.03
112.54
76.19
152.08
83.16
284.24
182.92
381.98
9,868.94
1,675.67
471.57
223.20
255.02
790.26
755.08
234.32
105.45
80.79
 
04
981.68
189.81
97.95
65.87
131.77
71.82
249.07
160.43
335.83
9,525.53
1,619.31
454.69
215.06
246.15
764.49
731.02
289.82
107.62
83.58
 
05
1,070.82
206.91
108.07
74.55
146.47
80.71
276.74
179.57
372.32
10,512.97
1,777.63
498.86
239.58
272.06
836.64
802.09
238.99
100.41
78.21
 
06
956.07
185.79
96.77
66.37
130.71
71.94
246.70
159.84
334.21
9,527.15
1,617.68
453.37
217.21
247.62
764.89
733.46
275.60
92.97
73.09
 
07
998.62
193.17
99.76
67.28
134.25
73.34
253.85
163.81
342.91
9,889.59
1,681.32
470.68
225.83
256.73
793.91
761.95
266.43
94.39
75.13
 
08
896.28
173.95
90.61
62.05
122.69
67.52
230.28
148.90
311.23
8,596.78
1,459.95
410.05
194.94
222.30
689.78
660.06
211.02
92.92
72.70
 
09
964.63
186.23
97.11
66.55
131.65
72.25
243.76
156.81
328.01
9,702.49
1,650.76
462.98
221.46
251.76
779.62
746.70
194.37
99.27
77.57
 
10
953.72
184.68
96.32
66.27
130.37
71.86
242.56
156.53
328.02
12,156.17
2,072.78
581.46
279.59
318.25
982.04
941.73
236.57
114.29
88.48
 
11
1,253.12
240.64
124.73
84.52
168.18
91.65
312.23
200.58
419.72
13,058.03
2,207.44
616.74
295.43
334.92
1,033.53
992.92
291.99
141.60
116.82
                                           
TABLE 8
                                   
General + Mental Health + Dental + Transportation Rates:
                                                                         
 
 
 
TANF
 
 
 
 
 
SSI-N
 
 
SSI-B
SSI-AB
 
Area
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO
+2MO
3MO-11MO
AGE
(1-5)
AGE
(6-13)
AGE
 (14-20)
AGE
(21-54)
AGE (55+)
 
AGE
(65-)
AGE (65+)
 
 
 
 
 
 
Female
Male
Female
Male
 
 
 
 
 
 
                                                     
01
989.41
189.42
99.54
77.51
144.32
83.82
248.89
160.57
330.37
9,129.34
1,535.07
442.61
271.66
298.04
815.62
716.94
239.71
114.40
94.40
 
02
989.41
189.42
100.40
84.17
145.87
85.37
248.08
159.76
330.06
9,129.35
1,535.08
445.43
278.85
278.66
762.76
702.08
258.46
116.28
96.28
 
03
1,124.90
217.04
113.67
84.35
158.10
89.18
285.61
184.29
383.36
9,868.98
1,675.71
478.24
258.90
277.16
813.45
765.20
242.19
113.12
88.46
 
04
981.69
189.82
99.24
75.23
138.67
78.72
250.64
162.00
337.41
9,525.59
1,619.37
465.45
272.59
281.83
801.87
747.32
308.92
125.50
101.46
 
05
1,070.83
206.92
109.22
82.85
152.59
86.83
278.13
180.96
373.73
10,513.01
1,777.67
505.19
273.45
293.06
858.64
811.69
243.93
109.13
86.93
 
06
956.09
185.81
98.86
80.97
145.54
86.77
251.46
164.60
338.41
9,527.21
1,617.74
462.97
274.99
302.86
849.27
763.59
276.66
96.84
76.96
 
07
998.64
193.19
101.65
81.00
144.37
83.46
256.15
166.11
345.23
9,889.65
1,681.38
480.18
276.62
288.23
826.91
776.34
271.97
106.99
87.73
 
08
896.29
173.96
91.67
69.75
128.37
73.20
231.57
150.19
312.53
8,596.82
1,459.99
416.09
227.24
242.33
710.77
669.21
217.06
105.24
85.02
 
09
964.64
186.24
98.61
77.39
139.64
80.24
245.57
158.62
329.84
9,702.53
1,650.80
470.17
259.90
275.60
804.59
757.59
199.36
109.52
87.82
 
10
953.74
184.70
98.39
81.28
141.44
82.93
245.07
159.04
330.56
12,156.22
2,072.83
590.37
327.23
347.79
1,012.99
955.23
241.48
121.05
95.24
 
11
1,253.14
240.66
126.65
98.40
178.42
101.89
314.55
202.90
422.07
13,058.08
2,207.49
625.08
340.04
362.58
1,062.51
1,005.56
299.65
148.17
123.39
                                           
Area
 
Corresponding Counties
                                                         
Area 1
 
Escambia, Okaloosa, Santa Rosa, Walton
   
Area 2
 
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Madison, Taylor, Washington, Wakulla
   
Area 3
 
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hernando,
Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union
     
Area 4
 
Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
     
Area 5
 
Pasco, Pinellas
                   
Area 6
 
Hardee, Highlands, Hillsborough, Manatee, Polk
   
Area 7
 
Brevard, Orange, Osceola, Seminole
       
Area 8
 
Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota
         
Area 9
 
Indian River, Okeechobee, St. Lucie, Martin, Palm Beach
     
Area 10
 
Broward
       
Area 11
 
Dade, Monroe
                     
created on august 11, 2006
                   

 
 

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

ATTACHMENT II

Medicaid Prepaid Health Plan Model Contract

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

 
Table of Contents

 
Section I Definitions and Acronyms
 

 
A.
Definitions
 

 
B.
Acronyms
 

 
Section II General Overview
 

 
A.
Purpose
 

 
B.
Responsibilities of the State of Florida (State) and the Agency for Health Care
Administration (Agency)
 

 
C .
General Responsibilities of the Health Plan
 

 
Section III Eligibility and Enrollment
 

 
A.
Eligibility
 

 
B.
Enrollment
 

 
C.
Disenrollment
 

 
Section IV Enrollee Services and Marketing
 

 
A.
Enrollee Services
 

 
B.
Marketing
 

 
Section V Covered Services
 

 
A.
Covered Services
 

 
B.
Optional Services
 

 
C.
Expanded Services
 

 
D.
Excluded Services
 

 
E.
Moral or Religious Objections
 

 
F.
Coverage Provisions
 

 
Section VI Behavioral Health Care
 

 
A.
General Provisions
 

 
B.
Service Requirements
 

 
C.
Behavioral Health Managed Care Local Advisory Group
 

 
D.
Community Behavioral Health Services Annual 80/20 Expenditure Report
 

 
Section VII Provider Network
 

 
A.
General Provisions
 

 
B.
Primary Care Providers
 

 
C.
Minimum Standards
 

 
D.
Appointment Waiting Times and Geographic Access Standards
 

 
E.
Behavioral Health Services
 

 
F.
Specialists and Other Providers
 

 
G.
Continuity of Care
 

 
H.
Network Changes
 

 
Section VIII Quality Management
 

 
A.
Quality Improvement
 

 
B.
Utilization Management (UM)
 

 
Section IX
 
 
Grievance System
 

 
A.
General Requirements
 

 
B.
The Grievance Process
 

 
C.
The Appeal Process
 

 
D.
Medicaid Fair Hearing System
 

 
Section X Administration and Management
 

 
A.
General Provisions
 

 
B.
Staffing
 

 
C.
Provider Contract Requirements
 

 
D.
Provider Termination
 

 
E.
Provider Services
 

 
F.
Medical Records Requirements
 

 
G.
Claims Payment
 

 
H.
Encounter Data
 

 
I.
Fraud Prevention
 

 
Section XI Information Management and Systems
 

 
A.
General Provisions
 

 
B.
Data and Document Management Requirements
 

 
C.
System and Data Integration Requirements
 

 
D.
Systems Availability, Performance and Problem Management Requirements
 

 
E.
System Testing and Change Management Requirements
 

 
F.
Information Systems Documentation Requirements
 

 
G.
Reporting Requirements - Specific to Information Management and Systems
Functions and Capabilities - and Technological Capabilities
 

 
H.
Other Requirements
 

 
I.
Compliance with Standard Coding Schemes
 

 
J.
Data Exchange and Formats and Methods Applicable to Health Plans
 

 
Section XII Reporting Requirements
 

 
A.
Health Plan Reporting Requirements
 

 
B.
Enrollment/Disenrollment Reports:
 

 
C.
Grievance System
 

 
D.
Provider Reporting
 

 
E.
Marketing Representative Report
 

 
F.
Critical Incidents
 

 
G.
Hernandez Settlement Agreement (HSA) Report
 

 
H.
Performance Measure Report
 

 
I.
Financial Reporting
 

 
J.
Suspected Fraud Reporting
 

 
K.
Information Systems Availability and Performance Report
 

 
L.
Claims Inventory Summary Report
 

 
M.
Child Health Check-Up Reports
 

 
N.
Pharmacy Encounter Data
 

 
O.
Transportation Services
 

 
P.
Enrollee Satisfaction Survey Summary
 

 
Q.
Stakeholders’ Satisfaction Survey Summary
 

 
R.
Behavioral Health Services Grievance and Appeals Reporting Requirements
 

 
S.
Critical Incident Reporting
 

 
T.
Required Staff/Providers
 

 
U.
FARS/CFARS
 

 
V.
Behavioral Health Encounter Report
 

 
W.
Behavioral Health Pharmacy Encounter Data Report
 

 
X.
Minority Participation Report
 

 
Section XIII Method of Payment
 

 
A.
Fixed Price Unit Contract
 

 
B.
Child Health Check-Up Incentive Program
 

 
C.
Capitation Rate
 

 
D.
Errors
 

 
E.
Member Payment Liability Protection
 

 
F.
Co-payments
 

 
G.
Enrollment Levels
 

 
H.
Transition to Medicaid Reform
 

 
I.
Cost Effectiveness
 

 
Section XIV Sanctions
 

 
A.
General Provisions
 

 
B.
Specific Sanctions
 

 
Section XV Financial Requirements
 

 
A.
Insolvency Protection
 

 
B.
Insolvency Protection Account Waiver
 

 
C.
Surplus Start Up Account
 

 
D.
Surplus Requirement
 

 
E.
Interest
 

 
F.
Inspection and Audit of Financial Records
 

 
G.
Physician Incentive Plans
 

 
H.
Third Party Resources
 

 
I.
Fidelity Bonds
 

 
Section XVI Terms and Conditions
 

 
A.
Agency Contract Management
 

 
B.
Applicable Laws and Regulations
 

 
C.
Assignment
 

 
D.
Attorney's Fees
 

 
E.
Conflict of Interest
 

 
F.
Contract Variation
 

 
G.
Court of Jurisdiction or Venue
 

 
H.
Damages for Failure to Meet Contract Requirements
 

 
I.
Disputes
 

 
J.
Force Majeure
 

 
K.
Legal Action Notification
 

 
L.
Licensing
 

 
M.
Misuse of Symbols, Emblems, or Names in Reference to Medicaid
 

 
N.
Offer of Gratuities
 

 
O.
Subcontracts
 

 
P.
Hospital Provider Contracts
 

 
Q.
Termination Procedures
 

 
R.
Waiver
 

 
S.
Withdrawing Services from a County
 

 
T.
MyFloridaMarketPlace Vendor Registration
 

 
U.
MyFloridaMarketplace Vendor Registration and Transaction Fee Exemption
 

 
V.
Ownership and Management Disclosure
 

 
W.
Minority Recruitment and Retention Plan
 

 
X.
Independent Provider
 

 
Y.
General Insurance Requirements
 

 
Z.
Worker's Compensation Insurance
 

 
AA.
State Ownership
 

 
BB.
Disaster Plan
 

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

Section I
 
Definitions and Acronyms
 

A.
Definitions

The following terms as used in this Contract shall be construed and/or
interpreted as follows, unless the Contract otherwise expressly requires a
different construction and/or interpretation.

Abandoned Call— A call in which the caller elects an option and is either not
permitted access to that option or disconnects from the system.

Abuse — Provider practices that are inconsistent with generally accepted
business or medical practices and that result in an unnecessary cost to the
Medicaid program or in reimbursement for goods or services that are not
medically necessary or that fail to meet professionally recognized standards for
health care; or recipient practices that result in unnecessary cost to the
Medicaid program.

Action— The denial or limited authorization of a requested service, including
the type or level of service, pursuant to 42 CFR 438.400(b). The reduction,
suspension or termination of a previously authorized service. The denial, in
whole or in part, of payment for a service. The failure to provide services in a
timely manner, as defined by the State. The failure of the Health Plan to act
within ninety (90) days from the date the Health Plan receives a Grievance, or
forty-five (45) days from the date the Health Plan receives an Appeal. For a
resident of a Rural area with only one (1) managed care entity, the denial of an
Enrollee's request to exercise his or her right to obtain services outside the
network.

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

Advanced Registered Nurse Practitioner (ARNP) — A licensed advanced registered
nurse practitioner who works in collaboration with a physician according to
protocol, to provide diagnostic and clinical interventions. An ARNP must be
authorized to provide these services by Chapter 464, F.S., and protocols filed
with the Board of Medicine.

Agency— State of Florida, Agency for Health Care Administration.

Agent— An entity that contracts with the State to perform administrative
functions, including but not limited to: Fiscal Agent activities; outreach and
education, eligibility and Enrollment activities; Systems and Technical support.

Ancillary Provider— A Provider of ancillary medical services who has contracted
with a Health Plan to provide ancillary medical services to the Health Plan's
Enrollees.

Authoritative Host:— A system that contains the master or “authoritative” data
for a particular data type, e.g. Enrollee, Provider, Health Plan, etc. The
Authoritative Host may feed data from its master data files to other systems in
real time or in batch mode. Data in an Authoritative Host is expected to be
up-to-date and reliable.

Automatic Assignment (or Auto-Assign)— The Enrollment of an eligible Medicaid
Recipient, for whom Enrollment is mandatory, in a Health Plan chosen by AHCA or
its Agent, and/or the assignment of a new Enrollee to a PCP chosen by the Health
Plan.

Appeal— A request for review of an Action, pursuant to 42 CFR 438.400(b).

Baker Act— The Florida Mental Health Act, pursuant to ss. 394.451-394.4789, F.S.

Behavioral Health Services— Services listed in the Community Mental Health
Services Coverage & Limitations Handbook and the Targeted Case Management
Coverage & Limitations Handbook as specified in this Contract in Section VI.A
Behavioral Health Care, General Provisions.

Behavioral Health Care Case Manager— An individual who provides mental health
care Case Management services directly to or on behalf of an Enrollee on an
individual basis in accordance with 65E-15, F.A.C., and the Medicaid Targeted
Case Management Handbook.

Behavioral Health Care Provider— A licensed mental health professional, such as
a "Clinical Psychologist," or registered nurse qualified due to training or
competency in mental health care, who is responsible for the provision of mental
health care to patients, or a physician licensed under Chapters 458 or 459,
F.S., who is under contract to provide Behavioral Health Services to Enrollees.

Benefits— A schedule of health care services to be delivered to Enrollees
covered by the Health Plan as set forth in Section V and Section VI of this
Contract.

Blocked Call— A call that cannot be connected immediately because no circuit is
available at the time the call arrives or the telephone system is programmed to
block calls from entering the queue when the queue backs up behind a defined
threshold.

Business Days— Traditional workdays, which are Monday, Tuesday, Wednesday,
Thursday, and Friday. State holidays are excluded.

Calendar Days— All seven (7) days of the week.

Capitation Rate— The per member per month amount, including any adjustments,
that is paid by the Agency to the Health Plan for each Medicaid Recipient
enrolled under this Contract for the provision of Medicaid services during the
payment period.

Case Management— A process which assesses, plans, implements, coordinates,
monitors and evaluates the options and services required to meet an Enrollee's
health needs using communication and all available resources to promote quality
cost-effective outcomes. Proper Case Management occurs across a continuum of
care, addressing the ongoing individual needs of an Enrollee rather than being
restricted to a single practice setting.

Cause— Special reasons that allow Mandatory Enrollees to change their Health
Plan option outside their Open Enrollment period. May also be referred to as
“Good Cause.”

Centers for Medicare & Medicaid Services (CMS) — The agency within the United
States Department of Health & Human Services that provides administration and
funding for Medicare under Title XVIII, Medicaid under Title XIX, and the State
Children’s Health Insurance Program under Title XXI of the Social Security Act.

Certification— The process of determining that a facility, equipment or an
individual meets the requirements of federal or State law, or whether Medicaid
payments are appropriate or shall be made in certain situations.

Child Health Check-Up Program (CHCUP) — A comprehensive and preventative health
examinations provided on a periodic basis that are aimed at identifying and
correcting medical conditions in Children/Adolescents. Policies and procedures
are described in the Child Health Check-Up Services Coverage and Limitations
Handbook.

Children/Adolescents— Enrollees under the age of 21.

Children & Families Services Program Office— Also referred to as the Children &
Families Safety & Preservation Program Office, located in the DCF; the State
agency responsible for overseeing programs that identify and protect abused and
neglected Children and attempt to prevent domestic violence.

Choice Counselor/Enrollment Broker— The State’s contracted or designated entity
that performs functions related to outreach, education, counseling, Enrollment,
and Disenrollment of Potential Enrollees into a Health Plan.

Choice Counseling Specialists— Certified individuals authorized by an
Agency-approved process who provide one-on-one information to Medicaid
Recipients, to assist the Medicaid Recipients in choosing the Health Plan that
best meets their health care needs and those of their family.

Cold Call Marketing— Any unsolicited personal contact with a Medicaid Recipient
by the Health Plan, its staff, its volunteers or its vendors with the purpose of
influencing the Medicaid Recipient to enroll in the Health Plan or either to not
enroll in, or disenroll from, another Health Plan.

Community Living Support Plan - A written document prepared by a mental health
resident of an assisted living facility with a limited mental health license and
the resident's mental health case manager in consultation with the administrator
or the administrator's designee of the assisted living facility with a limited
mental health license. A copy must be provided to the administrator. The plan
must include information about the supports, services, and special needs of the
resident which enable the resident to live in the assisted living facility and a
method by which facility staff can recognize and respond to the signs and
symptoms particular to that resident which indicate the need for professional
services.
 
Continuous Quality Improvement— A management philosophy that mandates
continually pursuing efforts to improve the quality of products and services
produced by an organization.

Contract— The agreement between the Health Plan and the Agency to provide
Medicaid services to Enrollees, comprised of the Contract, any addenda,
appendices, attachments, or amendments thereto.

Contract Period - The term of the contract from September 1, 2006 through August
31, 2009.

Contract Year - The period of time from September 1 through August 31 of each
calendar year.

Contracting Officer — The Secretary of the Agency or his/her delegate.

Cost Effective — The Health Plan’s per-member, per-month costs to the State,
including, but not limited to, FFS costs, administrative costs, and
case-management fees, must be no greater than the State's costs associated with
capitated Health Plans.

County Health Department (CHD)— CHDs are organizations administered by the
Department of Health for the purpose of providing health services as defined in
Chapter 154, F.S., which include the promotion of the public's health, the
control and eradication of preventable diseases, and the provision of primary
health care for special populations.

Coverage & Limitations Handbook (Handbook)— A document that provides information
to a Medicaid Provider regarding Enrollee eligibility, claims submission and
processing, Provider participation, covered care, goods and services,
limitations, procedure codes and fees, and other matters related to
participation in the Medicaid program.

Covered Services— Those services provided by the Health Plan in accordance with
this Contract, and as outlined in Section V Covered Services and Section VI
Behavioral Health Care in this Contract.

Crisis Support— Services for persons initially perceived to need emergency
mental health services, but upon assessment, do not meet the criteria for such
emergency care. These are acute care services that are available twenty-four
(24) hours a day, seven (7) days a week, for intervention. Examples include:
mobile crisis, crisis/emergency screening, crisis hot-line and emergency
walk-in.

Direct Ownership Interest — The ownership of stock, equity in capital or any
interest in the profits of the disclosing entity. A disclosing entity is defined
as a Medicaid provider or supplier, or other entity that furnishes services or
arranges for furnishing services under Medicaid, or health related services
under the social services program.

Direct Service Behavioral Health Care Provider— An individual qualified by
training or experience to provide direct behavioral health services under the
supervision of the Health Plan’s medical director.

Disease Management - A system of coordinated health care intervention and
communication for populations with conditions in which patient self-care efforts
are significant. Disease Management supports the physician or
practitioner/patient relationship and plan of care; emphasized prevention of
exacerbations and complications utilizing evidence-based practice guidelines and
patient empowerment strategies, and evaluates clinical, humanistic and economic
outcomes on an ongoing basis with the goal of improving overall health.

Disenrollment— The Agency approved discontinuance of an Enrollee's Enrollment in
a Health Plan.

Disclosing Entities— A Medicaid provider, other than an individual practitioner
or group of practitioners, or a fiscal agent that furnishes services or arranges
for furnishing services under Medicaid, or health related services under the
social services program.

Downward Substitution of Care— The use of less restrictive, lower cost services
than otherwise might have been provided, that are considered clinically
acceptable and necessary to meet specified objectives outlined in an Enrollee's
plan of treatment, provided as an alternative to higher cost services. For
services related to mental health, Downward Substitution of Care may include
care provided by private practice psychologists and social workers,
psycho-social rehabilitation, Medicaid community mental health services or
Medicaid mental health targeted Case Management, and other services considered
clinically appropriate, more cost-effective and less restrictive.

Durable Medical Equipment (DME)— Medical equipment that can withstand repeated
use, is customarily used to serve a medical purpose, is generally not useful in
the absence of illness or injury and is appropriate for use in the Enrollee's
home.

Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT)—See Child
Health Check Up Program.

Emergency Behavioral Health Services— Those services required to meet the needs
of an individual who is experiencing an acute crisis, resulting from a mental
illness, which is a level of severity that would meet the requirements for an
involuntary examination as specified in Section 394.463, F.S., and in the
absence of a suitable alternative or psychiatric medication, would require
hospitalization.

Emergency Medical Condition— (I) A medical condition manifesting itself by acute
symptoms of sufficient severity, which may include severe pain or other acute
symptoms, such that a prudent layperson who possesses an average knowledge of
health and medicine, could reasonably expect that the absence of immediate
medical attention could reasonably be expected to result in any of the
following: (1) Serious jeopardy to the health of a patient, including a pregnant
woman or fetus; (II) Serious impairment to bodily functions; (3) Serious
dysfunction of any bodily organ or part. (b) With respect to a pregnant woman:
(1) That there is inadequate time to effect safe transfer to another Hospital
prior to delivery; (2) That a transfer may pose a threat to the health and
safety of the patient or fetus; (3) That there is evidence of the onset and
persistence of uterine contractions or rupture of the membranes, in accordance
with Section 395.002, F.S.

Emergency Services and Care— Medical screening, examination and evaluation by a
physician or, to the extent permitted by applicable laws, by other appropriate
personnel under the supervision of a physician, to determine whether an
Emergency Medical Condition exists. If an Emergency Medical Condition exists,
Emergency Services and Care includes the care or treatment that is necessary to
relieve or eliminate the Emergency Medical Condition within the service
capability of the facility.

Emergency Transportation - The provision of Emergency Transportation Services in
accordance with Section 409.908(13)(d)(4), F.S.

Encounter Data - A record of Covered Services provided to Enrollees of a Health
Plan. An Encounter is an interaction between a patient and Provider (health
plan, rendering physician, pharmacy, lab, etc.) who delivers services or is
professionally responsible for services delivered to a patient.

Enrollee— A Medicaid Recipient currently enrolled in the Health Plan.

Enrollment— The process by which an eligible Medicaid Recipient becomes an
Enrollee in a Health Plan.

Enrollee Suicide Attempt— An act which clearly reflects an attempt by an
Enrollee to cause his or her own death, which results in bodily injury requiring
medical treatment by a licensed health care professional.

Expanded Services— A Health Plan Covered Service for which the Health Plan
receives no direct payment from the Agency.

Expedited Appeal Process— The process by which the Appeal of an Action is
accelerated because the standard time-frame for resolution of the Appeal could
seriously jeopardize the Enrollee's life, health or ability to obtain, maintain
or regain maximum function.

External Quality Review (EQR) — The analysis and evaluation by an EQRO of
aggregated information on quality, timeliness, and access to the health care
services that are furnished to Medicaid recipients by a Health Plan.

External Quality Review Organization (EQRO)— An organization that meets the
competence and independence requirements set forth in federal regulations 42 CFR
438.354, and performs EQR, other related activities as set forth in federal
regulations or both.

Federal Fiscal Year - The United States government’s fiscal year starts October
1 and ends on September 30.

Federally Qualified Health Center (FQHC)— An entity that is receiving a grant
under section 330 of the Public Health Service Act, as amended, and Section
1905(1)(2)(B) of the Social Security Act. FQHCs provide primary health care and
related diagnostic services and may provide dental, optometric, podiatry,
chiropractic and mental health services.

Fee-for-Service (FFS)— A method of making payment by which the Agency sets
prices for defined medical or allied care, goods or services.

Fiscal Agent— Any corporation, or other legal entity, that enters into a
contract with the Agency to receive, process and adjudicate claims under the
Medicaid program.

Fiscal Year — The State of Florida’s Fiscal Year starts July 1 and ends on June
30.

Florida Medicaid Management Information System (FMMIS)— The information system
used to process Florida Medicaid claims and payments to Health Plans, and to
produce management information and reports relating to the Florida Medicaid
program. This system is used to maintain Medicaid eligibility data and provider
enrollment data.

Florida Mental Health Act — Includes the Baker Act that covers admissions for
persons who are considered to have an emergency mental health condition (a
threat to themselves or others), as specified in ss. 394.451-394.4789, F.S.

Fraud — An intentional deception or misrepresentation made by a person with the
knowledge that the deception results in unauthorized benefit to herself or
himself or another person. The term includes any act that constitutes fraud
under applicable federal or state law.

Full-Time Equivalent Position (FTE)— The equivalent of one (1) full-time
employee who works 40 hours per week.

Good Cause— See Cause.

Grievance— An expression of dissatisfaction about any matter other than an
Action. Possible subjects for grievances include, but are not limited to, the
quality of care, the quality of services provided and aspects of interpersonal
relationships such as rudeness of a Provider or employee or failure to respect
the Enrollee's rights.

Grievance Procedure— The procedure for addressing Enrollees' grievances.

Grievance System— The system for reviewing and resolving Enrollee Grievances and
Appeals. Components must include a Grievance process, an Appeal process and
access to the Medicaid Fair Hearing system.

Health Assessment— A complete health evaluation combining health history,
physical assessment and the monitoring of physical and psychological growth and
development.

Health Care Professional— A physician or any of the following: podiatrist,
optometrist, chiropractor, psychologist, dentist, Physician Assistant, physical
or occupational therapist, therapist assistant, speech-language pathologist,
audiologist, Registered or practical Nurse (including nurse practitioner,
clinical nurse specialist, certified Registered Nurse anesthetist and certified
nurse midwife), a licensed certified social worker, registered respiratory
therapist and certified respiratory therapy technician.

Health Fair— An event conducted in a setting that is open to the public or
segment of the public (such as the "elderly" or "schoolchildren") during which
information about health-care services, facilities, research, preventative
techniques or other health-care subjects is disseminated. At least two (2)
health-related organizations that are not affiliated under common ownership must
actively participate in the Health Fair.

Health Maintenance Organization (HMO)— An organization or entity licensed in
accordance with Section 641 of the Florida Statutes or in accordance with the
Florida Medicaid State plan definition of an HMO.

Health Plan— An entity that integrates financing and management with the
delivery of health care services to an enrolled population. It employs or
contracts with an organized system of Providers, which deliver services and
frequently shares financial risk. For the purposes of this Contract, a Health
Plan has also contracted with the Agency to provide Medicaid services under the
Florida Medicaid Reform program, and includes health maintenance organizations
authorized under chapter 641 of the Florida Statutes, exclusive provider
organizations as defined in chapter 627 of the Florida Statutes, health insurers
authorized under chapter 624 of the Florida Statutes, and Provider Service
Networks as defined in Section 409.912, Florida Statutes.

Hospital— A facility licensed in accordance with the provisions of Chapter 395,
Florida Statutes or the applicable laws of the state in which the service is
furnished.

Hospital Services Agreement— The agreement between the Health Plan and a
Hospital to provide medical services to the Health Plan's Enrollees.

Indirect Ownership Interest — Ownership interest in an entity that has direct or
indirect ownership interest in the disclosing entity. The amount of indirect
ownership in the disclosing entity that is held by any other entity is
determined by multiplying the percentage of ownership interest at each level. An
indirect ownership interest must be reported if it equates to an ownership
interest of five percent (5%) or more in the disclosing entity. Example: If “A”
owns ten percent (10%) of the stock in a corporation that owns eighty percent
(80) of the stock of the disclosing entity, “A’s” interest equates to an eight
percent (8%) indirect ownership and must be reported.

Individuals with Special Health Care Needs — Adults and Children/Adolescents,
who face physical, mental or environmental challenges daily that place at risk
their health and ability to fully function in society. Factors include
individuals with mental retardation or related conditions; individuals with
serious chronic illnesses, such as human immunodeficiency virus (HIV),
schizophrenia or degenerative neurological disorders; individuals with
disabilities resulting from many years of chronic illness such as arthritis,
emphysema or diabetes; and Children/Adolescents and adults with certain
environmental risk factors such as homelessness or family problems that lead to
the need for placement in foster care.

Information— (i) Structured Data: Data that adhere to specific properties and
Validation criteria that are stored as fields in database records. Structured
queries can be created and run against structured data, where specific data can
be used as criteria for querying a larger data set; (ii) Document: Information
that does not meet the definition of structured data includes text, files,
spreadsheets, electronic messages and images of forms and pictures.

Information System(s)— A combination of computing hardware and software that is
used in: (a) the capture, storage, manipulation, movement, control, display,
interchange and/or transmission of information, i.e. structured data (which may
include digitized audio and video) and documents; and/or (b) the processing of
such information for the purposes of enabling and/or facilitating a business
process or related transaction.

Insolvency— A financial condition that exists when an entity is unable to pay
its debts as they become due in the usual course of business, or when the
liabilities of the entity exceeds its assets.

Licensed — A facility, equipment, or an individual that has formally met state,
county, and local requirements, and has been granted a license by a local, state
or federal government entity.

Licensed Practitioner of the Healing Arts — A psychiatric nurse, Registered
Nurse, advanced registered nurse practitioner, Physician Assistant, clinical
social worker, mental health counselor, marriage and family therapist, or
psychologist.

List of Excluded Individuals and Entities (LEIE)— A database maintained by the
Department of Health & Human Services, Office of the Inspector General. The LEIE
provides information to the public, health care providers, patients and others
relating to parties excluded from participation in Medicare, Medicaid and all
other federal health care programs.

Managed Behavioral Health Organization (MBHO)— A behavioral health-care delivery
system managing quality, utilization and cost of services. Additionally, an MBHO
measures performance in the area of mental disorders.

Mandatory Assignment— The process the Agency uses to assign Potential Enrollees
to a Health Plan. The Agency automatically assigns those Mandatory Potential
Enrollees who did not voluntarily choose a Health Plan.

Market Area— The geographic area in which the Health Plan is authorized to
market and/or conduct pre-enrollment activities.

Marketing— Any activity or communication conducted by or on behalf of any Health
Plan to a Medicaid Recipient who is not Enrolled with the Health Plan, that can
reasonably be interpreted as intended to influence the Medicaid Recipient to
enroll in the particular Health Plan, or either to not enroll in, or disenroll
from, another Health Plan.

Marketing Representative — A person who provides information, pre-enrollment
assistance, or otherwise promotes a Health Plan. Marketing Representatives shall
be limited to licensed insurance agents.

Medicaid Area — The specific counties designated by the Agency.

Medicaid— The medical assistance program authorized by Title XIX of the Social
Security Act, 42 U.S.C. §1396 et seq., and regulations there under, as
administered in the State of Florida by the Agency under 409.901 et seq., F.S.

Medicaid Recipient— Any individual whom DCF, or the Social Security
Administration on behalf of the DCF, determines is eligible, pursuant to federal
and State law, to receive medical or allied care, goods or services for which
the Agency may make payments under the Medicaid program, and who is enrolled in
the Medicaid program.

Medicaid Reform— The program resulting from Chapter 409.91211, F.S.

Medical Record— Documents corresponding to medical or allied care, goods or
services furnished in any place of business. The records may be on paper,
magnetic material, film or other media. In order to qualify as a basis for
reimbursement, the records must be dated, legible and signed or otherwise
attested to, as appropriate to the media.

Medically Necessary or Medical Necessity— Services that include medical or
allied care, goods or services furnished or ordered to:

 
1.
Meet the following conditions:

 
a.
Be necessary to protect life, to prevent significant illness or significant
disability or to alleviate severe pain;

 
b.
Be individualized, specific and consistent with symptoms or confirm diagnosis of
the illness or injury under treatment and not in excess of the patient's needs;

 
c.
Be consistent with the generally accepted professional medical standards as
determined by the Medicaid program, and not be experimental or investigational;

 
d.
Be reflective of the level of service that can be furnished safely and for which
no equally effective and more conservative or less costly treatment is available
statewide; and

 
e.
Be furnished in a manner not primarily intended for the convenience of the
Enrollee, the Enrollee's caretaker or the provider.

 
2.
Medically Necessary or Medical Necessity for those services furnished in a
Hospital on an inpatient basis cannot, consistent with the provisions of
appropriate medical care, be effectively furnished more economically on an
outpatient basis or in an inpatient facility of a different type.

 
3.
The fact that a provider has prescribed, recommended or approved medical or
allied goods or services does not, in itself, make such care, goods or services
Medically Necessary, a Medical Necessity or a Covered Service/Benefit.

Medicare — The medical assistance program authorized by Title XVIII of the
Social Security Act.

Meds AD— Those recipients up to 88% of FPL with assets up to $5,000 for an
individual and $6,000 for a couple without Medicare and those with Medicare that
are not receiving institutional care, hospice care, or home and community based
services.

Neglect — A failure or omission to provide care, supervision, and services
necessary to maintain enrollee’s physical and mental health, including but not
limited to, food, nutrition, supervision and medical services that are essential
for the well-being of the enrollee. Neglect might be a single incident or
repeated conduct that results in, or could reasonably expected to result in,
serious physical or psychological injury, or a substantial risk of death.

Newborn— A live child born to an Enrollee, who is a member of the Health Plan.

Non-Covered Service— A service that is not a Covered Service/Benefit of the
Medicaid State Plan or of the Health Plan.

Nursing Facility— An institutional care facility that furnishes medical or
allied inpatient care and services to individuals needing such services. See
Chapters 395 and 400, F.S.

Open Enrollment— The sixty (60) day period before the end of an Enrollee's
Enrollment year, during which an Enrollee may choose to change Health Plans for
the following Enrollment year.

Outpatient— A patient of an organized medical facility, or distinct part of that
facility, who is expected by the facility to receive, and who does receive,
professional services for less than a twenty-four (24) hour period, regardless
of the hours of admission, whether or not a bed is used and/or whether or not
the patient remains in the facility past midnight.

Overpayment — Includes any amount that is not authorized to be paid by the
Medicaid program whether paid as a result of inaccurate or improper cost
reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake. 

Participating Specialist— A physician, licensed to practice medicine in the
State of Florida, who contracts with the Health Plan to provide specialized
medical services to the Health Plan's Enrollees.

Peer Review— An evaluation of the professional practices of a provider by the
provider's peers in order to assess the necessity, appropriateness and quality
of care furnished as such care is compared to that customarily furnished by the
provider's peers and to recognized health care standards.

Penultimate Saturday— The Saturday preceding the last Saturday of the month.

Penultimate Sunday — The Sunday preceding the last Sunday of the month.

Pharmacy Benefits Administrator— An entity contracted to or included in a health
plan accepting pharmacy prescription claims for enrollees in the plan, assuring
these claims conform to coverage policy and determining the allowed payment.

Physician’s Assistant — A person who is a graduate of an approved program or its
equivalent or meets standards approved by the Board of Medicine and is certified
to perform medical services delegated by the supervising physician in accordance
with Chapter 458, F.S.

Physicians' Current Procedural Terminology (CPT)—A systematic listing and coding
of procedures and services published annually by the American Medical
Association.

Portable X-Ray Equipment— X-ray equipment transported to a setting other than a
hospital, Clinic or office of a physician or other Licensed Practitioner of the
Healing Arts.

Post-Stabilization Care Services— Covered Services related to an Emergency
Medical Condition that are provided after an Enrollee is stabilized in order to
maintain the condition, or to improve or resolve the Enrollee's condition
pursuant to 42 CFR 422.113.

Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid
Recipient who is subject to Mandatory Assignment or may voluntarily elect to
enroll in a given Health Plan, but is not yet an Enrollee of a specific Health
Plan.

Pre-Enrollment — The provision of Marketing and educational materials to a
Medicaid Recipient and assistance in completing the Request for Benefit
Information (RBI).

Pre-Enrollment Application— See Request for Benefit Information.

Prepaid Health Plan— A Health Plan reimbursed on a prepaid basis. (see Health
Plan)

Primary Care— Comprehensive, coordinated and readily-accessible medical care
including: health promotion and maintenance; treatment of illness and injury;
early detection of disease; and referral to specialists when appropriate.

Primary Care Case Management— The provision or arrangement of Enrollees’ primary
care and the referral of Enrollees for other necessary medical services on a
24-hour basis.

Primary Care Provider (PCP)— A Health Plan staff or contracted physician
practicing as a general or family practitioner, internist, pediatrician,
obstetrician, gynecologist, advanced registered nurse practitioners, physician
assistants or other specialty approved by the Agency, who furnishes Primary Care
and patient management services to an Enrollee. See Sections 641.19, 641.31 and
641.51, F.S.

Prior Authorization— The act of authorizing specific services before they are
rendered.

Protocols— Written guidelines or documentation outlining steps to be followed
for handling a particular situation, resolving a problem or implementing a plan
of medical, nursing, psychosocial, developmental and educational services.

Provider — A person or entity that is eligible to provide Medicaid services and
has a contractual agreement with the Health Plan to provide Medicaid services.

Provider Contract — An agreement between the Health Plan and a health care
Provider as described above.

Provider Service Network (PSN) — A network established or organized and operated
by a health care provider, or group of affiliated health care providers,
including minority physician networks and emergency room diversion programs that
meet the requirements of Section 409.91211, F.S., which provides a substantial
proportion of the health care items and services under a contract directly
through the provider or affiliated group of providers and may make arrangements
with physicians or other health care professionals, health care institutions, or
any combination of such individuals or institutions to assume all or part of the
financial risk on a prospective basis for the provision of basic health services
by the physicians, by other health professionals, or through the institutions.
The health care providers must have a controlling interest in the governing body
of the provider service network organization.
 
Public Event— An event sponsored for the public or segment of the public by two
(2) or more actively participating organizations, one (1) of which may be a
health organization.

Quality— The degree to which a Health Plan increases the likelihood of desired
health outcomes of its Enrollees through its structural and operational
characteristics and through the provision of health services that are consistent
with current professional knowledge.

Quality Enhancements - Certain health-related, community-based services that the
Health Plan must offer and coordinate access to for its Enrollees, such as
children’s programs, domestic violence classes, pregnancy prevention, smoking
cessation, or substance abuse programs. Health Plans are not reimbursed by the
Agency for these types of services.

Quality Improvement (QI) — The process of monitoring and assuring that the
delivery of health care services are available, accessible, timely, Medically
Necessary, and provided in sufficient quantity, of acceptable Quality, within
established standards of excellence, and appropriate for meeting the needs of
the Enrollees.
 
Quality Improvement Program (QIP) — The process of assuring the delivery of
health care is appropriate, timely, accessible, available and Medically
Necessary.

Registered Nurse (RN) — An individual who is licensed to practice professional
nursing in accordance with Chapter 464, F.S.
 
Request for Benefit Information (RBI)— The form completed by a Potential
Enrollee with the assistance of a Health Plan representative and submitted by
the Health Plan to the Choice Counselor/Enrollment Broker to initiate the
receipt of information for the Enrollment process. Also known as Pre-Enrollment
Application.

Residential Services — As applied to DJJ, refers to the out-of-home placement
for use in a level 4, 6, 8 or 10 facility as a result of a delinquency
disposition order. Also referred to as a Residential Commitment Program.

Risk Assessment — The process of collecting information from a person about
hereditary, lifestyle and environmental factors to determine specific diseases
or conditions for which the person is at risk.

Rural— An area with a population density of less than 100 individuals per square
mile, or an area defined by the most recent United State Census as rural, i.e.
lacking a metropolitan statistical area (MSA).

Rural Health Clinic (RHC)— A clinic that is located in an area that has a
health-care provider shortage. An RHC provides primary health care and related
diagnostic services and may provide optometric, podiatry, chiropractic and
mental health services. An RHC employs, contracts or obtains volunteer services
from licensed health care practitioners to provide services.

Sales Activities — Actions performed by an agent of any Health Plan, including
the acceptance of Pre-Enrollment Application Requests for Benefit Information,
for the purpose of Enrollment of Potential Enrollees.

Screen or Screening— Assessment of an Enrollee's physical or mental condition to
determine evidence or indications of problems and need for further evaluation or
services.

Service Area— The designated geographical area within which the Health Plan is
authorized by the Contract to furnish Covered Services to Enrollees.

Service Authorization— The Health Plan’s approval for services to be rendered.
The process of authorization must at least include a Health Plan Enrollee’s or a
Provider’s request for the provision of a service.

Service Location — Any location at which an Enrollee obtains any health care
service provided by the Health Plan under the terms of the Contract.

Sick Care — Non-urgent problems that do not substantially restrict normal
activity, but could develop complications if left untreated (e.g., chronic
disease).

Span of Control — Information systems and telecommunications capabilities that
the Health Plan itself operates or for which it is otherwise legally responsible
according to the terms and Conditions of this Contract. The Health Plan span of
control also includes Systems and telecommunications capabilities outsourced by
the Health Plan.

Special Supplemental Nutrition Program for Women, Infants & Children (WIC)—
Program administered by the Department of Health that provides nutritional
counseling; nutritional education; breast-feeding promotion and nutritious foods
to pregnant, postpartum and breast-feeding women, infants and children up to the
age of five (5) who are determined to be at nutritional risk and who have a low
to moderate income. An individual who is eligible for Medicaid is automatically
income eligible for WIC benefits. Additionally, WIC income eligibility is
automatically provided to an Enrollee's family that includes a pregnant woman or
infant certified eligible to receive Medicaid.

State — State of Florida.

Subcontract — An agreement entered into by the Health Plan for provision of
administrative services on its behalf.

Subcontractor — Any person or entity with which the Health Plan has contracted
or delegated some of its functions, services or responsibilities for providing
services under this Contract.

Subscriber Assistance Program - An external grievance program available to
Medicaid Recipients that will allow an additional avenue to resolve a Grievance
or Appeal.

Surface Mail — Mail delivery via land, sea, or air, rather than via electronic
transmission.
 
Surplus — Net worth, i.e., total assets minus total liabilities.

System Unavailability — As measured within the Health Plan’s information systems
Span of Control, when a system user does not get the complete, correct
full-screen response to an input command within three (3) minutes after
depressing the “Enter” or other function key.

Systems — See Information Systems.

Temporary Assistance to Needy Families (TANF)— Public financial assistance
provided to low-income families.

Transportation— An appropriate means of conveyance furnished to an Enrollee to
obtain Medicaid authorized/covered services.

Unborn Activation— The process by which an unborn child, who has been assigned a
Medicaid ID number is made Medicaid eligible upon birth.

Urban — An area with a population density of greater than 100 individuals per
square mile or an area defined by the most recent United State Census as urban,
i.e. as having a metropolitan statistical area (MSA).

Urgent Behavioral Health Care— Those situations that require immediate attention
and assessment within twenty-three (23) hours even though the Enrollee is not in
immediate danger to himself/herself or others and is able to cooperate in
treatment.

Urgent Care— Services for conditions, which, though not life-threatening, could
result in serious injury or disability unless medical attention is received
(e.g., high fever, animal bites, fractures, severe pain, etc.) or do
substantially restrict an Enrollee's activity (e.g., infectious illnesses, flu,
respiratory ailments, etc.).

Validation — The review of information, data, and procedures to determine the
extent to which they are accurate, reliable, free from bias and in accord with
standards for data collection and analysis.

Vendor — An entity submitting a proposal to become a Health Plan contractor.

Violation— A determination by the Agency that a Health Plan failed to act as
specified in this Contract or applicable statutes, rules or regulations
governing Medicaid Health Plans. Each day that an ongoing violation continues
shall be considered, for the purposes of this Contract, to be a separate
Violation. In addition, each instance of failing to furnish necessary and/or
required medical services or items to Enrollees shall be considered, for
purposes of this Contract, to be a separate Violation. As well, each day that a
Health Plan fails to furnish necessary and/or required medical services or items
to Enrollees shall be considered, for purposes of this Contract, to be a
separate Violation.

Well Care Visit— A routine medical visit for one (1) of the following: CHCUP
visit, family planning, routine follow-up to a previously treated condition or
illness, adult physicals or any other routine visit for other than the treatment
of an illness.

B.
Acronyms

ADL — Activities of Daily Living
 
ADM— Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
Children & Families (aka SAMH — listed below)
 
ALF— Assisted Living Facility
 
APD— Agency for People with Disabilities
 
BBA — Balanced Budget Act of 1997
 
CAP — Corrective Action Plan
 
CARES — Comprehensive Assessment & Review for Long-Term Care Services
 
CDC — Centers for Disease Control
 
CHD — County Health Department
 
CMS — Centers for Medicare & Medicaid Services
 
CFR — Code of Federal Regulations
 
CHCUP — Child Health Check-Up Program
 
CPT— Physicians’ Current Procedural Terminology
 
DCF— Department of Children & Families
 
DFS - Department of Financial Services
 
DHHS— United States Department of Health & Human Services
 
DOH— Department of Health
 
DJJ— Department of Juvenile Justice
 
DEA— Drug Enforcement Administration
 
DME— Durable Medical Equipment
 
EDI — Electronic Data Interchange 
 
EDT - Eastern Daylight Time
 
EPSDT— Early and Periodic Screening, Diagnosis & Treatment Program
 
EQR — External Quality Review
 
EQRO— External Quality Review Organization
 
EST— Eastern Standard Time
 
FAC— Florida Administrative Code
 
FFS— Fee-for-Service
 
FQHC— Federally Qualified Health Center
 
FTE— Full Time Equivalent Position
 
HIPAA— Health Insurance Portability & Accountability Act
 
HMO— Health Maintenance Organization
 
IBNR - Incurred but not reported
 
LEIE— List of Excluded Individuals & Entities
 
MBHO— Managed Behavioral Health Organization
 
ODBC — Open Database Connectivity
 
PCCB - Per capita capitation benchmark
 
PCP— Primary Care Physician
 
QI - Quality Improvement
 
QIP— Quality Improvement Program
 
RBI - Request for Benefit Information
 
RFP— Request for Proposal
 
RHC— Rural Health Clinic
 
SAMH— Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
Children & Families (aka ADM — listed above)
 
SFTP— Secure File Transfer Protocol
 
SOBRA— Sixth Omnibus Budget Reconciliation Act
 
SQL — Structured Query Language
 
SSI — Supplemental Security Income
 
UM — Utilization Management
 
WIC— Special Supplemental Nutrition Program for Women, Infants & Children
 

 

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

Section II
 
General Overview 
 

 
A.
Purpose

This Contract is an agreement between the Agency and the Health Plan for the
provision of pre-paid Medicaid services.

B.
Responsibilities of the State of Florida (State) and the Agency for Health Care
Administration (Agency)

1.  
The Agency will be responsible for administering the Medicaid program, including
all aspects of Medicaid Reform. The Agency will administer contracts, monitor
Health Plan performance, and provide oversight in all aspects of the Health
Plan’s operations.

2.  
The State has sole authority for determining eligibility for Medicaid and
whether Medicaid Recipients are mandated to enroll in, may enroll in, or may not
enroll in Medicaid Reform.

3.  
The Agency or its Agent will review the Florida Medicaid Management Information
System (FMMIS) file daily and will send written notification and information to
all Potential Enrollees. A Potential Enrollee will have thirty (30) Calendar
Days to select a Health Plan.

4.  
The Agency or its Agent will Auto-Assign Medicaid Recipients who do not select a
Medicaid health plan during their choice period to a health plan using a
pre-established algorithm.

5.  
Enrollment in the Health Plan, whether chosen or Auto-Assigned, is effective at
12:01 a.m. on the first (1st) Calendar Day of the month following Potential
Enrollee selection or Auto-Assignment, for those Potential Enrollees who choose
or are Auto-Assigned to the Health Plan on or between the first (1st) Calendar
Day of the month and the Penultimate Saturday of the month. For those Enrollees
who choose or are Auto-Assigned to the Health Plan between the Sunday after the
Penultimate Saturday and before the last Calendar Day of the month, Enrollment
in the Health Plan will be effective on the first (1st) Calendar Day of the
second (2nd) month after choice or Auto-assignment.

6.  
The Agency or its Agent will notify the Health Plan of an Enrollee’s selection
or assignment to the Health Plan.

7.  
The Agency or its Agent will send a written confirmation notice to Enrollees
identifying the chosen or Auto-Assigned Health Plan. If the Enrollee has not
chosen a PCP, the confirmation notice will advise the Enrollee that the Health
Plan will assign a PCP. Notice to the Enrollee will be made in writing and sent
via Surface Mail. Notice to the Health Plan will be made via file transfer.

8.  
Conditioned on continued eligibility, Mandatory Enrollees will have a Lock-In
period of twelve (12) consecutive months. After an initial ninety (90) day
change period, Mandatory Enrollees will only be able to disenroll from the
Health Plan for Cause. The Agency or its Agent will notify Enrollees at least
once every twelve (12) months, and at least sixty (60) Calendar Days prior to
the date the Lock-In period ends (the Open Enrollment period), that they have
the opportunity to change health plans. Enrollees who do not make a choice will
be deemed to have chosen to remain with their current health plan, unless the
current health plan no longer participates in Medicaid Reform. In this case, the
Enrollee will be Auto-Assigned to a new health plan.

9.  
The Agency or its Agent will automatically re-enroll an Enrollee into the health
plan in which he or she was most recently enrolled if the Enrollee has a
temporary loss of eligibility, defined for purposes of this Contract as less
than sixty (60) Calendar Days. In this instance, for Mandatory Potential
Enrollees, the Lock-In period will continue as though there had been no break in
eligibility, keeping the original twelve (12) month period.

10.  
If a temporary loss of eligibility has caused the Enrollee to miss the Open
Enrollment period, the Agency or its Agent will enroll the Enrollee in the
health plan in which he or she was enrolled prior to the loss of eligibility.
The Enrollee will have ninety (90) Calendar Days to disenroll without Cause.

11.  
The State will issue a Medicaid identification (ID) number to a newborn upon
notification from the Health Plan, the hospital, or other authorized Medicaid
provider, consistent with the unborn activation process.

12.  
The Agency or its Agent will notify Enrollees of their right to request
Disenrollment as follows:

 
a.
For Cause at any time; or

 
b.
Without Cause, at the following times:

 
(1)
During the ninety (90) days following the Enrollee's initial Enrollment, or the
date the Agency or its Agent sends the Enrollee notice of the enrollment,
whichever is later;

 
(2)
At least every twelve (12) months;

 
(3)
If the temporary loss of Medicaid eligibility has caused the Enrollee to miss
the Open Enrollment period;

(4)  
When the Agency or its Agent grants the Enrollee the right to terminate
Enrollment without Cause. The Agency or its Agent determines the Enrollee's
right to terminate Enrollment without Cause on a case-by-case basis.

13.  
The Agency or its Agent will process all Disenrollments from the Health Plan.
The Agency or its Agent will make final determinations about granting
Disenrollment requests and will notify the Health Plan via file transfer and the
Enrollee via Surface Mail of any Disenrollment decision.

14.  
When Disenrollment is necessary because an Enrollee loses Medicaid eligibility,
Disenrollment shall be immediate.

15.  
The Agency will conduct periodic monitoring of the Health Plan’s operations for
compliance with the provisions of the Contract and applicable federal and State
laws and regulations.

C .
General Responsibilities of the Health Plan 

 
1.
The Health Plan shall comply with all provisions of this Contract and its
amendments, if any, and shall act in good faith in the performance of the
Contract's provisions. The Health Plan shall develop and maintain written
policies and procedures to implement all provisions of this Contract. The Health
Plan agrees that failure to comply with all provisions of this Contract shall
result in the assessment of penalties and/or termination of the Contract, in
whole or in part, as set forth in this Contract.

 
2.
The Health Plan shall comply with all pertinent Agency rules in effect
throughout the duration of the Contract.

 
3.
The Health Plan shall comply with all current Florida Medicaid Handbooks
("Handbooks") as noticed in the Florida Administrative Weekly ("FAW"), or
incorporated by reference in rules relating to the provision of services set
forth in Section V, Covered Services, and Section VI, Behavioral Health Care,
except where the provisions of the Contract alter the requirements set forth in
the Handbooks promulgated in the Florida Administrative Code (FAC). In addition,
the Health Plan shall comply with the limitations and exclusions in the
Handbooks, unless otherwise specified by this Contract. In no instance may the
limitations or exclusions imposed by the Health Plan be more stringent than
those specified in the Handbooks. The Health Plan shall furnish services in an
amount, duration and scope that are no more restrictive than the services
provided in the non-Medicaid Reform FFS program and that may reasonably be
expected to achieve the purpose for which the services are furnished. The Health
Plan shall not arbitrarily deny or reduce the amount, duration or scope of a
required service solely because of the diagnosis, type of illness, or condition.

 
4.
The Health Plan may offer Expanded Services, as described in Section V, Covered
Services to Enrollees, in addition to the required services and Quality
Enhancements. The Health Plan shall define with specificity its Expanded
Services in regards to amount, duration and scope, and obtain approval, in
writing, by the Agency prior to implementation.

 
5.
This Contract including all attachments and exhibits, represents the entire
agreement between the Health Plan and the Agency and supersedes all other
contracts between the parties when it is executed by duly authorized signatures
of the Health Plan and the Agency. Correspondence and memoranda of understanding
do not constitute part of this Contract. In the event of a conflict of language
between the Contract and the attachments, the provisions of the Contract shall
govern. The Agency reserves the right to clarify any contractual relationship in
writing and such clarification shall govern. Pending final determination of any
dispute over any Agency decision, the Health Plan shall proceed diligently with
the performance of its duties as specified under the Contract and in accordance
with the direction of the Agency's Division of Medicaid.

 
6.
The Health Plan shall have a Quality Improvement program that ensures
enhancement of quality of care and emphasizes improving the quality of patient
outcomes. The Agency may restrict the Health Plan’s Enrollment activities if the
Health Plan does not meet acceptable Quality Improvement and performance
indicators, based on HEDIS reports and other outcome measures to be determined
by the Agency. Such restrictions may include, but shall not be limited to, the
termination of Mandatory Assignments.

 
7.
The Health Plan must demonstrate that it has adequate knowledge of Medicaid
programs, provision of health care services, medical claims data, and the
capability to design and implement cost savings methodologies. The Health Plan
must demonstrate the capacity for financial analyses, as necessary to fulfill
the requirements of this Contract. Additionally, the Health Plan must meet all
requirements for doing business in the State of Florida.

 

 
8.
The Health Plan may be required to provide to the Agency or its Agent
information or data that is not specified under this Contract. In such
instances, and at the direction of the Agency, the Health Plan shall fully
cooperate with such requests and furnish all information in a timely manner, in
the format in which it is requested. The Health Plan shall have at least thirty
(30) Calendar Days to fulfill such ad hoc requests.

 
9.
The Health Plan shall fully cooperate with, and provide necessary data to, the
Agency and its Agent for the design, management, operations and monitoring of
the Enhanced Benefits Program.

 
10.
The Health Plan shall provide care management services and monitor utilization
of services through the prior authorization of claims for Covered Services for
its Enrollees.

 
11.
The Health Plans shall collect and submit Encounter Data for each Contract Year
in the format required by the Agency and within the time frames specified by the
Agency. An encounter guide along with technical assistance will be forthcoming.
At a minimum the Health Plans shall be responsible for the following:

a.  
Health Plans shall collect and submit to the Agency or its designee, Enrollee
service level encounter data for all Covered Services;

b.  
Encounter data shall be submitted following HIPAA standards, namely the ANSI
X12N 837 Transaction formats (P - Professional, I - Institutional, and D -
Dental), and the National Council for Prescription Drug Programs NCPDP format
(for Pharmacy services); and

 
c.
All Covered Services rendered to Enrollees shall result in the creation of an
encounter record.

 

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Section III
 
Eligibility and Enrollment
 

A.
Eligibility

The following Populations represent broad categories that contain multiple
eligibility groups. Certain exceptions may apply within the broad categories and
will be determined by the Agency.

1.  
Eligible Populations

 
a.
The categories of eligible Medicaid Recipients authorized to be enrolled in the
Health Plan are:

 
(1)
Low Income Families and Children;

 
(2)
Sixth Omnibus Budget Reconciliation Act (SOBRA) Children;

 
(3)
Supplemental Security Income (SSI) Medicaid Only;

 
(4)
SSI Medicare, Part B only;

 
(5)
SSI Medicare, Parts A and B;

 
(6)
Medicaid Recipients who are residents in ALFs and are not enrolled in an ALF
waiver program;

 
(7)
Refugees;

 
(8)
The Meds AD population;

 
(9)
Individuals with Medicare coverage (e.g., dual eligible individuals) who are not
enrolled in a Medicare Advantage Plan;

 
(10)
Title XXI MediKids are eligible for Enrollment in the Health Plan in accordance
with Section 409.8132, F.S. Except as otherwise specified in this Contract,
Title XXI MediKids eligible participants are entitled to the same conditions and
services as currently eligible Title XIX Medicaid Recipients; and

 
(11)
Women enrolled in the Health Plan who change eligibility categories to the SOBRA
eligibility category due to pregnancy remain eligible for Enrollment in the
Health Plan.

2.  
Ineligible Populations

   
a.
The following categories describe Medicaid Recipients who are not eligible to
enroll in a Health Plan:

 
(1)
Pregnant women who have not enrolled in Medicaid Reform prior to the effective
date of their SOBRA eligibility;

 
(2)
Medicaid Recipients who, at the time of application for Enrollment and/or at the
time of Enrollment, are domiciled or residing in an institution, including:

(a) Nursing facilities (and have been CARES assessed);

(b) Sub-acute inpatient psychiatric (SIPP) facilities,

 
(c)
Intermediate care facility for persons with developmental disabilities (ICF-DD);

(d) State hospitals; or

(e) Correctional institutions.

 
(3)
Medicaid Recipients whose Medicaid eligibility was determined through the
medically needy program.

 
(4)
Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare
Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s);

 
(5)
Medicaid Recipients who have other creditable health-care coverage, such as
TriCare or a private health maintenance organization (HMO);

(6) Medicaid Recipients who reside in the following:

 
(a)
Residential commitment programs/facilities operated through the Department of
Juvenile Justice (DJJ);

 
(b)
Residential group care operated by the Family Safety & Preservation Program of
the DCF;

 
(c)
Children's residential treatment facilities purchased through the Substance
Abuse & Mental Health District ("SAMH") Offices of the DCF (also referred to as
Purchased Residential Treatment Services - "PRTS");

 
(d)
SAMH residential treatment facilities licensed as Level I and Level II
facilities; and

 
(e)
Residential Level I and Level II substance abuse treatment programs. See
Sections 65D-30.007(2)(a) and (b), F.A.C.

 
(7)
Medicaid Recipients participating in the Family Planning waiver;

 
(8)
Children/Adolescents with chronic conditions who are enrolled in Children’s
Medical Services (CMS);

 
(9)
Women eligible for Medicaid due to breast and/or cervical cancer;

 
(10)
Individuals eligible under a hospice-related eligibility group;

 
(11)
Medicaid Recipients who are members of the Florida Assertive Community Treatment
Team (FACT team);

 
(12)
Medicaid Recipients who are receiving services through a hospice program, the
Medicaid AIDS waiver (Project AIDS Care) program, a prescribed pediatric
extended care center;

 
(13)
Medicaid Recipients who are also members of a Medicare-funded health maintenance
organization (HMO);

 
(14)
Medicaid Recipients whose Medicaid eligibility has been determined through the
medically needy program; or

 
(15)
Family Planning waiver beneficiaries.

B.
Enrollment

1.  
General Provisions

 
a.
Only Medicaid Recipients who are included in the eligible population and living
in counties with authorized Health Plans are eligible to enroll and receive
services from the Health Plan.

 
b.
The Agency or its Agent shall be responsible for Enrollment, including
Enrollment into a Health Plan, Disenrollment, and outreach and education
activities. The Health Plan shall coordinate with the Agency and its Agent as
necessary for all Enrollment and Disenrollment functions.

 
c.
The Health Plan shall accept Medicaid Recipients without restriction and in the
order in which they enroll. The Health Plan shall not discriminate against
Medicaid Recipients on the basis of religion, gender, race, color, age, or
national origin, and shall not use any policy or practice that has the effect of
discriminating on the basis of religion, gender, race, color, or national
origin, or on the basis of health, health status, pre-existing condition, or
need for health care services.

 
d.
The Health Plan shall accept new Enrollees through-out the Contract period up to
the authorized maximum enrollment levels approved in Attachment I.

2.  
Enrollment with a Primary Care Provider (PCP)

 
a.
The Health Plan shall offer each Enrollee a choice of PCPs. After making a
choice, each Enrollee shall have a single PCP.

 
b.
The Health Plan shall assign a PCP to those Enrollees who did not choose a PCP
at the time of Health Plan selection. The Health Plan shall take into
consideration the Enrollee's last PCP (if the PCP is known and available in the
Health Plan's network), closest PCP to the Enrollee's home address, ZIP code
location, keeping Children/Adolescents within the same family together, age
(adults versus Children/Adolescents) and gender (OB/GYN).

 
c.
The Health Plan shall provide written notice of the following via Surface Mail
to the Enrollee, by the first day of the Enrollee’s enrollment or within five
(5) Calendar Days following the availability of the Enrollment file from the
Agency or its Agent, whichever is later:

 
(1)
The actual date of Enrollment, and the name, telephone number and address of the
Enrollee’s PCP assignment;

(2) The Enrollee's ability to choose a different PCP;

 
(3)
An explanation that a provider directory has been mailed separately with other
member materials; and

 
(4)
The procedures for changing PCPs, including provision of the Health Plan’s
toll-free member services telephone number, etc.

 
d.
The Health Plan shall permit Enrollees to change PCPs at any time.

 
e.
The Health Plan shall assign all Enrollees that are reinstated after a temporary
loss of eligibility to the PCP who was treating them prior to loss of
eligibility, unless the Enrollee specifically requests another PCP, the PCP no
longer participates in the Health Plan or is at capacity, or the Enrollee has
changed geographic areas.

3.  
Newborn Enrollment

 
a.
The Health Plan shall utilize the unborn activation process to facilitate
enrollment and shall be responsible for newborns from the date they are enrolled
in the Health Plan.

 
b.
Upon unborn activation, the newborn shall be enrolled in the Health Plan in
which his/her mother was enrolled during the next enrollment cycle.

 
c.
Newborn Enrollment shall occur through the following procedures:

 
(1)
Upon identification of an Enrollee's pregnancy, the Health Plan shall
immediately notify DCF of the pregnancy and any relevant information known
(i.e., due date and gender). The Health Plan must provide this notification by
completing the DCF-ES 2039 Form and submitting the completed form to DCF. The
Health Plan shall indicate its name and number as the entity initiating the
referral. The DCF-ES 2039 form is located on the Medicaid web site:

 
http://www.fdhc.state.fl.us/Medicaid/Newborn

 
(2)
DCF will generate a Medicaid ID number and the unborn child will be added to the
Medicaid file. This information will be transmitted to the Medicaid Fiscal
Agent. The Medicaid ID number will remain inactive until after the child is
born.

 
(3)
The Health Plan shall comply with all requirements set forth by the Agency or
its Agent related to Unborn Activation (see Policy Transmittal 06-02, Unborn
Activation Process). To ensure the prompt enrollment of Newborns, the Health
Plan shall ensure that the form DCF-ES 2039 (Form 2039) is completed and
submitted, via electronic submission, to the local DCF Economic Self-Sufficiency
Services Office immediately upon the birth of the child. If the Hospital is not
a participating Hospital, the Health Plan must complete and transmit the Form
2039 to DCF. With regard to participating Hospitals, as part of its
participating Hospital contract, the Health Plan must include a clause that
states whether the Health Plan or the participating Hospital will complete and
transmit Form 2039 to DCF for all Newborns.

 
(4)
Upon notification that a pregnant Enrollee has presented to the Hospital for
delivery, the Health Plan shall inform the Hospital, the pregnant Enrollee’s
attending physician and the newborn’s attending and consulting physicians that
the newborn is an Enrollee only if the Health Plan has verified that the newborn
has an unborn record on the system that is awaiting activation. At this time the
Health Plan shall initiate the Unborn Activation process.

 
(5)
Upon activation, the newborn shall be enrolled in the Health Plan in which
his/her mother was enrolled during the month of birth.

4.  
Enrollment Cessation

The Health Plan may request that the Agency halt or reduce Enrollment
temporarily if continued full Enrollment would exceed its capacity to provide
required services under the Contract. The Agency may also limit Health Plan
Enrollments when such action is considered to be in the Agency's best interest
in accordance with the provisions of this Contract.

5. Enrollment Notice

By the first day of the Enrollee’s enrollment or within five (5) Calendar Days
following receipt of the Enrollment file from Medicaid or its Agent, whichever
is later, the Health Plan shall mail the following information to all new
Enrollees:

 
a.
Notification that Enrollees can change their Health Plan selection, subject to
Medicaid limitations.

 
b.
Enrollment materials regarding PCP choice as described in Section III.B.,
including the Provider Directory.

c. New Enrollee Materials as described in Section IV.

C.
Disenrollment

1.  
General Provisions

 
a.
If the Contract is renewed, the Enrollment status of all Enrollees shall
continue uninterrupted.

 
b.
The Health Plan shall ensure that it does not restrict the Enrollee's right to
disenroll voluntarily in any way.

 
c.
The Health Plan or its agents shall not provide or assist in the completion of a
Disenrollment request or assist the Agency’s contracted Choice
Counselor/Enrollment Broker in the Disesnrollment process.

 
d.
The Health Plan shall ensure that Enrollees that are disenrolled and wish to
file an appeal have the opportunity to do so. All Enrollees shall be afforded
the right to file an appeal except for the following reasons for Disenrollment:

 
(1)
Moving out of the Service Area;

 
(2)
Loss of Medicaid eligibility; and

 
(3)
Enrollee death.

 
e.
An Enrollee may submit to the Agency or its Agent a request to disenroll from
the Health Plan without Cause during the ninety (90) Calendar Day change period
following the date of the Enrollee's initial Enrollment with the Health Plan, or
the date the Agency or its Agent sends the Enrollee notice of the Enrollment,
whichever is later. An Enrollee may request Disenrollment without Cause every
twelve (12) months thereafter.

 
f.
The effective date of an approved Disenrollment shall be the last Calendar Day
of the month in which Disenrollment was made effective by the Agency or its
Agent, but in no case shall Disenrollment be later than the first (1st) Calendar
Day of the second (2nd) month following the month in which the Enrollee or the
Health Plan files the Disenrollment request. If the Agency or its Agent fails to
make a Disenrollment determination within this timeframe, the Disenrollment is
considered approved.

 
g.
The Health Plan shall keep a daily written log or electronic documentation of
all oral and written Enrollee Disenrollment requests and the disposition of such
requests. The log shall include the following:

 
(1)
The date the request was received by the Health Plan;

 
(2)
The date the Enrollee was referred to the Agency's Choice Counselor/Enrollment
Broker or the date of the letter advising the Enrollee of the Disenrollment
procedure, as appropriate; and

 
(3)
The reason that the Enrollee is requesting Disenrollment.

 
h.
The Health Plan shall send to the Agency or its Agent a monthly summary report
of all submitted Disenrollment requests. This report must specify the reason for
such Disenrollment requests. It shall be reconciled to the Health Plan
Enrollment Report processed by the Agency or its Agent for the applicable month
and shall be reviewed by the Agency or its Agent for compliance with acceptable
reasons for Disenrollment. The Agency may reinstate Enrollment for any Enrollee
whose reason for Disenrollment is not consistent with established guidelines.

2.  
Cause for Disenrollment

 
a.
An Enrollee may request Disenrollment from the Health Plan for Cause at any
time. Such request shall be submitted to the Agency or its Agent. The following
reasons constitute Cause for Disenrollment from the Health Plan:

 
(1)
The Enrollee moves out of the county, or the Enrollee’s address is incorrect and
the Enrollee does not live in the county;

 
(2)
The Provider is no longer with the Health Plan;

 
(3)
The Enrollee is excluded from enrollment;

 
(4)
A substantiated marketing violation occurred;

 
(5)
The Enrollee is prevented from participating in the development of his/her
treatment plan;

 
(6)
The Enrollee has an active relationship with a provider who is not on the Health
Plan's network, but is in the network of another health plan;

 
(7)
The Enrollee is enrolled in the wrong Health Plan as determined by the Agency;

 
(8)
The Health Plan no longer participates in the county;

 
(9)
The State has imposed intermediate sanctions upon the Health Plan, as specified
in 42 CFR 438.702(a)(3);

 
(10)
The Enrollee needs related services to be performed concurrently, but not all
related services are available within the Health Plan network; or, the
Enrollee's PCP has determined that receiving the services separately would
subject the Enrollee to unnecessary risk;

 
(11)
The Health Plan does not, because of moral or religious objections, cover the
service the Enrollee seeks;

 
(12)
The Enrollee missed his/her Open Enrollment due to a temporary loss of
eligibility, defined as sixty (60) days or less; or

 
(13)
Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor
quality of care; lack of access to services covered under the Contract;
inordinate or inappropriate changes of PCPs; service access impairments due to
significant changes in the geographic location of services; lack of access to
Providers experienced in dealing with the Enrollee’s health care needs; or
fraudulent Enrollment.

3.  
Involuntary Disenrollment

 
a.
With proper written documentation, the following are acceptable reasons for
which the Health Plan shall submit Involuntary Disenrollment requests to the
Agency or its Choice Counselor/Enrollment Broker, as specified by the Agency:

 
(1)
Enrollee has moved out of the Service Area;

 
(2)
Enrollee death;

 
(3)
Determination that the Enrollee is ineligible for Enrollment based on the
criteria specified in this Contract in Section III.A.3, Excluded Populations;
and

 
(4)
Fraudulent use of the Enrollee ID card.

 
b.
The Health Plan shall promptly submit such Disenrollment requests to the Agency
or its Choice Counselor/Enrollment Broker, as specified by the Agency. In no
event shall the Health Plan submit the Disenrollment request at such a date as
would cause the Disenrollment to be effective later than forty-five (45)
Calendar Days after the Health Plan’s receipt of the reason for Involuntary
Disenrollment. The Health Plan shall ensure that Involuntary Disenrollment
documents are maintained in an identifiable Enrollee record.

 
c.
If the Health Plan submitted the Disenrollment request for one of the above
reasons, the Health Plan shall verify that the information is accurate.

 
d.
If the Health Plan discovers that an ineligible Enrollee has been enrolled, then
it shall request Disenrollment of the Enrollee and shall notify the Enrollee in
writing that the Health Plan is requesting Disenrollment and the Enrollee will
be disenrolled in the next Contract month, or earlier if necessary. Until the
Enrollee is Disenrolled, the Health Plan shall be responsible for the provision
of services to that Enrollee.

 
e.
On a monthly basis, the Health Plan shall review its ongoing Enrollment report
(FLMR 8200-R0004) to ensure that all Enrollees are residing in the same county
in which they were enrolled. The Health Plan shall update the records for all
Enrollees who have moved from one county to another, but are still residing in
the Health Plan’s Service Area, and provide the Enrollee with a new Provider
Directory for that county. For Enrollees with out-of-county addresses on the
Enrollment report, the Health Plan shall notify the Enrollee in writing that the
Enrollee should contact the Choice Counselor/Enrollment Broker or Medicaid
Options, depending on whether the Enrollee moves into a Reform or Non-Reform
County, respectively, to choose another Health Plan, or other managed care
option available in the Enrollee’s new county, and that the Enrollee will be
Disenrolled as a result of the Enrollee's contact with the Choice
Counselor/Enrollment Broker or Medicaid Options.

 
f.
The Health Plan may submit an Involuntary Disenrollment request to the Agency or
its Choice Counselor/Enrollment Broker, as specified by the Agency, after
providing to the Enrollee at least one (1) verbal warning and at least one (1)
written warning of the full implications of his or her failure of actions:

 
(1)
For an Enrollee who continues not to comply with a recommended plan of health
care. Such requests must be submitted at least sixty (60) Calendar Days prior to
the requested effective date.

 
(2)
For an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative
to the extent that his or her Enrollment in the Health Plan seriously impairs
the organization's ability to furnish services to either the Enrollee or other
Enrollees. This Section does not apply to Enrollees with mental health diagnoses
if the Enrollee’s behavior is attributable to the mental illness.

 
g.
The Agency may approve such requests provided that the Health Plan documents
that attempts were made to educate the Enrollee regarding his/her rights and
responsibilities, assistance which would enable the Enrollee to comply was
offered through Case Management, and it has been determined that the Enrollee’s
behavior is not related to the Enrollee’s medical or behavioral condition. All
requests will be reviewed on a case-by-case basis and subject to the sole
discretion of the Agency. Any request not approved is final and not subject to
dispute or appeal.

 
h.
The Health Plan shall not request Disenrollment of an Enrollee due to:

(1)  
Health diagnosis;

(2)  
Adverse changes in an Enrollee’s health status;

(3)  
Utilization of medical services;

(4)  
Diminished mental capacity;

(5)  
Pre-existing medical condition;

(6)  
Uncooperative or disruptive behavior resulting from the Enrollee’s special needs
(with the exception of C.4.f.2 above);

(7)  
Attempt to exercise rights under the Health Plan's Grievance System; or

(8)  
Request of one (1) PCP to have an Enrollee assigned to a different Provider out
of the Health Plan.

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Section IV
 
Enrollee Services and Marketing
 

 
A.
Enrollee Services

1.  
General Provisions

 
a.
The Health Plan shall have written policies and procedures for the provision of
Enrollee Services, as specified in this Contract. Such policies and procedures
shall be submitted to the Agency for approval.

 
b.
The Health Plan shall ensure that Enrollees are aware of their rights and
responsibilities, the role of PCPs, how to obtain care, what to do in an
emergency or urgent medical situation, how to request a Grievance, Appeal or
Medicaid Fair Hearing, how to report suspected Fraud and Abuse, procedures for
obtaining required Behavioral Health Services, including any additional Health
Plan phone numbers to be used for obtaining services, and all other requirements
and Benefits of the Health Plan.

 
c.
The Health Plan shall have the capability to answer Enrollee inquiries via
written materials, telephone, electronic transmission, and face-to-face
communication.

 
d.
Mailing envelopes for Enrollee materials shall contain a request for address
correction. For Enrollees whose Enrollee Materials are returned to the Health
Plan as undeliverable, the Health Plan shall use and maintain in a file a record
of all of the following methods to contact the Enrollee:

 
(1)
Telephone contact at the telephone number obtained from the local telephone
directory, directory assistance, city directory, or other directory;

 
(2)
Telephone contact with DCF and Families Economic Self-Sufficiency Services
Office staff to determine if they have updated address information and telephone
number; and

 
(3)
Routine checks (at least once a month for the first three (3) months of
Enrollment) on services or claims authorized or denied by the Health Plan to
determine if the Enrollee has received services, and to locate updated address
and telephone number information.

 
e.
New Enrollee materials are not required for a former Enrollee who was
disenrolled because of the loss of Medicaid eligibility and who regains his/her
eligibility within sixty (60) days and is automatically reinstated as a Health
Plan Enrollee. In addition, unless requested by the Enrollee, new Enrollee
materials are not required for a former Enrollee subject to Open Enrollment who
was disenrolled because of the loss of Medicaid eligibility, who regains his/her
eligibility within sixty (60) days of his/her managed care enrollment, and is
reinstated as a Health Plan Enrollee. A notation of the effective date of the
reinstatement on the most recent application or conspicuously in the Enrollee's
administrative file. Enrollees, who were previously enrolled in a Health Plan,
lose and regain eligibility after sixty (60) days, will be treated as new
Enrollees.

 
f.
The Health Plan shall notify, in writing, each person who is to be reinstated,
of the effective date of the reinstatement and the assigned Primary Care
Provider. The notifications shall distinguish between Enrollees subject to Open
Enrollment and Enrollees not subject to Open Enrollment and shall include
information regarding change procedures for Cause, or general Health Plan change
procedures through the Agency’s toll-free Choice Counselor/Enrollment Broker
telephone number, as appropriate. The notification shall also instruct the
Enrollee to contact the Health Plan if a new Enrollee card and/or a new Enrollee
handbook are needed. The Health Plan shall provide such notice to each affected
Enrollee by the first (1st) Calendar Day of the month following the Health
Plan’s receipt of the notice of reinstatement.

2.  
Requirements for Written Materials

 
a.
The Health Plan shall make all written materials available in alternative
formats and in a manner that takes into consideration the Enrollee's special
needs, including those who are visually impaired or have limited reading
proficiency. The Health Plan shall notify all Enrollees and Potential Enrollees
that information is available in alternative formats and how to access those
formats.

 
b.
The Health Plan shall make all written material available in English, Spanish,
and all other appropriate foreign languages. The appropriate foreign languages
comprise all languages in the Health Plan Service Area spoken by approximately
five percent (5%) or more of the total population. The Health Plan shall
provide, free of charge, interpreters for Potential Enrollees or Enrollees whose
primary language is a foreign language.

 
c.
The Health Plan shall provide Enrollee information in accordance with 42 CFR
438.10, which addresses information requirements related to written and oral
information provided to Enrollees, including: languages, format, Health Plan
features such as benefits, Service Area, Provider network and physician
incentive plans, Enrollment and Disenrollment rights and responsibilities, the
Grievance System, Advance Directives. The Health Plan shall notify Enrollees on
at least an annual basis of their right to request and obtain information in
accordance with the above regulations.

 
d.
All written materials shall be at or near the fourth (4th) grade comprehension
level. Suggested reference materials to determine whether the Health Plan’s
written materials meet this requirement are:

 
(1)
Fry Readability Index;

 
(2)
PROSE The Readability Analyst (software developed by Education Activities,
Inc.);

 
(3)
Gunning FOG Index;

 
(4)
McLaughlin SMOG Index;

 
(5)
The Flesch-Kincaid Index; or

 
(6)
Other software approved by the Agency.

 
e.
The Health Plan shall provide written notice to the Agency of any changes to any
written materials provided to Enrollees. Written materials shall be provided to
the Agency at least forty-five (45) Calendar Days prior to the effective date of
the change. Written notice of such changes shall be provided to Enrollees at
least thirty (30) days prior to the effective date of the change.

 
f.
All written materials, including any materials for the Health Plan Web site,
shall be submitted to the Agency for written approval prior to being
distributed.

3.  
New Enrollee Materials

 
a.
By the first day of the assigned Enrollee’s Enrollment or within five (5)
Calendar Days following receipt of the Enrollment file from Medicaid or its
Agent, whichever is later, the Health Plan shall mail to the new Enrollee the
Enrollee Handbook, the Provider Directory, the Enrollee Identification and the
following additional materials:

 
(1)
A request for the following information to be updated: Enrollee’s name, address
(home and mailing), county of residence, and telephone number;

 
(2)
A completed, signed and dated release form authorizing the Health Plan to
release medical information to the federal and State governments or their duly
appointed agents; and, current behavioral health care provider information;

 
(3)
A notice that Enrollees who lose eligibility and are disenrolled shall be
automatically re-Enrolled in the Health Plan if eligibility is regained within
180 days;

 
(4)
Each mailing shall include a postage paid, pre-addressed return envelope; and

 
(5)
The initial mailing may be combined with the PCP assignment notification. The
Health Plan shall document each mailing in the Health Plan’s records.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

4.  
Enrollee Handbook Requirements

 
a.
The Enrollee services handbook shall include the following information:

 
(1)
Table of Contents;

 
(2)
Terms and conditions of Enrollment including the reinstatement process;

 
(3)
Description of the Open Enrollment process;

 
(4)
Description of services provided, including limitations and general restrictions
on Provider access, exclusions and out-of-network use;

 
(5)
Procedures for obtaining required services, including second opinions, and
authorization requirements, including those services available without Prior
Authorization;

 
(6)
Toll-free telephone number of the appropriate Area Medicaid Office;

 
(7)
Emergency Services and procedures for obtaining services both in and out of the
Health Plan’s Service Area, including, an explanation that Prior Authorization
is not required for Emergency Services, the locations of any emergency settings
and other locations at which Providers and Hospitals furnish Emergency Services
and Post-Stabilization Care Services and use of the 911 telephone system, or its
equivalent;

 
(8)
The extent to which, and how, after-hours and emergency coverage is provided,
and that the Enrollee has a right to use any Hospital or other setting for
Emergency Care;

 
(9)
Procedures for Enrollment, including Enrollee rights and protections;

 
(10)
A notice advising Enrollees how to change PCPs;

 
(11)
Grievance System components and procedures;

 
(12)
Enrollee rights and procedures for Disenrollment, including the toll-free
telephone number for the Agency’s contracted Choice Counselor/Enrollment Broker;

 
(13)
Procedures for filing a request for Disenrollment for Cause;

 
(14)
Information regarding Newborn enrollment, including the mother’s responsibility
to notify the Health Plan and the mother’s DCF case worker of the Newborn’s
birth and selection of a PCP;

 
(15)
Enrollee rights and responsibilities, including the extent to which, and how,
Enrollees may obtain services from out-of-network providers and the right to
obtain family planning services from any participating Medicaid provider without
Prior Authorization for such services, and other provisions in accordance with
42 CFR 438.100;

 
(16)
Information on emergency transportation and non-emergency transportation,
counseling and referral services available under the Health Plan, and how to
access these services;

 
(17)
Information that interpretation services and alternative communication systems
are available, free of charge, for all foreign languages, and how to access
these services;

 
(18)
Information that Post-Stabilization Services are provided without Prior
Authorization and other Post-Stabilization Care Services rules set forth in 42
CFR 422.113(c);

 
(19)
Information that services will continue upon appeal of a suspended authorization
and that the Enrollee may have to pay in case of an adverse ruling;

 
(20)
Information regarding health care Advance Directives pursuant to Chapter 765,
F.S., and 42 CFR 422.128;

 
(21)
Cost sharing for the Enrollee, if any;

 
(22)
Instructions explaining how Enrollees may obtain information from the Health
Plan regarding quality performance indicators, including Enrollee information;

 
(23)
How and where to access any benefits that are available under the State Plan,
but not covered under the Contract, including cost sharing;

 
(24)
Any restrictions on the Enrollee's freedom of choice among network Providers;

 
(25)
A release document for each Enrollee authorizing the Health Plan to release
medical information to the federal and State governments or their duly appointed
Agents;

 
(26)
A notice that clearly states that the Enrollee may select an alternative
Behavioral Health Care Case Manager or direct service provider within the Health
Plan, if one is available;

 
(27)
A description of Behavioral Health Services provided, including limitations,
exclusions and out-of-network use;

 
(28)
An explanation that Enrollees may choose to have all family members served by
the same PCP or they may choose different PCPs;

 
(29)
A description of Emergency Behavioral Health Services procedures both in and out
of the Health Plan's Service Area;

 
(30)
Information to assist the Enrollee in assessing a potential behavioral health
problem;

 
(31)
Procedures for reporting Fraud, Abuse and Overpayment; and

 
(32)
Information regarding HIPAA relative to the Enrollee’s personal health
information (PHI).

 
b.
For a counseling or referral service that the Health Plan does not cover because
of moral or religious objections, the Health Plan need not furnish information
on how and/or where to obtain the services.

 
c.
Written information regarding Advance Directives provided by the Health Plan
must reflect changes in State law as soon as possible, but no later than ninety
(90) days after the effective date of the change.

 
d.
The Health Plan, in its Enrollee handbook and provider manual, shall clearly
specify required procedural steps in the Grievance Procedure, including the
address, telephone number and office hours of the Grievance staff. The Health
Plan shall specify phone numbers for a grievant to call to present a Grievance
or to contact the Grievance staff. Each phone number shall be toll-free within
the grievant’s geographic area and provide reasonable access to the Health Plan
without undue delays. The Grievance System must provide an adequate number of
phone lines to handle incoming Grievances and Appeals.

 
e.
The Health Plan shall make information available upon request regarding the
structure and operation of the Health Plan and any physician incentive plans, as
set forth in 42 CFR 438.10(g)(3).

5.  
Provider Directory

 
a.
The Health Plan shall mail a Provider Directory to all new Enrollees, including
Enrollees who reenrolled after the Open Enrollment period. The Health Plan shall
provide the most recently printed Provider Directory and include an addendum
listing those physicians, etc., no longer providing services to Enrollees of the
Health Plan and those physicians, etc., that have entered into an agreement to
provide services to Enrollees of the Health Plan since the Health Plan published
the most recently printed Provider Directory. In lieu of the Provider Directory
addendum, the Health Plan may enclose a letter, in Times New Roman font, and at
the fourth-grade reading level (as is required of all documents mailed to
Enrollees) stating that the most recent listing of Providers is available by
calling the Health Plan at its toll-free telephone number and at the Health
Plan's website and provide the Internet address that will take the Enrollee
directly to the online Provider Directory, without having to go to the Health
Plan's home page or any other website as a prerequisite to viewing the online
Provider Directory. The Health Plan must obtain the Agency's prior written
approval of the letter.

 
b.
The Provider Directory shall include the names, locations, office hours,
telephone numbers of, and non-English languages spoken by, current Health Plan
Providers. The Provider Directory shall include, at a minimum, information
relating to PCPs, specialists, pharmacies, hospitals, certified nurse midwives
and licensed midwives, and Ancillary Providers. The Provider Directory shall
also identify Providers that are not accepting new patients.

 
c.
The Health Plan shall maintain an online Provider Directory. The Health Plan
shall update the online Provider Directory on, at least, a monthly basis. The
Health Plan shall file an attestation to this effect with the Bureau of Managed
Health Care and the Bureau of Health Systems Development.

 
d.
If the Health Plan elects to use a more restrictive pharmacy network than the
network available to Medicaid Recipients enrolled in the Medicaid FFS program,
then the Provider Directory must include the names of the participating
pharmacies. If all pharmacies are part of a chain and are within the Health
Plan's Service Area under contract with the Health Plan, the Provider Directory
need only list the chain name.

 
e.
In accordance with section 1932(b)(3) of the Social Security Act, the Provider
Directory shall include a statement that some Providers may not perform certain
services based on religious or moral beliefs.

 
f.
The Health Plan shall arrange the Provider Directory as follows:

 
(1)
Providers are listed in alphabetical order, showing the Provider's name and
specialty;

 
(2)
Providers are listed by specialty, in alphabetical order; and

 
(3)
Behavioral Health Providers are listed by provider type.

6.  
Enrollee ID Card

 
a.
Immediately upon the Enrollee’s enrollment with the Health Plan, the Health Plan
shall mail, via Surface Mail, an Enrollee Identification (ID) Card. The Enrollee
ID Card shall include, at a minimum:

 
(1)
The Enrollee's name and Medicaid ID number;

 
(2)
The Health Plan's name, address and Enrollee services number; and

 
(3)
A telephone number that a non-contracted provider may call for billing
information.

7.  
Toll-Free Help Line

 
a.
The Health Plan shall operate a toll-free telephone help line. Such help line
shall respond to all areas of Enrollee inquiry.

 
b.
If the Health Plan has authorization requirements for prescribed drug services
and is subject to the Hernandez Settlement Agreement (HSA), the Health Plan may
allow the telephone help line staff to act as Hernandez Ombudsman, pursuant to
the terms of the HSA, so long as the Health Plan maintains a Hernandez Ombudsman
Log. The Health Plan may maintain the Hernandez Ombudsman Log as part of the
Health Plan’s telephone help line log, so long as the Health Plan can access the
Hernandez Ombudsman Log information separately for reporting purposes. The log
shall contain information as described in Section V.D.13, Prescribed Drug
Services.

 
c.
The Health Plan shall have telephone call policies and procedures that shall
include requirements for staffing, personnel, hours of operation, call response
times, maximum hold times, and maximum abandonment rates, monitoring of calls
via recording or other means, and compliance with standards.

 
d.
The telephone helpline shall handle calls from non-English speaking Enrollees,
as well as calls from Enrollees who are hearing impaired.

 
e.
The telephone help line shall be fully staffed between the hours of 8:00 a.m.
and 7:00 p.m., EDT or EST, as appropriate, Monday through Friday, excluding
State holidays. The telephone help line staff shall be trained to respond to
Enrollee questions in all areas, including but not limited to, Covered Services,
the Provider network, and non-emergency transportation.

 
f.
The Health Plan shall develop performance standards and monitor telephone help
line performance by recording calls and employing other monitoring activities.
Such standards shall be submitted and approved by the Agency. At a minimum, the
standards shall require that, measured on a monthly basis:

 
(1)
One hundred percent (100%) of all calls are answered within four (4) rings
(these calls may be placed in a queue);

 
(2)
The wait time in the queue shall not exceed three (3) minutes;

 
(3)
The Blocked Call rate does not exceed one percent (1%); and

 
(4)
The rate of Abandoned Calls does not exceed five percent (5%).

 
g.
The Health Plan shall have an automated system available between the hours of
8:00 p.m. and 7:00 a.m., EDT or EST, as appropriate, Monday through Friday and
at all hours on weekends and holidays. This automated system must provide
callers with operating instructions on what to do in case of an emergency and
shall include, at a minimum, a voice mailbox for callers to leave messages. The
Health Plan shall ensure that the voice mailbox has adequate capacity to receive
all messages. A Health Plan Representative shall return all messages on the next
Business Day.

8.  
Cultural Competency

 
a.
In accordance with 42 CFR 438.206, the Health Plan shall have a comprehensive
written Cultural Competency Plan describing how the Health Plan will ensure that
services are provided in a culturally competent manner to all Enrollees,
including those with limited English proficiency. The Cultural Competency Plan
must describe how the Providers, Health Plan employees, and systems will
effectively provide services to people of all cultures, races, ethnic
backgrounds, and religions in a manner that recognizes, values, affirms, and
respects the worth of the individual Enrollees and protects and preserves the
dignity of each Enrollee.

 
b.
The Health Plan may distribute a summary of the Cultural Competency Plan to
network Providers if the summary includes information on how the Provider may
access the full Cultural Competency Plan on the Health Plan’s website. This
summary shall also detail how the Provider can request a hard-copy from the
Health Plan at no charge to the Provider.

9.  
Translation Services

The Health Plan is required to provide oral translation services of information
to any Enrollee who speaks any non-English language regardless of whether an
Enrollee speaks a language that meets the threshold of a prevalent non-English
language. The Health Plan is required to notify its Enrollees of the
availability of oral interpretation services and to inform them of how to access
oral interpretation services. There shall be no charge to the Enrollee for
translation services.

B.
Marketing

1.  
General Provisions

 
a.
For each new Contract period, the Health Plan shall submit to the Agency for
written approval, pursuant to Section 409.912, F.S., its Marketing plan and all
Marketing and Request for Benefit Information (RBI) materials no later than
sixty (60) Calendar Days prior to Contract renewal, and for any changes in
Marketing and RBI materials during the re-contracting and renewal period, no
later than sixty (60) Calendar Days prior to implementation. The Marketing
materials shall be distributed in the Health Plan’s entire Service Area in
accordance with Section 4707 of the Balanced Budget Act of 1997 (BBA).

 
b.
Marketing materials include, but are not limited to, all solicitation materials,
forms, brochures, fact sheets, posters, lectures, Medicaid recruitment materials
and presentations, Request for Benefit Information forms (previously known as
pre-enrollment applications), etc.

 
c.
To announce a specific event, the Health Plan shall submit a request to market
pursuant to Section IV.B.4, Approval Process, of this Contract, and shall
include the announcement of the event that will be given out to the public.

 
d.
The Health Plan shall be responsible for developing and implementing a written
plan designed to solicit Enrollment from Potential Enrollees and to control the
actions of its Marketing staff. All of the Marketing policies set forth in this
Contract apply to staff, Subcontractors, Health Plan volunteers and all persons
acting for, or on behalf of, the Health Plan. All materials developed shall be
governed by the requirements set forth in this Section. Additionally, the Health
Plan is vicariously liable for any Marketing violations of its employees, agents
or Subcontractors.

 
e.
The Health Plan shall limit its Market Area to residents of the Service Area and
shall not market to residents of a Service Area not approved by the Agency.

2.  
Prohibited Activities

 

 
a.
The Health Plan is prohibited from engaging in the following non-exclusive list
of activities:

 
(1)
In accordance with Sections 409.912 and 409.91211, F.S., practices that are
discriminatory, including, but not limited to, attempts to discourage Enrollment
or reenrollment on the basis of actual or perceived health status;

 
(2)
Direct or indirect Cold Call Marketing for solicitation of Medicaid Recipients,
either by door-to-door, telephone or other means, in accordance with Section
4707 of the Balanced Budget Act of 1997, and section 409.912, F.S.

 
(3)
Overly aggressive solicitation, such as repeated telephoning, continued
recruitment after an offer for Enrollment is declined by a Medicaid Recipient,
or similar techniques. Health Plan representatives shall not directly solicit
Potential Enrollees for the purpose of enrolling in the Health Plan, except as
provided in Section IV.B.3., Permitted Activities.

 
(4)
In accordance with Section 409.912, F.S., activities that could mislead or
confuse Medicaid Recipients or Potential Enrollees, or misrepresent the Health
Plan, its Marketing Representatives, or the Agency. No fraudulent, misleading,
or misrepresentative information shall be used in Marketing, including
information regarding other governmental programs. Statements that could mislead
or confuse include, but are not limited to, any assertion, statement or claim
(whether written or oral) that:

 
(a)
The Medicaid Recipient must enroll in the Health Plan in order to obtain
Medicaid, or in order to avoid losing Medicaid benefits;

 
(b)
The Health Plan is endorsed by any federal, State or county government, the
Agency, or CMS, or any other organization which has not certified its
endorsement in writing to the Health Plan;

 
(c)
Marketing Representatives are employees or representatives of the federal, State
or county government, or of anyone other than the Health Plan or the
organization by whom they are reimbursed;

 
(d)
The State or county recommends that a Medicaid Recipient enroll with the Health
Plan; and/or

 
(e)
A Medicaid Recipient will lose benefits under the Medicaid program or any other
health or welfare benefits to which the Recipient is legally entitled, if the
Medicaid Recipient does not enroll with the Health Plan.

 
(5)
In accordance with section 409.912, F.S., granting or offering of any monetary
or other valuable consideration for Enrollment, except as authorized by Section
409.912, F.S.;

 
(6)
Offers of insurance, such as but not limited to, accidental death,
dismemberment, disability or life insurance;

 
(7)
Enlisting the assistance of any employee, officer, elected official or agent of
the State in recruitment of Medicaid Recipients, except as authorized in writing
by the Agency;

 
(8)
Offers of material or financial gain to any persons soliciting, referring or
otherwise facilitating Medicaid Recipient Enrollment, except for authorized
licensed Marketing Representatives. The Health Plan shall ensure that only
licensed Marketing Representatives market the Health Plan to Medicaid
Recipients;

 
(9)
Giving away promotional items in excess of one dollar ($1.00) retail value to
attract attention. Items to be given away shall bear the Health Plan's name and
shall only be given away at Health Fairs or other general Public Events. In
addition, such promotional items must be offered to the general public and shall
not be limited to Medicaid Recipients who indicate they will enroll in the
Health Plan;

 
(10)
In accordance with Section 409.912, F.S., Marketing to Medicaid Recipients in
State offices unless approved in writing and approved by the affected State
Agency when solicitation occurs in the office of another State Agency. The
Agency shall ensure that Marketing Representatives stationed in State offices
market to Medicaid Recipients only in designated areas and in such a way as to
not interfere with the Medicaid Recipients' activities in the State office. The
Health Plan shall not use any other State facility, program, or procedure in the
recruitment of Medicaid Recipients except as authorized in writing by the
Agency. Request for approval of activities at State offices must be submitted to
the Agency at least thirty (30) Calendar Days prior to the activity;

 
(11)
Marketing face-to-face to assigned Enrollees or Medicaid Recipients unless the
Enrollee or Recipient contacts the Health Plan and requests information. Upon
such request the Health Plan shall notify the Choice Counselor/Enrollment Broker
of such request, and the Health Plan shall keep documentation of such contacts
and visits in the Enrollee’s file;

 
(12)
Providing any gift, commission, or any form of compensation to the Choice
Counselor/Enrollment Broker, including the Choice Counselor/Enrollment Broker's
full-time, part-time or temporary employees and Subcontractors;

 
(13)
The Health Plan shall not market, prior to the Enrollment, the incentives that
shall be offered to the Enrollee as described in Section VIII.B.7., Incentive
Programs. Marketing representatives may describe the programs (not the
incentives) that shall be offered (e.g., prenatal classes). The Health Plan may
inform Enrollees once they are actually enrolled in the Health Plan about the
specific incentives available; or

 
(14)
All activities included in section 641.3903, F.S.

3.  
Permitted Activities

 
a.
The Health Plan may engage in the following activities under the supervision and
with the written approval of the Agency:

 
(1)
The Health Plan upon written approval of the Agency, may have a marketer in
Provider offices as long as the Provider approves and the marketer provides
information to the Potential Enrollee only upon request. In addition, the Health
Plan and the Provider shall not require the Potential Enrollee to visit the
marketer, nor shall the marketer approach the Potential Enrollee. No Sales
Activities shall be allowed in Provider offices.

 
(2)
The Health Plan may leave Agency approved referral cards in Provider offices, at
Public Events and Health Fairs. These cards may be completed by Potential
Enrollees and delivered to the Health Plan or turned in at the Provider office.
Information on the card is limited to the name, address and telephone number of
the Potential Enrollee and space for signature. A space to note a contact time
may be provided. A follow up visit to the Potential Enrollee’s home may not
occur prior to the referral being logged by the Health Plan’s regional or
headquarters Enrollee services office. Twenty-four (24) hours or the next
Business Day shall elapse after the request is logged before the home visit may
occur.

 
(3)
The Health Plan may market at State offices, Health Fairs and Public Events and
contact thereafter, in person, Potential Enrollees who request further
information about the Health Plan, in accordance with Section 4707 of the BBA.
The Health Plan shall submit, for review and approval by the Agency, its intent
to market at Health Fairs and Public Events at least two (2) weeks prior to the
event. The Health Plan shall obtain complete disclosure of information, in a
format to be approved by the Agency, from each organization participating in a
Health Fair or Public Event prior to the event. The information disclosure is
only required when the Health Plan is the primary organizer of the Health Fair
or Public Event. If the Health Plan has been invited by a community organization
to be a sponsor of an event, the Health Plan shall provide the Agency with a
copy of the invitation in lieu of the information disclosure. All disclosure
information shall be sent to the Agency with the Health Plan’s request for
approval of the event.

 
(4)
The main purpose of a Health Fair or a Public Event shall not be Medicaid Health
Plan marketing, but Medicaid Health Plan marketing may be provided at these
events, subject to Agency rules and oversight.

 
(5)
Upon the effective date of Enrollment, Health Plan marketing staff or other
Health Plan staff may visit Enrollees in order to obtain completed new Enrollee
materials. All such visits must be documented in the Enrollee's file.

 
(6)
The Health Plan may leave Agency approved written materials (brochures or
posters, etc.) in Provider Offices, at Public Events, and at Health Fairs.

 
(7)
Marketing face-to-face to Potential Enrollees may be allowed if the Potential
Enrollee contacts the Health Plan’s headquarters or regional Enrollee services
office directly to request a home visit. The Health Plan shall not allow the
visit to the Potential Enrollee’s home to occur before the next Business Day or
twenty-four (24) hours have elapsed since the request for the visit. The Health
Plan must be able to provide evidence to the Agency that the twenty-four (24)
hour or next Business Day requirement has been met. The Health Plan will be
required, upon request by the Agency, to provide a log that shows how initial
contact with the Potential Enrollee was made. Only Agency registered Marketing
Representatives shall be allowed to make home visits. Each Health Plan shall
make available to the Agency, as requested, a report of the number of home
visits made by each Agency registered Marketing Representative to Potential
Enrollee’s homes.

4.  
Approval Process

 
a.
The Health Plan shall submit a detailed description of its Marketing plan and
copies of all Marketing materials, the Health Plan or its Subcontractors’ plan
to distribute, to the Agency for prior approval. This requirement includes, but
is not limited to: posters, brochures, websites, and any materials that contain
statements regarding the Health Plan’s Covered Services and Provider
network-related materials. Neither the Health Plan nor its Subcontractors shall
distribute any Marketing materials without prior written approval from the
Agency.

 
b.
Health Fairs and Public Events shall be approved or denied by the Agency using
the following process:

 
(1)
A Health Plan shall submit its bi-monthly Marketing schedule to the Agency, two
(2) weeks in advance of each month. The Marketing Schedule may be revised if a
Health Plan provides notice to the Agency one (1) week prior to the Public Event
or the Health Fair. The Agency may expedite this process as needed.

 
(2)
The Agency will approve or deny the Health Plan's bi-monthly Marketing schedule
and revision request no later than five (5) Business Days from receipt of the
schedule and/or revision request.

 
(3)
The Health Plan shall use the standard Agency format. Such format will include
minimum requirements for necessary information. The Agency will explain in
writing what is sufficient information for each requirement.

 
(4)
The Agency will establish a statewide log to track the approval and disapproval
of Health Fairs and Public Events.

 
(5)
The Agency may provide verbal approvals or disapprovals to meet the five (5)
Business Day requirement, but the Agency will follow up in writing with specific
reasons for disapprovals within five (5) Business Days of verbal disapprovals.

5.  
Provider Compliance

 
a.
The Health Plan shall ensure its health care Providers comply with the following
Marketing requirements:

 
(1)
Health care Providers may give out Health Plan brochures at Health Fairs or in
their own offices comparing the Benefits of different Health Plans with which
they contract. However, they cannot orally compare Benefits among Health Plans,
unless Marketing Representatives from each Health Plan are present.

 
(2)
Health care Providers may co-sponsor events, such as Health Fairs and
cooperatively market and advertise with the Health Plan in indirect ways; such
as television, radio, posters, fliers, and print advertisement.

 
(3)
Health care Providers may announce a new affiliation with a Health Plan or give
a list of Health Plans with which they contract to their patients.

 
(4)
Health care Providers shall not furnish lists of their Medicaid Recipients to
Health Plans with which they contract, or any other entity, nor can Providers
furnish other Health Plans' membership lists to any Health Plan, nor can
Providers take applications in their offices.

6.  
Marketing Representatives

 
a.
The Health Plan shall not Subcontract with any brokerage firm or independent
agent for purposes of Marketing.

 
b.
The Health Plan shall be required to register each Marketing Representative with
the Agency. The registration shall consist of providing the Agency with the
representative's name, address, telephone number, cellular telephone number, DFS
license number, the names of all Medicaid health plans with which the Marketing
Representative was previously employed, and the name of the Medicaid health plan
with which the Marketing Representative is presently employed.

 
c.
The Health Plan shall provide the Agency, on a monthly basis, information on
terminations of all Marketing Representatives. The Health Plan shall maintain
and make available to the Agency upon request evidence of current licensure and
contractual agreements with all Marketing Representatives used by the Health
Plan to recruit Medicaid Recipients.

 
d.
The Health Plan shall report to DFS and the Agency any Marketing Representative
who violates any requirements of this Contract, within fifteen (15) Calendar
Days of knowledge of such violation.

 
e.
While Marketing, Marketing Representatives shall wear picture identification
that includes their DFS license number and identifies the Health Plan
represented.

 
f.
The Marketing Representative shall inform the Medicaid Recipient that the
Representative is not an employee of the State and is not a Choice Counseling
Specialist, but is a Representative of the Health Plan.

 
g.
The Health Plan shall not pay commission compensation, or shall recoup
commissions paid, to Marketing Representatives for new Enrollees whose voluntary
Disenrollment is effective within the first (1st) three (3) months of their
initial Enrollment, unless the Disenrollment is due to the Enrollee moving out
of the county in which the Health Plan has been authorized to operate. In
addition, the Health Plan shall not pay commission compensation, or shall recoup
commission paid, to Marketing Representatives for excluded Medicaid Recipients,
per Section III.A.2, Ineligible Populations, who were enrolled in error. A
Marketing Representative's total monthly commission cannot exceed forty percent
(40%) of the Marketing Representative's total monthly compensation, excluding
benefits.

 
h.
The Health Plan shall instruct and provide initial and periodic training to its
Marketing Representatives regarding the Marketing provisions of this Contract.

 
i.
The Health Plan shall implement procedures for background and reference checks
for use in its Marketing Representative hiring practices.

7.  
Request for Benefit Information (RBI) Activities

 
a.
The Health Plan shall refer Potential Enrollees interested in enrolling in the
Health Plan to the Choice Counselor/Enrollment Broker.

 
b.
In accordance with Section 409.912, F.S., and Agency guidelines, and upon
approval of the Agency, the Health Plan may assist Potential Enrollees in
obtaining information through the completion of an RBI, previously known as a
pre-enrollment application for information.

 
c.
RBIs may be for an individual or for a family. No health status information may
be asked on the RBI. Each RBI shall include an option for the Potential Enrollee
to request information about all Health Plan choices and shall include the name
and toll-free telephone number of the Choice Counselor/Enrollment Broker Help
Line. All RBIs shall contain the following information only for each Potential
Enrollee:

 
(1)
Name;

 
(2)
Address (home and mailing);

 
(3)
County of residence;

 
(4)
Telephone number;

 
(5)
Date of Application;

 
(6)
Applicant’s signature or signature of parent or guardian; and

 
(7)
Marketing Representative’s signature and DFS license number.

 
d.
At the time of completion of the RBI, the Health Plan shall furnish the
Potential Enrollee with a copy of the completed RBI.

 
e.
The Health Plan shall accept RBIs only from Potential Enrollees who reside
within the authorized Service Area. In addition, the Health Plan shall use the
provider number associated with the county in which the Potential Enrollee
resides.

 
f.
If the Voluntary Potential Enrollee is recognized to be in foster care by the
Health Plan, and is dependent, prior to Enrollment, the Health Plan must receive
written authorization from (1) a parent, (2) a legal guardian, or (3) DCF or
DCF’s delegate. If a parent is unavailable, the Health Plan shall obtain
authorization from DCF. The RBI shall include information that the Potential
Enrollee is in foster care.

 
g.
The Health Plan shall provide a reasonable written explanation of the Health
Plan Benefits to the Potential Enrollee prior to accepting the RBI. The Health
Plan shall explain to all Potential Enrollees that the family may choose to have
all members served by the same PCP or they may choose different PCPs based on
each Enrollee’s needs. The information must comply with 42 CFR 438.10.

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Section V
 
Covered Services 
 

A.
Covered Services 

 
1.
The Health Plan shall ensure the provision of services in sufficient amount,
duration and scope to be reasonably expected to achieve the purpose for which
the services are furnished and shall ensure the provision of the following
covered services as defined and specified in this Contract. The Health Plan
shall not arbitrarily deny or reduce the amount, duration, or scope of a
required service solely because of the diagnosis, type of illness or condition.
The Health Plan may place appropriate limits on a service on the basis of such
criteria as Medical Necessity or for utilization control, consistent with the
terms of this Contract, provided the services furnished can be reasonably
expected to achieve their purpose.

 
2.
The Health Plan is responsible for ensuring that all provider, service and
product standards specified in the Agency's Medicaid Services Coverage &
Limitations Handbooks and the Health Plan's own provider handbooks are
incorporated into the Health Plan's participation agreements by reference.
Exceptions exist where different standards are specified elsewhere in this
Contract, if the standard is waived in writing by the Division of Medicaid on a
case-by-case basis, when the Medicaid Recipient's medical needs would be equally
or better served in an alternative care setting, or when using alternative
therapies or devices within the prevailing medical community.

 
3.
The Health Plan must require out-of-network providers to coordinate with respect
to payment and must ensure that cost to the Enrollee is no greater than it would
be if the Covered Services were furnished within the network.

 
4.
The Health Plan shall ensure the provision of the following Covered Services:

Child Health Check-Up
Inpatient Hospital Services
Community Mental Health Services.
Mental Health Targeted Case Management
Family Planning Services
Outpatient Hospital and Emergency Services
Freestanding Dialysis Centers
Physician Services
Hearing Services
Prescribed Drug Services
Home Health Services and Durable Medical Equipment
Therapy Services
Independent Laboratory and X-Ray Services 
Visual Services
Behavioral Health Services
 

B.
Optional Services

 
1.
These following services are rendered within Medicaid guidelines at the option
of the Health Plan and the Agency as described below:

 
 Covered
  Not Covered
 Dental Services  
 X
 Transportation Services
 X
 

 

C.
Expanded Services

 
1.
The following services are defined as Expanded Services that may be offered by
the Health Plan following the Agency’s written approval:

 
a.
Services in excess of the amount, duration and scope of those listed in Section
V, Covered Services;

 
b.
Services and benefits not listed in Section V, Covered Services;

 
c.
The Health Plan may offer, upon written Agency approval, an over-the-counter
expanded drug benefit, not to exceed twenty-five dollars ($25.00) per household,
per month. Such benefits shall be limited to nonprescription drugs containing a
national drug code ("NDC") number, first aid supplies and birth control
supplies. Such benefits must be offered directly through the Health Plan's
fulfillment house or through a Subcontractor. The Health Plan shall make
payments for the over-the-counter drug benefit directly to the Subcontractor, if
applicable.

 
2.
The following is a list of the Health Plan’s Expanded Services:

   
a. Annual comprehensive oral exam, x-rays (one per year), 2 cleanings per year,
silver amalgam fillings, one peridontic deep cleaning per year, 2 peridontic
scaling and root planning per year;

   
b. Unlimited eye exams and eyeglasses, if medically necessary;

   
c. Up to $25 credit per household each month for selected over the counter drugs
and/or health supplies;

   
d. Free approved round trip transportation to medical appointments;

   
e. Hearing exam and one hearing aid every three years, if medically necessary
(hearing aid only).

   
f. Circumcision up to 1 year.

D.
Excluded Services 

 
1.
The Health Plan is not obligated to provide any services not specified in this
Contract. Enrollees who require services available through Medicaid but not
covered by this Contract shall receive the services through the Medicaid
fee-for-service reimbursement system. In such cases, the Health Plan's
responsibility is limited to case coordination and referral. Therefore, the
Health Plan shall determine the need for the services and refer the Enrollee to
the appropriate service provider. The Health Plan may request assistance from
the local Medicaid Field Office for referral to the appropriate service setting.

 
2.
The Health Plan shall consult the DCF office to identify appropriate methods of
assessment and referral for those Enrollees requiring long-term care
institutional services, institutional services for persons with developmental
disabilities or state hospital services. The Health Plan is responsible for
transition and referral of these Enrollees to appropriate service providers,
including helping the Enrollees to obtain an attending physician. The Plan shall
disenroll all Enrollees requiring these services in accordance with Section
III.C.3.a.(3) of this Contract.

E.
Moral or Religious Objections

 
1.
The Health Plan is required to provide or arrange for all Covered Services. If,
during the course of the Contract period, pursuant to 42 CFR 438.102, the Health
Plan elects not to provide, reimburse for, or provide coverage of a counseling
or referral service because of an objection on moral or religious grounds, the
Health Plan shall notify:

 
a.
The Agency within one hundred and twenty (120) Calendar Days prior to adopting
the policy with respect to any service; and

 
b.
Enrollees within thirty (30) Calendar Days prior to adopting the policy with
respect to any service.

F.
Coverage Provisions 

 
1.
The Health Plan shall provide the following services in accordance with the
provisions herein, and in accordance with the Florida Medicaid Coverage and
Limitations Handbooks and the Florida Medicaid State Plan. The Health Plan shall
comply with all State and federal laws pertaining to the provision of such
services.

 
2.
Advance Directives

 
a.
In compliance with 42 CFR 438.6(i)(1)-(2) and 42 CFR 422.128, the Health Plan
shall written policies and procedures for Advance Directives, including health
Advance Directives. Such Advance Directives shall be included in each Enrollee's
Medical Record. The Health Plan shall provide these policies and procedures to
all Enrollee's eighteen (18) years of age and older and shall advise Enrollees
of:

 
(1)
Their rights under State law, including the right to accept or refuse medical or
surgical treatment and the right to formulate Advance Directives; and

 
(2)
The Health Plan's written policies respecting the implementation of those
rights, including a statement of any limitation regarding the implementation of
Advance Directives as a matter of conscience.

 
b.
The information must include a description of State law and must reflect changes
in State law as soon as possible, but no later than ninety (90) Calendar Days
after the effective change.

 
c.
The Health Plan's information must inform Enrollees that complaints may be filed
with the State's complaint hotline.

 
d.
The Health Plan shall educate its staff about its policies and procedures on
Advance Directives, situations in which Advance Directives may be of benefit to
Enrollees, and their responsibility to educate Enrollees about this tool and
assist them to make use of it.

 
e.
The Health Plan shall educate Enrollees about their ability to direct their care
using this mechanism and shall specifically designate which staff and/or network
Providers are responsible for providing this education.

 
3.
Child Health Check-Up Program (CHCUP)

 
a.
The Health Plan shall provide a health screening evaluation that shall consist
of: comprehensive health and developmental history (including assessment of past
medical history, developmental history and behavioral health status);
comprehensive unclothed physical examination; developmental assessment;
nutritional assessment; appropriate immunizations according to the appropriate
Recommended Childhood Immunization Schedule for the United States; laboratory
testing (including blood lead testing); health education (including anticipatory
guidance); dental screening (including a direct referral to a dentist for
Enrollees beginning at three (3) years of age or earlier as indicated); vision
screening, including objective testing as required; hearing screening, including
objective testing as required; diagnosis and treatment; and referral and
follow-up as appropriate.

 
b.
For Children/Adolescents who the Health Plan identifies through blood lead
screenings as having abnormal levels of lead, the Health Plan shall provide Case
Management follow-up services as required in Chapter Two of the Child Health
Check-Up Services Coverage and Limitations Handbook. Screening for lead
poisoning is a required component of this Contract. The Health Plan shall
require all Providers to screen all Enrolled Children/Adolescents for lead
poisoning at twelve (12) and twenty-four (24) months of age. In addition,
Children/Adolescents between the ages of twenty-four (24) months and seventy-two
(72) months of age must receive a screening blood lead test if there is no
record of a previous test. The Health Plan shall provide additional diagnostic
and treatment services determined to be Medically Necessary to a
Child/Adolescent diagnosed with an elevated blood lead level. The Health Plan
shall recommend, but shall not require, the use of paper filter tests as part of
the lead screening requirement.

 
c.
The Health Plan shall inform Enrollees of all testing/screenings due in
accordance with the periodicity schedule specified in the Medicaid Child Health
Check-Up Services Coverage and Limitations Handbook. The Health Plan shall
contact Enrollees to encourage them to obtain health assessment and preventative
care.

 
d.
The Health Plan shall authorize Enrollee referrals to appropriate Providers
within four (4) weeks of these examinations for further assessment and treatment
of conditions found during the examination. The Health Plan shall ensure that
the referral appointment is scheduled for a date within six (6) months of the
initial examination, or within the time periods set forth in Section VII.D., as
applicable.

 
e.
The Health Plan shall offer scheduling assistance and Transportation to
Enrollees in order to assist them to keep, and travel to, medical appointments.

 
f.
The CHCUP program includes the maintenance of a coordinated system to follow the
Enrollee through the entire range of screening and treatment, as well as
supplying CHCUP training to medical care Providers.

 
g.
The Health Plan shall achieve a CHCUP screening rate of at least sixty percent
(60%) for those Enrollees who are continuously enrolled for at least eight (8)
months during the Federal Fiscal Year (October 1 - September 30) in accordance
with Section 409.912, F.S. This screening compliance rate shall be based on the
CHCUP screening data reported by the Health Plan and due to the Agency by
January 15 following the end of each Federal Fiscal Year as specified in Section
XII, Reporting, of this Contract. The data shall be monitored by the Agency for
accuracy and, if the Health Plan does not achieve the sixty percent (60%)
screening rate for the Federal Fiscal Year reported, the Health Plan shall file
a corrective action plan (CAP) with the Agency no later than February 15,
following the fiscal year reported. Any data reported by the Health Plan that is
found to be inaccurate shall be disallowed by the Agency and the Agency shall
consider such findings as being in violation of the Contract and may sanction
the Health Plan accordingly.

 
h.
The Health Plan shall adopt annual screening and participation goals to achieve
at least an eighty percent (80%) CHCUP screening and participation rate. For
each Federal Fiscal Year that the Health Plan does not meet the eighty percent
(80%) screening and participation rate, it must file a CAP with the Agency no
later than February 15 following the Federal Fiscal Year being reported.

 
4.
Co-Payments

 
a.
The Health Plan shall not require a co-payment or cost sharing for services
listed in Section V.A., Covered Services, Section V.B., Optional Services, if
provided, or Section V.C., Expanded Services, nor may the Health Plan charge
Enrollees for missed appointments.

 
5.
Dental Services (Optional)

 
a.
Dental services are defined in the Medicaid Dental Services Coverage and
Limitations Handbook. Children’s Medicaid dental services include diagnostic
services, preventive treatment, restorative treatment, endodontic treatment,
periodontal treatment, restorative treatment, surgical procedures and/or
extractions, orthodontic treatment and complete and partial dentures for
beneficiaries under age 21. Complete and partial denture relines and repairs are
also included, as well as adjunctive and emergency services. Adult services
include adult full and partial denture services and Medically Necessary
emergency dental procedures to alleviate pain or infection. Emergency dental
care shall be limited to emergency oral examinations, necessary radiographs,
extractions, and incision and drainage of abscess.

6. Diabetes Supplies and Education
 

 
a.
In the same manner as specified in Section 641.31, F.S., the Health Plan shall
provide coverage for Medically Necessary equipment, supplies, and services used
to treat diabetes, including outpatient self-management training and educational
services, if the Enrollee’s PCP, or the physician to whom the Enrollee has been
referred who specializes in treating diabetes, certifies that the equipment,
supplies and services are Medically Necessary. 

7. Emergency Services

 
a.
The Health Plan shall advise all Enrollees of the provisions governing Emergency
Services and Care. The Health Plan shall not deny claims for Emergency Services
and Care received at a Hospital due to lack of parental consent. In addition,
the Health Plan shall not deny payment for treatment obtained when a
representative of the Health Plan instructs the Enrollee to seek Emergency
Services and Care in accordance with section 743.64, F.S.

 
b.
The Health Plan shall not:

 
(1)
Require Prior Authorization for an Enrollee to receive pre-Hospital transport or
treatment or for Emergency Services and Care;

 
(2)
Specify or imply that Emergency Services and Care are covered by the Health Plan
only if secured within a certain period of time;

 
(3)
Use terms such as "life threatening" or "bona fide" to qualify the kind of
emergency that is covered; or

 
(4)
Deny payment based on a failure by the Enrollee or the Hospital to notify the
Health Plan before, or within a certain period of time after, Emergency Services
and Care were given.

 
c.
The Health Plan shall provide pre-Hospital and Hospital-based trauma services
and Emergency Services and Care to Enrollees. See Sections 395.1041, 395.4045
and 401.45, F.S.

 
d.
When an Enrollee presents himself/herself at a Hospital seeking Emergency
Services and Care, the determination that an Emergency Medical Condition exists
shall be made, for the purposes of treatment, by a physician of the Hospital or,
to the extent permitted by applicable law, by other appropriate personnel under
the supervision of a Hospital physician. See Sections 409.9128 and 409.901, F.S.

 
(1)
The physician, or the appropriate personnel, shall indicate on the Enrollee's
chart the results of all screenings, examinations and evaluations.

 
(2)
The Health Plan shall compensate the provider for all screenings, evaluations
and examinations that are reasonably calculated to assist the provider in
arriving at the determination as to whether the Enrollee's condition is an
Emergency Medical Condition.

 
(3)
The Health Plan shall pay for all Emergency Services and Care in accordance with
this Contract.

 
(4)
If the provider determines that an Emergency Medical Condition does not exist,
the Health Plan is not required to pay for services rendered subsequent to the
provider's determination.

 
e.
If the provider determines that an Emergency Medical Condition exists, and the
Enrollee notifies the Hospital or the Hospital emergency personnel otherwise
have knowledge that the patient is an Enrollee of the Health Plan, the Hospital
must make a reasonable attempt to notify the Enrollee's PCP, if known, or the
Health Plan, if the Health Plan has previously requested in writing that said
notification be made directly to the Health Plan, of the existence of the
Emergency Medical Condition.

 
f.
If the Hospital, or any of its affiliated providers, do not know the Enrollee's
PCP, or have been unable to contact the PCP, the Hospital must:

 
(1)
Notify the Health Plan as soon as possible before discharging the Enrollee from
the emergency care area; or

 
(2)
Notify the Health Plan within twenty-four (24) hours or on the next Business Day
after admission of the Enrollee as an inpatient to the Hospital.

 
g.
If the Hospital is unable to notify the Health Plan, the Hospital must document
its attempts to notify the Health Plan, or the circumstances that precluded the
Hospital's attempts to notify the Health Plan. The Health Plan shall not deny
payment for Emergency Services and Care based on a Hospital's failure to comply
with the notification requirements of this Section.

 
h.
If the Enrollee's PCP responds to the Hospital's notification, and the Hospital
physician and the PCP discuss the appropriate care and treatment of the
Enrollee, the Health Plan may have a member of the Hospital staff with whom it
has a Participating Provider contract participate in the treatment of the
Enrollee within the scope of the physician's Hospital staff privileges.

 
i.
The Health Plan may transfer the Enrollee, in accordance with State and federal
law, to a Participating Hospital that has the service capability to treat the
Enrollee's Emergency Medical Condition. The attending emergency physician, or
the provider actually treating the Enrollee, is responsible for determining when
the Enrollee is sufficiently stabilized for transfer discharge, and that
determination is binding on the entities identified in 42 CFR 438.114(b) as
responsible for coverage and payment.

 
j.
Notwithstanding any other State law, a Hospital may request and collect any
insurance or financial information necessary to determine if the patient is an
Enrollee of the Health Plan, in accordance with federal law, from an Enrollee,
so long as Emergency Services and Care are not delayed in the process.

 
k.
In accordance with 42 CFR 438.414 and 42 CFR 422.113(c), the Health Plan shall
cover Post-Stabilization Care Services without authorization, regardless of
whether the Enrollee obtains a service within or outside the Health Plan's
network for the following situations:

 
(1)
Post-Stabilization Care Services that were pre-approved by the Health Plan;

 
(2)
Post-Stabilization Care Services that were not pre-approved by the Health Plan
because the Health Plan did not respond to the treating provider's request for
pre-approval within one (1) hour after the treating provider sent the request;

 
(3)
The treating Provider could not contact the Health Plan for pre-approval; and

 
(4)
Those Post-Stabilization Care Services that a treating physician viewed as
Medically Necessary after stabilizing an Emergency Medical Condition. These are
non-emergency services; the Health Plan can choose not to cover if provided by a
non-participating provider, except in those circumstances detailed in k. (1),
(2), and (3) above. 

 
l.
The Health Plan shall not deny claims for the provision of Emergency Services
and Care submitted by a nonparticipating provider solely based on the period
between the date of service and the date of clean claim submission, unless that
period exceeds 365 days.

 
m.
Reimbursement for services provided to an Enrollee under this Section by a
non-participating provider shall be the lesser of:

 
(1)
The non-participating provider's charges;

 
(2)
The usual and customary provider charges for similar services in the community
where the services were provided;

 
(3)
The amount mutually agreed to by the Health Plan and the non-participating
provider within sixty (60) Calendar Days after the non-participating provider
submits a claim; or

 
(4)
The Medicaid rate.

 
n.
Notwithstanding the requirements set forth in this Section, the Health Plan
shall make payment on all claims for Emergency Services and Care by
nonparticipating providers pursuant to the requirements set forth in Section
641.3155, F.S.

 
8.
Emergency Services - Behavioral Health Services

 
a.
In cases in which the Enrollee has no identification, or is unable to verbally
identify himself/herself when presenting for Behavioral Health Services, the
out-of-area, non-participating provider shall notify the Health Plan within
twenty-four (24) hours of learning the Enrollee's identity. The out-of-area,
non-participating provider shall deliver to the Health Plan the Medical Records
that document that the identity of the Enrollee could not be ascertained at the
time the Enrollee presented for Emergency Behavioral Health Services due to the
Enrollee's condition.

 
b.
If the out-of-area, non-participating provider fails to provide the Health Plan
with an accounting of the Enrollee's presence and status within twenty-four (24)
hours after the Enrollee presents for treatment and provides identification, the
Health Plan shall only approve claims for the time period required for treatment
of the Enrollee's Emergency Behavioral Health Services, as documented by the
Enrollee's Medical Record.

 
c.
The Health Plan shall review and approve or disapprove all out-of-plan Emergency
Behavioral Health Service claims within the time frames specified for emergency
claims payment in Section V.E.7., Emergency Services.

 
d.
The Health Plan shall submit to the Agency for review and final determination
all denied Appeals from Behavioral Health Care Providers and out-of-plan,
non-participating behavioral health care providers for denied Emergency
Behavioral Health Service claims. The provider, whether a participating provider
or not, must submit the denied Appeal to the Agency within ten (10) days after
receiving notice of the Health Plan's final Appeal determination.

 
e.
The Health Plan must evaluate and authorize or deny services for Enrollees
presenting at non-participating receiving facilities (that are not Crisis
Stabilization Units), within the Health Plan's service area, for involuntary
examination within three (3) hours of being notified by phone by the receiving
facility.

 
f.
The receiving facility must notify the Health Plan within four (4) hours of the
Enrollee presenting. If the Receiving Facility fails to notify the Health Plan
of the Enrollee's presence and status within four (4) hours, the Health Plan
shall pay only for the first four (4) hours of the Enrollee's treatment, subject
to Medical Necessity.

 
g.
If the receiving facility is a non-participating receiving facility and
documents in the Medical Record that it is unable, after a good faith effort, to
identify the Enrollee and, therefore, fails to notify the Health Plan of the
Enrollee's presence, the Health Plan shall pay for medical stabilization lasting
no more than three (3) days from the date the Enrollee presented at the
receiving facility, as documented by the Enrollee's Medical Record and subject
to Medical Necessity, unless there is irrefutable evidence in the Medical Record
that a longer period was required to treat the Enrollee.

 
9.
Family Planning Services

 
a.
The Health Plan shall provide family planning services for the purpose of
enabling Enrollees to make comprehensive and informed decisions about family
size and/or spacing of births. The Health Plan shall provide the following
services: planning and referral, education and counseling, initial examination,
diagnostic procedures and routine laboratory studies, contraceptive drugs and
supplies, and follow-up care in accordance with the Medicaid Physicians Services
Coverage and Limitations Handbook. Policy requirements include:

(1) The Health Plan shall furnish services on a voluntary and confidential
basis. 

 
(2)
The Health Plan shall allow Enrollees freedom of choice of family planning
methods covered under the Medicaid program, including Medicaid covered implants,
where there are no medical contra-indications.

 
(3)
The Health Plan shall render the services to Enrollees under the age of eighteen
(18) provided the Enrollee is married, a parent, pregnant, has written consent
by a parent or legal guardian, or in the opinion of a physician, the Enrollee
may suffer health hazards if the services are not provided. See Section
390.01114, F.S.

 
(4)
The Health Plan shall allow each Enrollee to obtain family planning services
from any Provider and require no prior authorization for such services. If the
Enrollee receives services from a non-network Medicaid provider, then the Plan
must reimburse at the Medicaid reimbursement rate, unless another payment rate
is negotiated.

 
(5)
The Health Plan shall make available and encourage all pregnant women and
mothers with infants to receive postpartum visits for the purpose of voluntary
family planning, including discussion of all appropriate methods of
contraception, counseling and services for family planning to all women and
their partners. The Health Plan shall direct Providers to maintain documentation
in the Enrollee's Medical Records to reflect this provision. See Section
409.912, F.S.

 
(6)
The provisions of this subsection shall not be interpreted so as to prevent a
health care provider or other person from refusing to furnish any contraceptive
or family planning service, supplies or information for medical or religious
reasons. A health care provider or other person shall not be held liable for
such refusal.

 
10.
Hospital Services — Inpatient

 
a.
Inpatient Services are Medically Necessary services ordinarily furnished by a
State licensed acute care Hospital for the medical care and treatment of
inpatients provided under the direction of a physician or dentist in a Hospital
maintained primarily for the care and treatment of patients with disorders other
than mental diseases. Inpatient psychiatric Hospital services are Medically
Necessary Behavioral Health Care Services and may be provided in a general
Hospital psychiatric unit or in a specialty Hospital.

 
(1)
Inpatient services include, but are not limited to, rehabilitation Hospital care
(which are counted as inpatient Hospital days), medical supplies, diagnostic and
therapeutic services, use of facilities, drugs and biologicals, room and board,
nursing care and all supplies and equipment necessary to provide adequate care.
See the Medicaid Hospital Services Coverage & Limitations Handbook.  

 
(2)
Inpatient services also include inpatient care for any diagnosis including
psychiatric and mental health (Baker Act and non-Baker Act), tuberculosis and
renal failure when provided by general acute care Hospitals in both emergent and
non-emergent conditions.

 
(3)
The Health Plan may provide services in a nursing home as downward substitution
for Inpatient Services. In such cases, said inpatient care shall not be counted
as inpatient hospital days.

 
(4)
The health screening examination shall consist of:

 
(a)
Comprehensive health and developmental history, including an assessment of past
medical history, developmental history and behavioral health status;

 
(b)
Comprehensive unclothed physical examination;

 
(c)
Developmental assessment;

 
(d)
Nutritional assessment;

 
(e)
Appropriate immunizations according to the appropriate Recommended Childhood
Immunization Schedule for the United States;

 
(f)
Laboratory testing, including blood lead screenings, where required (for
Children/Adolescents whom the Health Plan identifies through blood lead
screenings as having abnormal levels of lead, the Health Plan shall provide case
management follow-up services as required in Chapter 2 of the Child Health
Check-Up Services Coverage and Limitations Handbook);

 
(g)
Health education (including anticipatory guidance);

 
(h)
Dental screening (including a direct referral to a dentist, or to a Prepaid
Dental Health Plan (PDHP), where applicable, for Children/Adolescents beginning
at 3 years of age or earlier as indicated);

 
(i)
Vision screening, including objective testing, when required;

 
(j)
Hearing screening, including objective testing, when required;

 
(k)
Diagnosis, treatment, referral and follow-up, as appropriate.

 

 
(5)
The Health Plan shall cover physical therapy services when Medically Necessary
and when provided during an Enrollee's inpatient stay.

 
(6)
The Health Plan shall provide up to twenty-eight (28) inpatient hospital days in
an inpatient Hospital substance abuse treatment program for pregnant substance
abusers who meet ISD Criteria with Florida Medicaid modifications, as specified
in InterQual Level of Care 2003-Acute Criteria-Pediatric and/or InterQual Level
of Care 2003-Acute Criteria-Adult (McKesson Health Solutions, LLC, “McKesson”),
2003 Edition or the most current edition, for use in screening cases admitted to
rehabilitative Hospitals and CON approved rehabilitative units in acute care
Hospitals with admission dates of January 1, 2003 and after. In addition, the
Health Plan shall provide inpatient Hospital treatment for severe withdrawal
cases exhibiting medical complications which meet the severity of illness
criteria under the alcohol/substance abuse system-specific set which generally
requires treatment on a medical unit where complex medical equipment is
available. Withdrawal cases (not meeting the severity of illness criteria under
the alcohol/substance abuse criteria) and substance abuse rehabilitation (other
than for pregnant women), including court ordered services, are not covered in
the inpatient Hospital setting.

 
(7)
The Health Plan shall adhere to the provisions of the Newborns and Mothers
Health Protection Act (NMHPA) of 1996 regarding postpartum coverage for mothers
and their newborns. Therefore, the Health Plan shall provide for no less than a
forty-eight (48) hour Hospital length of stay following a normal vaginal
delivery, and at least a ninety-six (96) hour Hospital length of stay following
a Cesarean section. In connection with coverage for maternity care, the Hospital
length of stay is required to be decided by the attending physician in
consultation with the mother.

 
(8)
The Health Plan shall provide up to forty-five (45) days of inpatient coverage
per Enrollee from July 1 or the initial date of Enrollment, whichever comes
later, through June 30 of each year.

 
(9)
The Health Plan shall prohibit the following practices:

 
(a)
Denying the mother or newborn child eligibility, or continued eligibility, to
enroll or renew coverage under the terms of the Health Plan, solely for the
purpose of avoiding the NMHPA requirements;

 
(b)
Providing monetary payments or rebates to mothers to encourage them to accept
less than the minimum protections available under NMHPA;

 
(c)
Penalizing or otherwise reducing or limiting the reimbursement of an attending
physician because the physician provided care in a manner consistent with NMHPA;

 
(d)
Providing incentives (monetary or otherwise) to an attending physician to induce
the physician to provide care in a manner inconsistent with NMHPA;

 
(e)
Restricting for any portion of the forty-eight (48) hour, or ninety-six (96)
hour, period prescribed by NMHPA in a manner that is less favorable than the
Benefits provided for any preceding portion of the Hospital stay; and

 
(f)
The Health Plan shall pay for any Medically Necessary duration of stay in a
noncontracted facility which results from a medical emergency until such time as
the Plan can safely transport the Enrollee to a Plan participating facility.

 
b.
The Health Plan’s inpatient Hospital services also includes the following:

 
(1)
Medically Necessary and appropriate transplants, including:

(a) Bone marrow, all ages;

(b) Cornea, all ages; and

(c) Kidney, all ages.

 
(2)
For other transplants not covered by Medicaid, the evaluations, pre-transplant
care and post-transplant follow-up care are covered by Medicaid and, therefore,
must be covered by the Health Plan even though the transplant procedure is not
covered. Transplant service components are also covered under outpatient
services, physician services and prescribed drug services per the applicable
Medicaid Services Coverage and Limitations handbooks.

 
(3)
The Health Plan is not responsible for the cost of transplant evaluations,
pre-transplant care and post-transplant follow-up care, when an adult Enrollee
(age 21 and over) is listed with the United Network for Organ Sharing (UNOS) as
a level 1A, 1B, or 2 candidate for heart transplant. The Health Plan must
disenroll said Enrollees at the conclusion of the transplant evaluation and
cannot re-enroll the Enrollee until at least one (1) year post transplant.

 
(4)
The Health Plan is not responsible for the cost of a completed adult heart
transplant evaluation regardless of whether or not the Enrollee was determined a
candidate for a transplant. The Health Plan is responsible, however, for the
cost of adult heart transplant evaluations that are not completed for any
reason.

 
(5)
The Health Plan is not responsible for the cost of pre-transplant care and post
transplant follow-up care when an Enrollee has been listed as a candidate for a
pediatric heart, lung or heart/lung transplant (ages 20 and under) or a liver
transplant (all ages). If, at the conclusion of the transplant evaluation, the
Enrollee is listed with UNOS as a level 1A, 1B or 2 for heart, lung or
heart/lung or, Model End Stage Renal Disease (MELD) score of 11-25, for a liver
transplant, the Health Plan must disenroll the Enrollee. The Enrollee will have
the option to re-enroll at one (1) year post transplant. The Health Plan is
responsible for the cost of the above-referenced transplant evaluations.

 
11.
Hospital Services — Outpatient

 
a.
Outpatient Hospital services consist of preventive, diagnostic, therapeutic or
palliative care under the direction of a physician or dentist at a licensed
acute care Hospital. Outpatient Hospital services include Medically Necessary
emergency room services, dressings, splints, oxygen and physician ordered
services and supplies for the clinical treatment of a specific diagnosis or
treatment.

 
a.
The Health Plan shall provide outpatient Hospital services and Emergency
Services and Care as Medically Necessary and appropriate and without any
specified dollar limitations.

 
b.
The Health Plan shall have a procedure for the authorization of dental care and
associated ancillary medical services provided in an outpatient Hospital setting
if that care meets the following requirements:

 
(1)
Is provided under the direction of a dentist at a licensed Hospital; and

 
(2)
Is Medically Necessary; or

 
(3)
The Health Plan shall pay for any Medically Necessary duration of stay in a
noncontracted facility which results from a medical emergency, until such time
as the Health Plan can safely transport the Enrollee to a participating
facility.

 
12.
Hospital Services — Ancillary Services

 
a.
The Health Plan shall provide Medically Necessary ancillary medical services at
the Hospital without limitation. Ancillary Hospital services include, but are
not limited to, radiology, pathology, neurology, neonatology, and
anesthesiology. When the Health Plan or the Health Plan's authorized physician
authorizes these services (either inpatient or outpatient), the Health Plan must
reimburse the provider of the service at the Medicaid line item rate, unless the
Health Plan and the Hospital have negotiated another reimbursement rate. Also,
the Health Plan must reimburse non-network physicians for emergency ancillary
services provided in a Hospital setting.

 
b.
If the Health Plan provides dental services as an optional service, the Health
Plan shall have a procedure for the authorization of Medically Necessary dental
care and associated ancillary services provided in licensed ambulatory surgical
center settings if that care is provided under the direction of a dentist as
described in the State plan.

 
13.
Hysterectomies, Sterilizations and Abortions

 
a.
The Health Plan shall maintain a log of all hysterectomy, sterilization and
abortion procedures performed for its Enrollees. The log must include, at a
minimum, the Enrollee’s name and identifying information, date of procedure, and
type of procedure. The Health Plan shall provide abortions only in the following
situations:

 
(1)
If the pregnancy is a result of an act of rape or incest; or

 
(2)
The physician certifies that the woman is in danger of death unless an abortion
is performed.

 
14.
Immunizations

 
a.
The Health Plan shall:

 
1.
Provide immunizations in accordance with the Recommended Childhood Immunization
Schedule for the United States, or when Medically Necessary for the Enrollee's
health;

 
2.
Provide for the simultaneous administration of all vaccines for which an
Enrollee under the age of twenty (20) is eligible at the time of each visit;

 
3.
Follow only true contraindications established by the Advisory Committee on
Immunization Practices ("ACIP"), unless:

 
(a)
In making a medical judgment in accordance with accepted medical practices, such
compliance is deemed medically inappropriate; or

 
(b)
The particular requirement is not in compliance with Florida law, including
Florida law relating to religious or other exemptions;

 
4.
Participate, or direct its Providers to participate, in the Vaccines For
Children Program ("VFC"). See Section 1905(r)(1) of the Social Security Act. The
VFC is administered by the Department of Health, Bureau of Immunizations, and
provides vaccines at no charge to physicians and eliminates the need to refer
children to CHDs for immunizations.

 
5.
The Health Plan shall provide coverage and reimbursement to the Participating
Provider for immunizations covered by Medicaid, but not provided through VFC;

 
6.
Ensure that Providers have a sufficient supply of vaccines if the Health Plan is
the VFC enrollee. The Health Plan shall direct those Providers that are directly
enrolled in the VFC program to maintain adequate vaccine supplies;

 
7.
Pay no more than the Medicaid program vaccine administration fee of ten dollars
($10.00) per administration, unless another rate is negotiated with the
Participating Provider.

 
8.
Pay the immunization administration fee at no less than the Medicaid rate when
an Enrollee receives immunizations from a non-participating provider, so long
as:

 
(a)
The non-participating provider contacts the Health Plan at the time of service
delivery;

 
(b)
The Health Plan is unable to document to the non-participating provider that the
Enrollee has already received the immunization; and

 
(c)
The non-participating provider submits a claim for the administration of
immunization services and provides Medical Records documenting the immunization
to the Health Plan.

     

 
15.
Pregnancy Related Requirements

 
a.
The Health Plan must provide the most appropriate and highest level of quality
care for pregnant Enrollees. Required care includes the following:

 
(1)
Florida's Healthy Start Prenatal Risk Screening - The Health Plan shall ensure
that the Provider offers Florida's Healthy Start prenatal risk screening to each
pregnant Enrollee as part of her first prenatal visit. As required by Section
383.14, F.S., and 64C-7.009, F.A.C. 

 
(a)
The Health Plan shall ensure that the Provider uses the DOH prenatal risk form
(DH Form 3134), which can be obtained from the local CHD.

 
(b)
The Health Plan shall ensure that the Provider retains a copy of the completed
screening instrument in the Enrollee's Medical Record and provides a copy to the
Enrollee.

 
(c)
The Health Plan shall ensure that the Provider submits the completed DH Form
3134 to the CHD in the county in which the prenatal screen was completed within
ten (10) Business Days of completion.

 
(d)
The Health Plan shall collaborate with the Healthy Start care coordinator within
the Enrollee's county of residence to assure risk appropriate care is delivered.

 
(2)
Florida's Healthy Start Infant (Postnatal) Risk Screening Instrument - The
Health Plan shall ensure that the Provider completes the Florida Healthy Start
Infant (Postnatal) Risk Screening Instrument (DH Form 3135) with the Certificate
of Live Birth and transmits the documents to the CHD in the county in which the
infant was born within ten (10) Business Days of completion. The Health Plan
shall ensure that the Provider retains a copy of the completed DH Form 3135 in
the Enrollee's Medical Record and provides a copy to the Enrollee.

 
(3)
Pregnant Enrollees or infants who do not score high enough to be eligible for
Healthy Start care coordination may be referred for services, regardless of
their score on the Healthy Start risk screen, in the following ways:

 
(a)
If the referral is to be made at the same time the Healthy Start risk screen is
administered, the Provider may indicate on the risk screening form that the
Enrollee or infant is invited to participate based on factors other than score;
or

 

 
(b)
If the determination is made subsequent to risk screening, the Provider may
refer the Enrollee or infant directly to the Healthy Start care coordinator
based on assessment of actual or potential factors associated with high risk,
such as HIV, hepatitis B, substance abuse or domestic violence.

 
(4)
The Health Plan shall refer all pregnant women, breast-feeding and postpartum
women, infants and Children/Adolescents up to age five (5) to the local WIC
office.

(a) The Health Plan shall provide:

 
(i)
A completed Florida WIC program Medical Referral Form with the current height or
length and weight (taken within sixty (60) Calendar Days of the WIC
appointment);

 
(ii)
Hemoglobin or hematocrit; and

 
(iii)
Any identified medical/nutritional problems.

 
(b)
For subsequent WIC certifications, the Health Plan shall ensure that Providers
coordinate with the local WIC office to provide the above referral data from the
most recent CHCUP.

 
(c)
Each time the Health Plan completes a WIC Referral Form, the Health Plan shall
ensure that the Provider gives a copy of the WIC Referral Form to the Enrollee
and retains a copy in the Enrollee's Medical Record.

 
(5)
The Health Plan shall ensure that the Providers provide all women of
childbearing age HIV counseling and offer them HIV testing. See Chapter 381,
F.S.

 
(a)
The Health Plan shall ensure that its Providers, in accordance with Florida law,
offer all pregnant women counseling and HIV testing at the initial prenatal care
visit and again at twenty-eight (28) to thirty-two (32) weeks.

 
(b)
The Health Plan shall ensure that its Providers attempt to obtain a signed
objection if a pregnant woman declines an HIV test. See Section 384.31, F.S. and
64D-3.019, F.A.C.

 
(c)
The Health Plan shall ensure that all pregnant women who are infected with HIV
are counseled about and offered the latest antiretroviral regimen recommended by
the U.S. Department of Health & Human Services (U.S. Department of Health &
Human Services, Public Health Service Task Force Report entitled Recommendations
for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the
United States. To receive a copy of the guidelines, contact the DOH, Bureau of
HIV/AIDS at (850) 245-4334, or go to http://aidsinfo.nih.gov/guidelines/).

 
(6)
The Health Plan shall ensure that its Providers screen all pregnant Enrollees
receiving prenatal care for the Hepatitis B surface antigen (HBsAg) during the
first (1st) prenatal visit.

 
(a)
The Health Plan shall ensure that the Providers perform a second (2nd) HBsAg
test between twenty-eight (28) and thirty-two (32) weeks of pregnancy for all
pregnant Enrollees who tested negative at the first (1st) prenatal visit and are
considered high-risk for Hepatitis B infection. This test shall be performed at
the same time that other routine prenatal screening is ordered.

 
(b)
All HBsAg-positive women shall be reported to the local CHD and to Healthy
Start, regardless of their Healthy Start screening score.

 
(7)
The Health Plan shall ensure that infants born to HBsAg-positive Enrollees shall
receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine once they
are physiologically stable, preferably within twelve (12) hours of birth and
shall complete the Hepatitis B Maxine series according to the recommended
vaccine schedule established by the Recommended Childhood Immunization Schedule
for the United States.

 
(a)
The Health Plan shall ensure that its Providers test infants born to
HBsAg-positive Enrollees for HBsAg and Hepatitis B surface antibodies (anti-HBs)
six (6) months after the completion of the vaccine series to monitor the success
or failure of the therapy.

 
(b)
The Health Plan shall ensure that Providers report to the local CHD a positive
HBsAg result in any child aged twenty-four (24) months or less within
twenty-four (24) hours of receipt of the positive test results.

 
(c)
The Health Plan shall ensure that infants born to Enrollees who are
HBsAg-positive are referred to Healthy Start regardless of their Healthy Start
screening score.

 
(8)
The Health Plan shall report to the Perinatal Hepatitis B Prevention Coordinator
at the local CHD all prenatal or postpartum Enrollees who test HBsAg-positive.
The Health Plan also shall report said Enrollees’ infants and contacts to the
Perinatal Hepatitis B Prevention Coordinator at the local CHD.

 
(a)
The Health Plan shall report the following information - name, date of birth,
race, ethnicity, address, infants, contacts, laboratory test performed, date the
sample was collected, the due date or EDC, whether or not the Enrollee received
prenatal care, and immunization dates for infants and contacts.

 
(b)
The Health Plan shall use the Perinatal Hepatitis B Case and Contact Report (DH
Form 1876) for reporting purposes.

 
(9)
The Health Plan shall ensure that the PCP maintains all documentation of Healthy
Start screenings, assessments, findings and referrals in the Enrollees’ Medical
Records. The Health Plan shall ensure quick access to Enrollees’ Medical Records
in the Provider Contract.

 
(10)
The Health Plan shall provide the most appropriate and highest level of quality
care for pregnant Enrollees, including, but not limited to, the following:

 
(a)
Prenatal Care - The Health Plan shall:

 
(i)
Require a pregnancy test and a nursing assessment with referrals to a physician,
PA or ARNP for comprehensive evaluation;

 
(ii)
Require Case Management through the gestational period according to the needs of
the Enrollee;

 
(iii)
Require any necessary referrals and follow-up;

 
(iv)
Schedule return prenatal visits at least every four (4) weeks until the
thirty-second (32nd) week, every two (2) weeks until the thirty-sixth (36th)
week, and every week thereafter until delivery, unless the Enrollee’s condition
requires more frequent visits; 

 
(v)
Contact those Enrollees who fail to keep their prenatal appointments as soon as
possible, and arrange for their continued prenatal care;

 
(vi)
Assist Enrollees in making delivery arrangements, if necessary; and

 
(vii)
Ensure that all Providers screen all pregnant Enrollees for tobacco use and make
certain that the Providers make available to the pregnant Enrollees smoking
cessation counseling and appropriate treatment as needed.

 
(b)
Nutritional Assessment/Counseling - The Health Plan shall ensure that its
Providers supply nutritional assessment and counseling to all pregnant
Enrollees. The Health Plan shall:

 
(i)
Ensure the provision of safe and adequate nutrition for infants by promoting
breast-feeding and the use of breast milk substitutes;

 
(ii)
Offer a mid-level nutrition assessment;

 
(iii)
Provide individualized diet counseling and a nutrition care plan by a public
health nutritionist, a nurse or physician following the nutrition assessment;
and

 
(iv)
Documentation of the nutrition care plan in the Medical Record by the person
providing counseling.

 
(c)
Obstetrical Delivery - The Health Plan shall develop and use generally accepted
and approved protocols for both low risk and high risk deliveries which reflect
the highest standards of the medical profession, including Healthy Start and
prenatal screening, and ensure that all Providers use these protocols.

 
(i)
The Health Plan shall ensure that all Providers document preterm delivery risk
assessments in the Enrollee’s Medical Record by the twenty-eighth (28th) week.

 
(ii)
If the Provider determines that the Enrollee’s pregnancy is high risk, the
Health Plan shall ensure that the Provider’s obstetrical care during labor and
delivery includes preparation by all attendants for symptomatic evaluation and
that the Enrollee progresses through the final stages of labor and immediate
postpartum care.

 
(d)
Newborn Care - The Health Plan shall make certain that its Providers supply the
highest level of care for the Newborn beginning immediately after birth. Such
level of care shall include, but not be limited to, the following:

 
(i)
Instilling of prophylactic eye medications into each eye of the Newborn;

 
(ii)
When the mother is Rh negative, the securing of a cord blood sample for type Rh
determination and direct Coombs test;

 
(iii)
Weighing and measuring of the Newborn;

 
(iv)
Inspecting the Newborn for abnormalities and/or complications;

 
(v)
Administering of one half milligram of vitamin K;

 
(vi)
APGAR scoring;

 
(vii)
Any other necessary and immediate need for referral in consultation from a
specialty physician, such as the Healthy Start (postnatal) infant screen; and

 
(viii)
Any necessary Newborn and infant hearing screenings (to be conducted by a
licensed audiologist pursuant to Chapter 468, F.S., a physician licensed under
Chapters 458 or 459, F.S., or an individual who has completed documented
training specifically for newborn hearing screenings and who is directly or
indirectly supervised by a licensed physician or a licensed audiologist).

 
(e)
Postpartum Care - The Health Plan shall:

 
(i)
Provide a postpartum examination for the Enrollee within six (6) weeks after
delivery;

 
(ii)
Ensure that its Providers supply voluntary family planning, including a
discussion of all methods of contraception, as appropriate;

 
(iii)
Ensure that eligible Newborns are enrolled with the Health Plan and that
continuing care of the Newborn be provided through the CHCUP program component.

 
16.
Prescribed Drug Services

 
a.
The Health Plan shall provide those products and services associated with the
dispensing of medicinal drugs pursuant to a valid prescription, as defined in
Chapter 465, F.S. Prescribed Drug Services generally include all prescription
drugs listed in the Agency’s Prescribed Drug List (“PDL”). See Section
409.91195, F.S. The PDL shall include at least two (2) products, when available,
in each therapeutic class. Antiretroviral agents are not subject to the PDL.
Pursuant to Section 409.912(39), F.S., policy requirements include, but are not
limited to, the following:

 
(1)
The Health Plan shall make available those drugs and dosage forms listed in the
PDL.

 
(2)
The Health Plan shall not arbitrarily deny or reduce the amount, duration or
scope of prescriptions solely based on the Enrollee’s diagnosis, type of illness
or condition. The Health Plan may place appropriate limits on prescriptions
based on criteria such as Medical Necessity, or for the purpose of utilization
control, provided the Health Plan reasonably expects said limits to achieve the
purpose of the Prescribed Drug Services set forth in the Medicaid State Plan.

 
(3)
The Health Plan shall make available those drugs not on the PDL, when requested
and approved, if the drugs on the PDL have been used in a step therapy sequence
or when other documentation is provided.

 
(4)
The Health Plan shall submit an updated PDL to the Agency annually, by October 1
of each Contract Year, and provide thirty (30) days written notice of any
changes to the Bureau of Managed Health Care and Pharmacy Services.

 
b.
The Health Plan shall provide to Enrollees, who desire to quit smoking, one (1)
course of nicotine replacement therapy, of twelve (12) weeks duration, or the
manufacturer’s recommended duration, per year. The Health Plan may use either
nicotine transdermal patches or nicotine gum.

 
c.
If the Health Plan has authorization requirements for prescribed drug services,
the Health Plan shall comply with all aspects of the Settlement Agreement to
Hernandez, et. al. v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA). An
HSA situation arises when an Enrollee attempts to fill a prescription at a
participating pharmacy location and is unable to receive his/her prescription as
a result of:

 
(1)
An unreasonable delay in filling the prescription;

 
(2)
A denial of the prescription;

 
(3)
The reduction of a prescribed good or service; and/or

 

 
(4)
The termination of a prescription.

 
d.
The Health Plan shall ensure that its Enrollees are receiving the functional
equivalent of those goods and services received by non-Medicaid Reform
fee-for-service Medicaid Recipients in accordance with the HSA. 

 

 
(1)
The Health Plan shall maintain a log of all correspondences and communications
from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log” shall
contain, at a minimum, the Enrollee’s name, address and telephone number and any
other contact information, the reason for the participating pharmacy location’s
denial (an unreasonable delay in filling a prescription, a denial of a
prescription and/or the termination of a prescription), the pharmacy’s name (and
store number, if applicable), the date of the call, a detailed explanation of
the final resolution, and the name of prescribed good or service.

 
(2)
The Health Plan’s Enrollees are third party beneficiaries for this Section of
the Contract.

 
(3)
The Health Plan shall conduct HSA surveys on an annual basis, of no less than
five percent (5%) of all participating pharmacy locations to ensure compliance
with the HSA.

(a)  
The Health Plan may survey less than five percent (5%), with written approval
from the Agency, if the Health Plan can show that the number of participating
pharmacies it surveys is a statistically significant sample that adequately
represents the pharmacies that have contracted with the Health Plan to provide
pharmacy services.

(b)  
The Health Plan shall not include in the HSA Survey any participating pharmacy
location that the Health Plan found to be in complete compliance with the HSA
requirements within the last twelve (12) months.

(c)  
The Health Plan shall require all participating pharmacy locations that fail any
aspect of the HSA survey to undergo mandatory training within six (6) months and
then be re-evaluated within one (1) month of the Health Plan’s HSA training to
ensure that the participating pharmacy location is in compliance with the HSA.

(d)  
The Health Plan shall ensure that it complies with all aspects and surveying
requirements set forth in Policy Transmittal 06-01, Hernandez Settlement
Requirements, an electronic copy of which can be found at:

http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_prov.shtml

 
(4)
The Health Plan shall offer to train all new and existing participating pharmacy
locations regarding the HSA requirements.

 
(5)
The Health Plan may delegate any or all functions to one (1) or more Pharmacy
Benefits Administrators (PBA). Before entering into a Subcontract, the Health
Plan shall:

(a)  
Provide a copy of the model Subcontract between the Health Plan and the PBA to
the Bureau of Managed Health Care;

(b)  
Receive written approval from the Bureau of Managed Health Care for the use of
said model Subcontract; and

(c)  
Work with the Fiscal Agent to integrate the systems.

 
e.
The Health Plan shall reimburse all pharmacies for the cost of a brand name drug
if:

 
(1)
Writes in his/her own handwriting on the valid prescription that the “Brand Name
is Medically Necessary” (pursuant to Section 465.025, F.S.); and

 
(2)
Submits a completed “Multisource Drug and Miscellaneous Prior Authorization”
form to the Health Plan indicating that the Enrollee has had an adverse reaction
to a generic drug or has had, in the prescriber’s medical opinion, better
results when taking the brand-name drug.

 
f.
Effective September 1, 2006, hemophilia-related drugs identified by the Agency
for distribution through the Hemophilia Disease Management Pilot Program will be
reimbursed on a Fee-for-Service basis. Upon implementation of the Hemophilia
Disease Management Pilot Program, the Health Plan shall coordinate the care of
its’ Enrollees with Agency-approved organizations and shall not be responsible
for the distribution of Hemophilia-related drugs.

 
g.
Health Plans shall submit pharmacy encounter data in a format supplied by the
Agency on an ongoing quarterly payment schedule, as specified in Section XII of
this Contract. For example, data for all claims paid during 04/01/06 and
06/30/06 is due to the Agency by 07/31/06.

 
17.
Quality Enhancements

 
a.
In addition to the covered services specified in this Section, the Health Plan
shall offer Quality Enhancements ("QEs") to Enrollees as specified below.

 
1.
The Health Plan shall offer QEs in community settings that are accessible to
Enrollees.

 
2.
The Health Plan shall inform Enrollees and Providers of the QEs, and how to
access services related to QEs, through the Enrollee and Provider Handbooks.

 
3.
The Health Plan shall develop and maintain written policies and procedures to
implement QEs.

 
4.
 The Health Plan may cosponsor the annual training of Providers, provided that
the training meets the Provider training requirements for the programs listed
below. The Plan is encouraged to actively collaborate with community agencies
and organizations, including CHD's, local Early Intervention Programs, Healthy
Start Coalitions and local school districts in offering these services.

 
5.
If the Health Plan involves the Enrollee in an existing community program for
purposes of meeting the QE requirement, the Health Plan shall document referrals
to the community program, shall follow-up on the Enrollee's receipt of services
from the community program and record the Enrollee's involvement in the
Enrollee’s Medical Record.

 
6.
QE programs shall include, but not be limited to, the following:

 
(1)
Children's Programs - The Health Plan shall provide regular general wellness
programs targeted specifically toward Enrollees from birth to the age of five
(5), or the Health Plan shall make a good faith effort to involve Enrollees in
existing community Children's Programs.

 
(a)
Children's Programs shall promote increased utilization of prevention and early
intervention services for at-risk Enrollees with Children/Adolescents in the
target population. The Health Plan shall approve claims for services recommended
by the Early Intervention Program when they are Covered Services and Medically
Necessary.

 
(b)
The Health Plan shall offer annual training to Providers that promote proper
nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention and early
intervention services.

 
(2)
Domestic Violence - The Health Plan shall ensure that PCPs screen Enrollees for
signs of domestic violence and shall offer referral services to applicable
domestic violence prevention community agencies.

 
(3)
Pregnancy Prevention - The Health Plan shall conduct regularly scheduled
Pregnancy Prevention programs, or shall make a good faith effort to involve
Enrollees in existing community Pregnancy Prevention programs, such as the
Abstinence Education Program. The programs shall be targeted towards teen
Enrollees, but shall be open to all Enrollees, regardless of age, gender,
pregnancy status or parental consent.

 
(4)
Prenatal/Postpartum Pregnancy Programs - The Health Plan shall provide regular
home visits, conducted by a home health nurse or aide, and counseling and
educational materials to pregnant and postpartum Enrollees who are not in
compliance with the Health Plan's prenatal and postpartum programs. The Health
Plan shall coordinate its efforts with the local Healthy Start Care Coordinator
to prevent duplication of services.

 
(5)
Smoking Cessation - The Health Plan shall conduct regularly scheduled Smoking
Cessation programs as an option for all Enrollees, or the Health Plan shall make
a good faith effort to involve Enrollees in existing community or Smoking
Cessation programs. The Health Plan shall provide Smoking Cessation counseling
to Enrollees. The Health Plan shall provide Participating PCPs with the Quick
Reference Guide to assist in identifying tobacco users and supporting and
delivering effective Smoking Cessation interventions (The Quick Reference Guide
is a distilled version of the Public Health Service sponsored Clinical Practice
Guideline, Treating Tobacco Use & Dependence. The Plan can obtain copies of the
Quick Reference guide by contacting the DHHS, Agency for Health Care Research &
Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O. Box 8547,
Silver Spring, MD 20907).

 
(6)
Substance Abuse - The Health Plan shall offer Substance Abuse screening training
to its Providers on an annual basis.

 
(a)
The Health Plan shall have all PCPs screen Enrollees for signs of Substance
Abuse as part of prevention evaluation at the following times:

 
(i)
Initial contact with a new Enrollee;

 
(ii)
Routine physical examinations;

 
(iii)
Initial prenatal contact;

 
(iv)
When the Enrollee evidences serious over-utilization of medical, surgical,
trauma or emergency services; and

 
(v)
When documentation of emergency room visits suggests the need.

 
(b)
The Health Plan shall offer targeted Enrollees either community or Health Plan
sponsored Substance Abuse programs.

 
18.
Protective Custody

 
a.
The Health Plan shall provide a physical screening within seventy-two (72)
hours, or immediately if required, for all enrolled Children/Adolescents taken
into protective custody, emergency shelter or the foster care program by DCF.
See Rule 65C-12.002, F.A.C.

 
b.
The Health Plan shall provide these required examinations, or, if unable to do
so within the required time frames, must approve the out-of-network claim and
forward it to the Agency and/or its Agent.

 
c.
For all CHCUP screenings for Children/Adolescents whose Enrollment and Medicaid
eligibility are undetermined at the time of entry into the care and custody of
DCF, and who are later determined to be Enrollees at the time the examinations
took place, the Health Plan shall approve the claims and forward them to the
Agency and/or the Fiscal Agent.

 
19.
Therapy Services

 
a.
Medicaid therapy services are physical, speech-language (including augmentative
and alternative communication systems), occupational and respiratory therapies.
The Health Plan shall cover therapy services consistent with handbook
requirements. Medicaid pays only for therapy services that are Medically
Necessary for the provision of therapy evaluations and individual therapy
treatment. Therapy services are limited to Children/Adolescents under the age of
twenty-one (21). Adults are covered for physical and respiratory therapy
services under the outpatient Hospital services program. The Agency shall
reimburse schools participating in the certified school match program for
school-based therapy services rendered to Enrollees. The provision of
school-based therapy services to an Enrollee does not replace, substitute or
fulfill a service prescription or doctors' orders for therapy services external
to the Health Plan. The Health Plan shall:

 

 
(1)
Refer Enrollees to appropriate Providers for further assessment and treatment of
conditions;

 
(2)
Offer Enrollees scheduling assistance in making treatment appointments and
obtaining transportation; and

 
(3)
Provide for care management in order to follow the Enrollee’s progress from
screening through his/her course of treatment.

 
20.
Transportation Services

 
a.
Transportation services are an Optional Service (as described in Section V.B.,
Optional Services, above). Transportation services include the arrangement and
provision of an appropriate mode of Transportation for Enrollees to receive
medical care services. The Health Plan shall comply with the limitations and
exclusions in the Medicaid Transportation Coverage, Limitations & Reimbursement
Handbook (the “Transportation Handbook”), including Emergency Transportation
Services. In any instance where compliance conflicts with the terms of this
Contract, the Contract terms shall take precedence. In no instance may the
limitations or exclusions imposed by the Health Plan be more stringent than
those specified in the Transportation Handbook.

 
b.
The Health Plan shall have the option to provide Transportation services
directly through the Health Plan’s network of Transportation Providers, or
through a Provider contract relationship, which may include the CTD.

 
c.
Regardless of whether the Health Plan chooses to coordinate with a
Transportation Provider or provide Transportation services directly, the Health
Plan shall be responsible for monitoring the provision of services. The Health
Plan:

 
(1)
Shall assure that Transportation providers are appropriately licensed and
insured in accordance with the provisions of the Transportation Handbook;

 
(2)
Must provide Transportation Services for all Enrollees seeking necessary
Medicaid services;

 
(3)
Is not obligated to follow the requirements of the Commission for the
Transportation Disadvantaged or the Transportation Coordinating Boards as set
forth in Chapter 427, F.S., unless the Health Plan has chosen to coordinate
services with the CTD;

 
(4)
Shall be responsible for the cost of transporting an Enrollee from a
nonparticipating facility or Hospital to a participating facility or Hospital if
the reason for transport is solely for the Health Plan's convenience; and

 
(5)
Shall approve claims for Transportation Providers in accordance with the
requirements set forth in this Contract.

 
d.
The Health Plan may delegate the provision of Transportation Services to a third
party.

 
(1)
The Health Plan shall provide a copy of the model Participating Transportation
Subcontract to the Bureau of Managed Health Care.

 
(2)
The Health Plan may subcontract with more than one (1) Transportation Provider.

 
(3)
The Health Plan shall maintain oversight of any third party providing services
on the Health Plan's behalf.

 
e.
The Health Plan shall provide the following non-emergency Transportation, at a
minimum, as part of its line of Transportation services (as defined in the
Transportation Handbook):

 
(1)
Ambulatory Transportation;

 
(2)
Long haul ambulatory Transportation;

 
(3)
Wheelchair Transportation;

 
(4)
Stretcher Transportation;

 
(5)
Multiload Transportation;

 
(6)
Mass transit Transportation;

 
(7)
Over-the-road bus;

 
(8)
Over-the-road train;

(9) Private volunteer Transportation; 

 
(10)
Escort services (including medical escort); and

 
(11)
Commercial air carrier Transportation.

 
f.
Before providing Transportation services, the Health Plan shall provide to the
Bureau of Managed Health Care a copy of its policies and procedures relating to
the following:

 
(1)
How the Health Plan will determine eligibility for each Enrollee;

 
(2)
The Health Plan's course of action as to how it will determine what type of
Transportation to provide to a particular Enrollee;

 
(3)
The Health Plan's procedure for providing Prior Authorization to Enrollees
requesting Transportation services;

 
(4)
The Health Plan's comprehensive employee training program to investigate
potential Fraud;

 
(5)
How the Health Plan will review Transportation Providers who demonstrate a
pattern or practice of:

 
(a)
Falsified encounter or service reports;

 
(b)
Overstated reports or up-coded levels of service; and/or

 
(c)
Fraud or Abuse, as defined in section 409.913, F.S.

 
(6)
How the Health Plan will review Transportation Providers that:

 
(a)
Alter, falsify or destroy records prior to the end of the five (5) year records
retention requirement;

 
(b)
Make false statements about credentials;

 
(c)
Misrepresent medical information to justify referrals;

 
(d)
Fail to provide scheduled Transportation for Enrollees;

 
(e)
Charge Enrollees for Covered Services; and/or

 
(f)
Have committed, or been suspected of committing, Fraud or Abuse, as defined in
Section 409.913, F.S.

 
(7)
How the Health Plan will provide Transportation Services outside of the Health
Plan's service area. The Health Plan shall state clearly the guidelines it will
use in order to control costs when providing Transportation Services outside of
the Health Plan's service area.

 
g.
The Health Plan shall report immediately, in writing to the Agency Contract
Manager, the Bureau of Medicaid Program Integrity (MPI), and Medicaid Fraud
Control Unit (MFCU), any aspect of Transportation Service delivery, by any
Transportation services provider, or any adverse or untoward incident (See
section 641.55, F.S.). The Health Plan shall also report, immediately upon
identification, in writing to the Agency Contract Manager, the MPI and the MFCU,
all instances of suspected Enrollee or Transportation Services Provider fraud or
abuse (as defined in Section 409.913, F.S.)

 
(1)
The Health Plan shall file a written report with the Agency Contract Manager,
the Bureau of Managed Health Care, MPI and MFCU immediately upon the detection
of a potentially or suspected fraudulent or abusive action by a Transportation
services Provider. At a minimum, the report must contain the name, tax
identification number and contract information of the Transportation services
Provider and a description of the suspected fraudulent or abusive act. The
report shall be in the form of a narrative.

 
h.
Insurance, Safety Requirements and Standards (including, but not limited to,
41-2, F.A.C.)

 
(1)
The Health Plan shall ensure compliance with the minimum liability insurance
requirement of $100,000 per person and $200,000 per incident for all
Transportation services purchased or provided for the Transportation
disadvantaged through the Health Plan. See Section 768.28(5), F.S. The Health
Plan shall indemnify and hold harmless the local, State, and federal governments
and their entities and the Agency from any liabilities arising out of or due to
an accident or negligence on the part of the Health Plan and/or all
Transportation Providers under contract to the Health Plan. The Health Plan may
act as a Transportation Provider, in which case it must follow all requirements
set forth below for Transportation Providers.

 
(2)
The Health Plan, and all Transportation Providers, shall ensure that all
operations and services are in compliance with all federal and State safety
requirements, including, but not limited to, Section 341.061(2)(a), F.S., and
Chapter 14-90, F.A.C.

 
(3)
The Health Plan, and all Transportation Providers, shall ensure continuing
compliance with all applicable State or federal laws relating to drug testing,
including, but not limited to, to Section 112.0455, F.S., Rule 14-17.012,
Chapters 59A-24 and 60L-19, F.A.C., 41 USC 701, 49 CFR, Parts 29 and 382, and 46
CFR, Parts 4, 5, 14, and 16.

 
(4)
The Health Plan and all Transportation Providers shall adhere to the following
standards, including, but not limited to:

 
(a)
Drug and alcohol testing for safety sensitive job positions relating to the
provision of Transportation services regarding pre-employment, randomization,
post-accident, and reasonable suspicion as required by the Federal Highway
Administration and the Federal Transit Administration;

 
(b)
Use of child safety restraint devices, where the use of such devices would not
interfere with the safety of a child (for example, a child in a wheelchair);

 
(c)
Enrollee property that can be carried by the passenger and/or driver, and can be
stowed safely on the vehicle, shall be transported with the passenger at no
additional charge. The driver shall provide Transportation of the following
items, as applicable, within the capabilities of the vehicle:

 
(i)
Wheelchairs;

 
(ii)
Child seats;

 
(iii)
Stretchers;

 
(iv)
Secured oxygen;

 
(v)
Personal assistive devices; and/or

 
(vi)
Intravenous devices.

 
(d)
Vehicle transfer points shall provide shelter, security, and safety of
Enrollees;

 
(e)
Maintain inside all vehicles copies of the Health Plan’s toll-free phone number
for Enrollee complaints;

 
(f)
The interior of all vehicles shall be free from dirt, grime, oil, trash, torn
upholstery, damaged or broken seats, protruding metal or other objects or
materials which could soil items placed in the vehicle or provide discomfort for
Enrollees;

 
(g)
Maintain a passenger/trip database for each Enrollee transported by the Health
Plan/Transportation Provider;

 
(h)
Ensure adequate seating for paratransit services for each Enrollee and escort,
child, or personal care attendant, and shall ensure that the vehicle does not
transport more passengers than the registered passenger seating capacity in a
vehicle at any time;

 
(i)
Ensure adequate seating space for transit services for each Enrollee and escort,
child, or personal care attendant, and shall ensure that transit vehicles
provide adequate seating or standing space to each rider, and shall ensure that
the vehicle does not transport more passengers than the registered passenger
seating or standing capacity in a vehicle at any time;

 
(j)
Drivers for paratransit services shall identify themselves by name and company
in a manner that is conducive to communications with the specific passenger,
upon pickup of each Enrollee, group of Enrollees, or representative, guardian,
or associate of the Enrollee, except in situations where the driver regularly
transports the Enrollee on a recurring basis;

 
(k)
Each driver must have photo identification that is viewable by the passenger.
Name patches, inscriptions or badges that affix to driver clothing are
acceptable. For transit services, the driver photo identification shall be in a
conspicuous location in the vehicle;

 
(l)
The paratransit driver shall provide the Enrollee with boarding assistance, if
necessary or requested, to the seating portion of the vehicle. The boarding
assistance shall include, but not be limited to, opening the vehicle door,
fastening the seat belt or utilization of wheel chair securement devices,
storage of mobility assistive devices and closing the vehicle door. In the
door-through-door paratransit service category, the driver shall open and close
doors to buildings, except in situations in which assistance in opening and/or
closing building doors would not be safe for passengers remaining in the
vehicle. The driver shall provide assisted access in a dignified manner. Drivers
may not assist wheelchair passengers up or down more than one (1) step, unless
it can be performed safely as determined by the Enrollee, guardian, and driver;

 
(m)
Smoking, eating and drinking are prohibited in any vehicle, except in cases in
which, as a Medical Necessity, the Enrollee requires fluids or sustenance during
transport;

 
(n)
Ensure that all vehicles are equipped with two-way communications, in good
working order and audible to the driver at all times, by which to communicate
with the Transportation services hub or base of operations;

 
(o)
Ensure that all vehicles have working air conditioners and heaters. The Health
Plan shall ensure that all vehicles that do not have a working air conditioner
or heater are removed from the vehicle pool and scheduled for repair or
replacement;

 
(p)
Develop and implement a first aid policy and cardiopulmonary resuscitation
policy;

 
(q)
Ensure that all drivers providing Transportation services undergo a background
screening;

 
(r)
Establish Enrollee pick-up windows and communicate these windows to
Transportation Providers and Enrollees;

 
(s)
Establish a minimum 24-hour advance notification policy to obtain Transportation
Services. The Health Plan shall communicate said policy to Transportation
Providers and Enrollees;

 
(t)
Establish a performance measure to evaluate the safety of the Transportation
services provided by Transportation Providers;

 
(u)
Establish a performance measure to evaluate the reliability of the vehicles
utilized by Transportation Providers;

 
(v)
Establish a performance measure to evaluate the quality of service provided by a
Transportation Provider;

 
(w)
The Health Plan shall submit these performance measures to the Agency for
written approval by the end of the first month of this contract term;

 
(x)
The Health Plan shall report the results of these evaluations to the Agency as
described in Section XII, Reporting Requirements; and

 
(y)
Ensure that all drivers speak English.

 
i.
Operational Standards - Each Health Plan shall implement, or ensure that each
Transportation Provider has implemented, policies and procedures that, at a
minimum, comply with the following (for reference, see 14-90, F.A.C.):

 
(1)
Address the following safety elements and requirements:

 
(a)
Safety policies and responsibilities;

 
(b)
Vehicle and equipment standards and procurement criteria;

 
(c)
Operational standards and procedures;

 
(d)
Vehicle driver and employee selection;

 
(e)
Driving requirements;

 
(f)
Vehicle driver and employee training;

 
(g)
Vehicle maintenance;

 
(h)
Investigations of events described below;

 
(i)
Hazard identification and resolution;

 
(j)
Equipment for transporting wheelchairs;

 
(k)
Safety data acquisition and analysis;

 
(l)
Safety standards for private contract vehicle transit system(s) that provide(s)
Transportation services for compensation as a result of a contractual agreement
with the vehicle transit system.

 
(2)
Shall submit an annual safety certification to the Agency verifying the
following:

 
(a)
Adoption of policies and procedures that, at a minimum, establish standard set
forth in this Section; and

 
(b)
The Health Plan/Transportation Provider is in full compliance with the policies
and procedures relating to Transportation services, and that it has performed
annual safety inspections on all vehicles operated by the Health
Plan/Transportation Provider, by persons meeting the requirements set forth
below.

 
(3)
The Health Plan shall suspend immediately a Transportation Provider if, in the
sole discretion of the Health Plan, and at any time, continued use of that
Transportation Provider, is unsafe for passenger service or poses a potential
danger to public safety.

 
(4)
Address the following security requirements:

 
(a)
Security policies, goals, and objectives;

 
(b)
Organization, roles, and responsibilities;

 
(c)
Emergency management processes and procedures for mitigation, preparedness,
response, and recovery;

 
(d)
Procedures for investigation of any event involving a vehicle, or taking place
on vehicle transit system controlled property, resulting in a fatality, injury,
or property damage as discussed below;

 
(e)
Procedures for the establishment of interfaces with emergency response
organizations;

 
(f)
Employee security and threat awareness training programs;

 
(g)
Conduct and participate in emergency preparedness drills and exercises; and

 
(h)
Security requirements for Transportation Providers that provide Transportation
services for compensation as a result of a contractual agreement with the Health
Plan/Transportation Provider.

 
(5)
Shall establish criteria and procedures for selection, qualification, and
training of all drivers. The criteria shall include, at a minimum, the
following:

 
(a)
Driver qualifications and background checks with minimum hiring standards;

 
(b)
Driving and criminal background checks for all new drivers;

 
(c)
Verification and documentation of valid driver licenses for all employees who
drive vehicles;

 
(d)
Training and testing to demonstrate and ensure adequate skills and capabilities
to safely operate each type of vehicle or vehicle combination before driving
unsupervised;

 
(e)
At a minimum, drivers shall be given explicit instructional and procedural
training and testing in the following areas:

 
(i)
The Health Plan’s/Transportation Provider’s safety and operational policies and
procedures;

 
(ii)
Operational vehicle and equipment inspections;

 
(iii)
Vehicle equipment familiarization;

 
(iv)
Basic operations and maneuvering;

 
(v)
Boarding and alighting passengers;

 
(vi)
Operation of wheelchair lift and other special equipment and driving conditions;

 
(vii)
Defensive driving;

 
(viii)
Passenger assistance and securement;

 
(ix)
Handling of emergencies and security threats; and

 
(x)
Security and threat awareness.

 
(f)
Shall provide written operational and safety procedures to all vehicle drivers
before the drivers are allowed to drive unsupervised. These procedures and
instructions shall address, at a minimum, the following:

 
(i)
Communication and handling of unsafe conditions, security threats, and
emergencies;

 
(ii)
Familiarization and operation of safety and emergency equipment, wheelchair lift
equipment, and restraining devices; and

 
(iii)
Application and compliance with applicable federal and State rules and
regulations. The provisions in Sections V.E.20.i.(5)(e) and (f), above, shall
not apply to personnel licensed and authorized by the Plan/Transportation
Provider to drive, move, or road test a vehicle in order to perform repairs or
maintenance services where it has been determined that such temporary operation
does not create an unsafe operating condition or create a hazard to public
safety.

 
(g)
Shall maintain the following records for at least five (5) years:

 
(i)
Records of vehicle driver background checks and qualifications;

 
(ii)
Detailed descriptions of training administered and completed by each vehicle
driver;

 
(iii)
A record of each vehicle driver’s duty status, which shall include total days
worked, on-duty hours, driving hours and time of reporting on- and off-duty each
day; and

 
(iv)
Any documents required to be prepared by this Contract.

 
(h)
Shall establish a drug-free workplace policy statement, in accordance with 49
CFR Part 29 and a substance abuse management and testing program, in accordance
with 49 CFR Parts 40 and 655; and

 
(i)
Shall require that drivers write and submit a daily vehicle inspection report,
pursuant to Rule 14-90.006, F.A.C.

 
(6)
Shall establish a maintenance policy and procedures for preventative and routine
maintenance for all vehicles. The maintenance policy and procedures shall
ensure, at a minimum, that:

 
(a)
All vehicles, all parts and accessories on such vehicles, and any additional
parts and accessories which may affect the safety of vehicle operation,
including frame and frame assemblies, suspension systems, axles and attaching
parts, wheels and rims, and steering systems, are regularly and systematically
inspected, maintained and lubricated in accordance with the standards developed
and established according to the vehicle manufacturer’s recommendations and
requirements;

 
(b)
That a recording and tracking system is established for the types of
inspections, maintenance, and lubrication intervals, including the date or
mileage when these services are due. Required maintenance inspections shall be
more comprehensive than daily inspections performed by the driver;

 
(c)
That proper preventive maintenance is performed when on all vehicles; and

 
(d)
That the Health Plan/Transportation Provider maintains and provides written
documentation of preventive maintenance, regular maintenance, inspections,
lubrication, and repairs performed for each vehicle under their control. Such
records shall be maintained by the Health Plan/Transportation Provider for at
least five (5) years and include, at a minimum, the following information:

 
(i)
Identification of the vehicle, including make, model, and license number or
other means of positive identification and ownership;

 
(ii)
Date, mileage, and type of inspection, maintenance, lubrication, or repair
performed;

 
(iii)
Date, mileage, and description of each inspection, maintenance, and lubrication
intervals performed;

 
(iv)
If not owned by the Health Plan/Transportation Provider, the name of any person
or lessor furnishing any vehicle; and

 
(v)
The name and address of any entity or contractor performing an inspection,
maintenance, lubrication, or repair.

 
(7)
The Health Plan/Transportation Provider shall investigate, or cause to be
investigated, any event involving a vehicle or taking place on Health
Plan/Transportation Provider controlled property resulting in a fatality,
injury, or property damage as follows:

 
(a)
A fatality, where an individual is confirmed dead, within three (3) days of a
Transportation services related event, excluding suicides and deaths from
illnesses. The Health Plan must file detailed report of the incident with the
Agency within ten (10) days of the event (see Section 641.55(6), F.S.);

 
(b)
Injuries requiring immediate medical attention away from the scene for two (2)
or more individuals;

 
(c)
Property damage to Health Plan/Transportation Provider vehicles, other Health
Plan/Transportation Provider property or facilities, or any other property,
except the Health Plan/Transportation Provider shall have the discretion to
investigate events resulting in property damage totaling less than $1,000;

 
(d)
Evacuation of a vehicle due where there is imminent danger to passengers on the
vehicle, excluding evacuations due to vehicle operation issues;

 
(e)
Each investigation shall be documented in a final report that includes a
description of investigation activities, identified causal factors and a
corrective action plan;

 
(i)
Each corrective action plan shall identify the action to be taken by the Health
Plan/Transportation Provider and the schedule for its implementation; and

 
(ii)
The Health Plan/Transportation Provider must monitor and track the
implementation of each corrective action plan.

 
(f)
The Health Plan/Transportation Provider shall maintain all investigation
reports, corrective action plans, and related supporting documentation for a
minimum of five (5) years from the date of completion of the investigation.

 
j.
Medical Examinations for Drivers - The Health Plan/Transportation Provider shall
establish medical examination requirements for all applicants for driver
positions and for existing drivers. The medical examination requirements shall
include a pre-employment examination for applicants, an examination at least
once every two (2) years for existing drivers, and a return to duty examination
for any driver prior to returning to duty after having been off duty for thirty
(30) or more days due to an illness, medical condition, or injury.

 
(1)
Medical examinations may be performed and recorded according to qualification
standards adopted by the Health Plan/Transportation Provider, provided the
medical examination qualification standards adopted by the Health
Plan/Transportation Provider meet or exceed those provided in Department Form
Number 725-030-11, Medical Examination Report for Bus Transit System Driver,
Rev. 07/05, hereby incorporated by reference. Copies of Form Number 725-030-11
are available from the Florida Department of Transportation, Public Transit
Office, 605 Suwannee Street, Mail Station 26, Tallahassee, Florida 32399-0450 or
on-line at www.dot.state.fl.us/transit.

 
(2)
Medical examinations shall be performed by a Doctor of Medicine or Osteopathy, a
Physician Assistant (PA) or ARNP licensed or certified by the State of Florida.
The examination shall be conducted in person, and not via the Internet. If
medical examinations are performed by a PA or ARNP, they must be performed under
the supervision or review of a Doctor of Medicine or Osteopathy.

 
(a)
An ophthalmologist or optometrist licensed by the State of Florida may perform
as much of the examination as pertains to visual acuity, field of vision and
color recognition.

 
(b)
Upon completion of the examination, the examining medical professional shall
complete, sign, and date the medical examination report.

 
(3)
The Health Plan/Transportation Provider shall have on file proof of medical
examination, i.e., a completed and signed medical examination report for each
driver, dated within the past twenty-four (24) months. Medical examination
reports of employee drivers shall be maintained by the Health
Plan/Transportation Provider for a minimum of five (5) years from the date of
the examination.

 
k.
Operational and Driving Requirements

 
(1)
The Health Plan/Transportation Provider shall not permit a driver to drive a
vehicle when such driver’s license has been suspended, canceled or revoked. The
Health Plan/Transportation Provider shall require a driver who receives a notice
that his or her license to operate a motor vehicle has been suspended, canceled,
or revoked notify his or her employer of the contents of the notice immediately,
and no later than the end of the business day following the day he or she
received the notice.

 
(2)
At all times, the Health Plan/Transportation Provider shall operate vehicles in
compliance with applicable traffic regulations, ordinances and laws of the
jurisdiction in which they are being operated.

 
(3)
The Health Plan/Transportation Provider shall not permit or require a driver to
drive more than twelve (12) hours in any one twenty-four (24) hour period, or
drive after having been on duty for sixteen (16) hours in any one twenty-four
(24) hour period. The Health Plan/Transportation Provider shall not permit a
driver to drive until the driver fulfills the requirement of a minimum eight (8)
consecutive hours off-duty. A driver’s work period shall begin from the time he
or she first reports for duty to his or her employer. A driver is permitted to
exceed his or her regulated hours in order to reach a regularly established
relief or dispatch point, provided the additional driving time does not exceed
one (1) hour.

 
(4)
The Health Plan/Transportation Provider shall not permit or require a driver to
be on duty more than seventy-two (72) hours in any period of seven (7)
consecutive days; however, twenty-four (24) consecutive hours off-duty shall
constitute the end of any such period of seven (7) consecutive days. The Health
Plan/Transportation Provider shall ensure that a driver who has reached the
maximum 72 hours of on-duty time during the seven (7) consecutive days has a
minimum of twenty-four (24) consecutive hours off-duty before returning to
on-duty status.

 
(5)
A driver is permitted to drive for more than the regulated hours for safety and
protection of the public due to conditions such as adverse weather, disaster,
security threat, a road or traffic condition, medical emergency or an accident.

 
(6)
The Health Plan/Transportation Provider shall not permit or require any driver
to drive when his or her ability is impaired, or likely to be impaired, by
fatigue, illness, or other causes, as to make it unsafe for the driver to begin
or continue driving.

 
(7)
The Health Plan/Transportation Provider shall require pre-operational or daily
inspection of all vehicles and reporting of all defects and deficiencies likely
to affect safe operation or cause mechanical malfunctions.

 
(a)
The Health Plan/Transportation Provider shall maintain a log detailing a daily
inspection or test of the following parts and devices to ascertain that they are
in safe condition and in good working order:

 
(i)
Service brakes;

 
(ii)
Parking brakes;

 
(iii)
Tires and wheels;

 
(iv)
Steering;

 
(v)
Horn;

 
(vi)
Lighting devices;

 
(vii)
Windshield wipers;

 
(viii)
Rear vision mirrors;

 
(ix)
Passenger doors and seats;

 
(x)
Exhaust system;

 
(xi)
Equipment for transporting wheelchairs; and

 
(xii)
Safety, security, and emergency equipment.

 
(b)
The Health Plan/Transportation Provider shall review daily inspection reports
and document corrective actions taken as a result of any deficiencies identified
by any inspections.

 
(c)
The Health Plan/Transportation Provider shall retain records of all inspections
and any corrective action documentation for five (5) years.

 
(8)
The driver shall not operate a vehicle with passenger doors in the open position
when passengers are aboard. The driver shall not open the vehicle’s doors until
the vehicle comes to a complete stop. The Health Plan/Transportation Provider
shall not operate a vehicle with inoperable passenger doors with passengers
aboard, except to move the vehicle to a safe location.

 
(9)
During darkness, interior lighting and lighting in stepwells on vehicles shall
be sufficient for passengers to enter and exit safely.

 
(10)
Passenger(s) shall not be permitted in the stepwell(s) of any vehicle while the
vehicle is in motion, or to occupy an area forward of the standee line.

 
(11)
Passenger(s) shall not be permitted to stand on or in vehicles not designed and
constructed for that purpose.

 
(12)
The Health Plan/Transportation Provider shall not refuel vehicles in a closed
building. The Health Plan/Transportation Provider shall minimize the number of
times a vehicle shall refuel when passengers are onboard.

 
(13)
The Health Plan/Transportation Provider shall require the driver to be properly
secured to the driver’s seat with a restraining belt at all times while the
vehicle is in motion.

 
(14)
The driver shall not leave vehicles unattended with passenger(s) aboard for
longer than five (5) minutes. The Health Plan/Transportation Provider shall
ensure that the driver sets the parking or holding brake any time the vehicle is
left unattended.

 
(15)
The Health Plan/Transportation Provider shall not leave vehicles unattended in
an unsafe condition with passenger(s) aboard at any time.

 
l.
Vehicle Equipment Standards and Procurement Criteria

 
(1)
The Health Plan/Transportation Provider shall ensure that vehicles procured and
operated meet the following requirements, at a minimum:

 
(a)
The capability and strength to carry the maximum allowed load and not exceed the
manufacturer’s gross vehicle weight rating (GVWR), gross axle weighting, or tire
rating;

 
(b)
Structural integrity that mitigates or minimizes the adverse effects of
collisions; and

 
(c)
Federal Motor Vehicle Safety Standards (FMVSS), 49 C.F.R. Part 571, Sections
102, 103, 104, 105, 108, 207, 209, 210, 217, 220, 221, 225, 302, 403, and 404,
October 1, 2004, are hereby incorporated by reference.

 
(2)
Proof of strength and structural integrity tests on new vehicles procured shall
be submitted by manufacturers or the Health Plan/Transportation Providers to the
Department of Transportation (See 14-90, F.A.C.).

 
(3)
The Health Plan/Transportation Provider shall ensure that every vehicle operated
in the State in connection with this Contract shall be equipped as follows:

 
(a)
Mirrors - There must be at least two (2) exterior rear vision mirrors, one (1)
at each side. The mirrors shall be firmly attached to the outside of the vehicle
and so located as to reflect to the driver a view to the rear along both sides
of the vehicle.

 
(i)
Each exterior rear vision mirror, on Type I buses shall have a minimum
reflective surface of fifty (50) square inches and the right (curbside) mirror
shall be located on the bus so that the lowest part of the mirror and its
mounting is a minimum eighty (80) inches above the ground. All Type I buses
shall be equipped with an inside rear vision mirror capable of giving the driver
a clear view of seated or standing passengers. Buses having a passenger exit
door that is located inconveniently for the driver’s visual control shall be
equipped with additional interior mirror(s), enabling the driver to view the
passenger exit door. The exterior right (curbside) rear vision mirror and its
mounting on Type I buses may be located lower than 80 inches from the ground,
provided such buses are used exclusively for paratransit services. See Section
341.031, F.S.

 
(ii)
In lieu of interior mirrors, trailer buses and articulated buses may be equipped
with closed circuit video systems or adult monitors in voice control with the
driver.

 
(b)
Wiring and Battery - Electrical wiring shall be maintained so as not to come in
contact with moving parts, or heated surfaces, or be subject to chafing or
abrasion which may cause insulation to become worn.

 
(i)
Every Type I bus manufactured on or after February 7, 1988, shall be equipped
with a storage battery(ies) electrical power main disconnect switch. The
disconnect switch shall be practicably located in an accessible location
adjacent to or near to the battery(ies) and be legibly and permanently marked
for identification.

 
(ii)
Every storage battery on each public-sector bus shall be mounted with proper
retainment devices in a compartment which provides adequate ventilation and
drainage.

 
(c)
Brake Interlock Systems - All Type I buses having a rear exit door shall be
equipped with a rear exit door/brake interlock that automatically applies the
brake(s) upon driver activation of the rear exit door to the open position.
Interlock brake application shall remain activated until deactivation by the
driver and the rear exit door returns to the closed position. The rear exit door
interlock on such buses shall be equipped with an identified override switch
enabling emergency release of the interlock function, which shall not be located
within reach of the seated driver. Air pressure application to the brake(s)
during interlock operation, on buses equipped with rear exit door/brake
interlock, shall be regulated at the original equipment manufacturer’s
specifications.

 
(4)
Standee Line and Warning - Every vehicle designed and constructed to allow
standees shall be plainly marked with a line of contrasting color at least two
(2) inches wide or be equipped with some other means to indicate that any
passenger is prohibited from occupying a space forward of a perpendicular plane
drawn through the rear of the driver’s seat and perpendicular to the
longitudinal axis of the vehicle. A sign shall be posted at or near the front of
the vehicle stating that it is a violation for a vehicle to be operated with
passengers occupying an area forward of the line.

 
(5)
Handrails and Stanchions - Every vehicle designed and constructed to allow
standees shall be equipped with overhead grab rails for standee passengers.
Overhead grab rails shall be continuous, except for a gap at the rear exit door,
and terminate into vertical stanchions or turn up into a ceiling fastener.

 
(a)
Every Type I and Type II bus designed for carrying more than sixteen (16)
passengers shall be equipped with grab handles, stanchions, or bars at least ten
(10) inches long and installed to permit safe on-board circulation, seating and
standing assistance, and boarding and unloading by elderly and handicapped
persons. Type I buses shall be equipped with a safety bar and panel directly
behind each entry and exit stepwell.

 
(6)
Flooring, Steps, and Thresholds - Flooring, steps, and thresholds on all
vehicles shall have slip resistant surfaces without protruding or sharp edges,
lips, or overhangs, to prevent tripping hazards. All step edges and thresholds
shall have a band of color(s) running the full width of the step or edge which
contrasts with the step tread and riser, either light-on-dark or dark-on-light.

 
(7)
Doors - Power activated doors on all vehicles shall be equipped with a manual
device designed to release door closing pressure.

 
(8)
Emergency Exits - All vehicles shall have an emergency exit door, or in lieu
thereof, shall be provided with emergency escape push-out windows. Each
emergency escape window shall be in a form of a parallelogram with dimensions of
not less than 18" by 24", and each shall contain an area of not less than 432
square inches. There shall be a sufficient number of such push-out or kick-out
windows in each vehicle to provide a total escape area equivalent to 67 square
inches per seat, including the driver’s seat.

 
(a)
No less than forty percent (40%) of the total escape area shall be on one (1)
side of the vehicle. Emergency escape kick-out or push-out windows and emergency
exit doors shall be conspicuously marked by a sign or light and shall always be
kept in good working order so that they may be readily opened in an emergency.

 
(b)
All such windows and doors shall not be obstructed by bars or other such means
located either inside or outside so as to hinder escape. Vehicles equipped with
an auxiliary door for emergency exit shall be equipped with an audible alarm and
light indicating to the driver when a door is ajar or opened while the engine is
running.

 
(c)
Supplemental security locks operable by a key are prohibited on emergency exit
doors unless these security locks are equipped and connected with an ignition
interlock system or an audio visual alarm located in the driver’s compartment.
Any supplemental security lock system used on emergency exits shall be kept
unlocked whenever a vehicle is in operation.

 
(9)
Tires and Wheels - Tires shall be properly inflated in accordance with
manufacturer’s recommendations.

 
(a)
No vehicle shall be operated with a tread groove pattern depth:

 
(i)
Less than 4/32 (1/8) of an inch, measured at any point on a major tread groove
for tires on the steering axle of all vehicles. The measurements shall not be
made where tie bars, humps, or fillets are located.

 
(ii)
Less than 2/32 (1/16) of an inch, measured at any point on a major tread groove
for all other tires of all vehicles. The measurements shall not be made where
tie bars, humps, or fillets are located.

 
(b)
The Health Plan/Transportation Provider shall not operate any vehicle with
recapped, regrooved or retreaded tires on the steering axle.

 
(c)
The Health Plan/Transportation Provider shall ensure that all wheels are visibly
free from cracks and distortion and shall not have missing, cracked, or broken
mounting lugs.

 
(10)
Suspension - The suspension system of all vehicles, including springs, air bags,
and all other suspension parts as applicable, shall be free from cracks, leaks,
or any other defect which would or may cause its impairment or failure to
function properly.

 
(11)
Steering and Front Axle - The steering system of all vehicles shall have no
indication of leaks which would or may cause its impairment to function
properly, and shall be free from cracks and excessive wear of components that
would or may cause excessive free play or loose motion in the steering system or
above normal effort in steering control.

 
(12)
Seat Belts - Every vehicle shall be equipped with an adjustable driver’s
restraining belt in compliance with the requirements of FMVSS 209, “Seat Belt
Assemblies” (see 49 CFR 571.209) and FMVSS 210, “Seat Belt Assembly Anchorages”
(49 CFR 571.210). 

 
(13)
Safety Equipment - Every vehicle shall be equipped with one (1) fully charged
dry chemical or carbon dioxide fire extinguisher, having at least a 1A:BC rating
and bearing the label of Underwriter’s Laboratory, Inc.

 
(a)
Each fire extinguisher shall be securely mounted on the vehicle in a conspicuous
place or a clearly marked compartment and be readily accessible.

 
(b)
Each fire extinguisher shall be maintained in efficient operating condition and
equipped with some means of determining if it is fully charged.

 
(c)
Every Type I bus shall be equipped with portable red reflector warning devices
(see Section 316.300, F.S.).

 
(14)
Vehicles used for the purpose of transporting individuals with disabilities
shall meet the requirements set forth in 49 CFR Part 38, hereby incorporated by
reference, and the following:

 
(a)
Installation of a wheelchair lift or ramp shall not cause the manufacturer’s
GVWR, gross axle weight rating, or tire rating to be exceeded.

 
(b)
Except in locations within 3 1/2 inches of the vehicle floor, all readily
accessible exposed edges or other hazardous protrusions of parts of wheelchair
lift assemblies or ramps that are located in the passenger compartment shall be
padded with energy absorbing material to mitigate injury in normal use and in
case of a collision. This requirement shall also apply to parts of the vehicle
associated with the operation of the lift or ramp.

 
(c)
The controls for operating the lift shall be at a location where the driver or
lift attendant has a full view, unobstructed by passengers, of the lift
platform, its entrance and exit, and the wheelchair passenger, either directly
or with partial assistance of mirrors. Lifts located entirely to the rear of the
driver’s seat shall not be operable from the driver’s seat, but shall have an
override control at the driver’s position that can be activated to prevent the
lift from being operated by the other controls (except for emergency manual
operation upon power failure).

 
(d)
The installation of the wheelchair lift or ramp and its controls and the method
of attachment in the vehicle body or chassis shall not diminish the structural
integrity of the vehicle nor cause a hazardous imbalance of the vehicle. No part
of the assembly, when installed and stowed, shall extend laterally beyond the
normal side contour of the vehicle or vertically beyond the lowest part of the
rim of the wheel closest to the lift.

 
(e)
Each wheelchair lift or ramp assembly shall be legibly and permanently marked by
the manufacturer or installer with the following minimum information:

 
(i)
The manufacturer’s name and address;

 
(ii)
The month and year of manufacture; and

 
(iii)
A certificate that the wheelchair lift or ramp securement devices, and their
installation, conform to State of Florida requirements applicable to accessible
vehicles.

 
(15)
Wheelchair lifts, ramps, securement devices, and restraints shall be inspected
and maintained as specified above. Instructions for normal and emergency
operation of the lift or ramp shall be carried or displayed in every vehicle.

 
m.
Vehicle Safety Inspections

 
(1)
The Health Plan/Transportation Provider shall require that all vehicles be
inspected in accordance with the vehicle inspection procedures set forth above.

 
(2)
It is the Health Plan’s/Transportation Provider’s responsibility to ensure that
each individual performing a vehicle safety inspection is qualified as follows:

 
(a)
Understands the requirements set forth in 14-90, F.A.C., and can identify
defective components;

 
(b)
Is knowledgeable of, and has mastered the methods, procedures, tools, and
equipment used when performing an inspection; and

 
(c)
Has at least one (1) year of training and/or experience as a mechanic or
inspector in a vehicle maintenance program and has sufficient general knowledge
of vehicles owned and operated by the Health Plan/Transportation Provider to
recognize deficiencies or mechanical defects.

 
(3)
The Health Plan/Transportation Provider shall ensure that each vehicle receiving
a safety inspection is checked for compliance with the safety devices and
equipment requirements as referenced or specified above. Specific operable
equipment and devices include the following:

 
(a)
Horn;

 
(b)
Windshield wipers;

 
(c)
Mirrors;

 
(d)
Wiring and battery(ies);

 
(e)
Service and parking brakes;

 
(f)
Warning devices;

 
(g)
Directional signals;

 
(h)
Hazard warning signals;

 
(i)
Lighting systems and signaling devices;

 
(j)
Handrails and stanchions;

 
(k)
Standee line and warning;

 
(l)
Doors and interlock devices;

 
(m)
Stepwells and flooring;

 
(n)
Emergency exits;

 
(o)
Tires and wheels;

 
(p)
Suspension system;

 
(q)
Steering system;

 
(r)
Exhaust system;

 
(s)
Seat belts;

 
(t)
Safety equipment; and

 
(u)
Equipment for transporting wheelchairs.

 
(4)
A safety inspection report shall be prepared by the individual(s) performing the
inspection which shall include the following:

 
(a)
Identification of the individual(s) performing the inspection;

 
(b)
Identification of the Health Plan/Transportation Provider operating the vehicle;

 
(c)
The date of the inspection;

 
(d)
Identification of the vehicle inspected;

 
(e)
Identification of the equipment and devices inspected including the
identification of equipment and devices found deficient or defective; and

 
(f)
Identification of corrective action(s) for deficient or defective items and
date(s) of completion of corrective action(s).

 
(5)
Records of annual safety inspections and documentation of any required
corrective actions shall be retained for compliance review a minimum of five (5)
years by the Health Plan/Transportation Provider.

 
n.
Certification - Each Health Plan/Transportation Provider shall submit an annual
safety and security certification in accordance with 14-90.10, F.A.C., and shall
submit to any and all safety and security inspections and reviews in accordance
with 14-90.12, F.A.C.

 
o.
The Health Plan shall report the following by August 15th of each year:

 
(1)
The estimated number of one-way passenger trips to be provided in the following
categories, as defined in the Transportation Handbook:

 
(a)
Ambulatory Transportation;

 
(b)
Long haul ambulatory Transportation;

 
(c)
Wheelchair Transportation;

 
(d)
Stretcher Transportation;

 
(e)
Ambulatory multiload Transportation;

 
(f)
Wheelchair multiload Transportation;

 
(g)
Mass transit pending Transportation;

 
(h)
Mass transit Transportation;

 
(i)
Mass transit Transportation (Enrollee has pass); and

 
(j)
Mass transit Transportation (sent pass to Enrollee).

 
(2)
The actual amount of funds expended and the total number of trips provided
during the previous fiscal year; and

 
(3)
The operating financial statistics for the previous fiscal year.

 
p
The Health Plan shall provide the total number of vehicles in each category,
other than public Transportation, that will serve each county as well as a
provider directory for all Transportation Services.

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Section VI
 
Behavioral Health Care
 

 
A.
General Provisions

 
1.
The Health Plan shall provide Medically Necessary Behavioral Health Services for
all Enrollees pursuant to this Contract. The Health Plan shall provide a full
range of Behavioral Health Services authorized under the State Plan and
specified by this Contract.

 
a.
Nothing in this contract shall be construed as preventing the plan from
substituting additional services supported by nationally recognized  evidence
based clinical guidelines for those provided in the Handbooks described above,
or from using different or alternative services, based on nationally recognized
evidence based practices, methods, or approaches to assist individual enrollees,
provided that the net effect of this substitution and these alternatives is that
the overall benefits available to the enrollee are at least equivalent to those
described in the applicable Handbooks.  Provision of substitution or alternate
services shall not supplant or relieve the plan from providing covered services
if needed.

 
2.
The Health Plan shall provide the following services as described in the Mental
Health Targeted Case Management Coverage & Limitations Handbook, and the
Community Behavioral Health Services Coverage & Limitations Handbook (the
Handbooks). The Health Plan shall not alter the amount, duration and scope of
such services from that specified in the Handbooks. The Health Plan shall not
establish service limitations that are lower than, or inconsistent with the
Handbooks.

 
a.
Inpatient Hospital services for psychiatric conditions (ICD-9-CM codes 290
through 290.43, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through
312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and 315.9);

 
b.
Outpatient Hospital services for psychiatric conditions (ICD-9-CM codes 290
through 290.43, 293 through 298.9, 300 through 301.9, 302.7, 306.51 through
312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and 315.9);

 
c.
Psychiatric physician services (for psychiatric specialty codes 42, 43, 44 and
ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300 through 301.9,
302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5,
315.8, and 315.9);

 
d.
Community mental health services (ICD-9-CM codes 290 through 290.43, 293.0
through 298.9, 300 through 301.9, 302.7, 306.51 through 312.4 and 312.81 through
314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these procedure codes
H0001, H0001HN; H0001H0, H0001TS; H0031; H0031 HO; H0031HN; H0031TS; H0032;
H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO; H2010HE; H2010HF;
H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN; H2019HO; H2019HQ;
H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF; T1023HE; or T1023HF.

 
e.
Mental Health Targeted Case Management (Children: T1017HA; Adults: T1017); and

 
f.
Mental Health Intensive Targeted Case Management (Adults: T1017HK).

 
3.
Non-Covered Services

 
a.
The following services are not covered by the Health Plan. Should the Health
Plan determine the need for, or be advised of the need for, these or other
services not customarily covered by the Health Plan, the Health Plan shall refer
the Enrollee to the appropriate provider:

(1) Specialized Therapeutic Foster Care;
 
(2) Therapeutic Group Care Services;

(3) Behavioral Health Overlay Services;

 
(4)
Community Substance Abuse Services, except as required by this Contract;

(5) Residential Care;

(6) Sub-acute Inpatient Psychiatric Program (SIPP) Services;

(7) Clubhouse Services;

(8) Comprehensive Behavioral Assessment; and

(9) Florida Assertive Community Treatment Services (FACT).

     

 
(1)
The Health Plan shall not be responsible for the provision of Behavioral Health
Services to Enrollees assigned to a FACT team by the DCF Substance Abuse and
Mental Health Program (SAMH) Office. The Health Plan shall disenroll these
Enrollees from the Health Plan so that the Enrollees can receive all Behavioral
Health Services through the funding mechanism developed by DCF/SAMH and AHCA.

 
4.
The Health Plan shall provide Outpatient Medical Services in accordance with
Section V, Covered Services, of this Contract.

 
5.
If an Enrollee makes a request for Behavioral Health Services to the Health
Plan, the Health Plan shall provide the Enrollee with the name (or names) of
qualified Behavioral Health Care Providers, and if requested, assist the
Enrollee with making an appointment with the Provider that is within the
required access times indicated in Section VII.D., Appointment Waiting Times and
Geographic Access Standards, and Section VII.E., Behavioral Health Services.

 
6.
Services available under the Health Plan shall represent a comprehensive range
of appropriate services for both Children/Adolescents and adults who experience
impairments ranging from mild to severe and persistent. This Section outlines
the Agency’s expectations and requirements related to each of the categories of
service.

 
a.
The Health Plan may provide Expanded Services under the Contract as a
substitution of care or downward substitution.

 
b.
When the Health Plan intends to provide a service as a downward substitution,
the provider must use clinical rationale for determining the benefit of the
service for the Enrollee.

 
7.
The Health Plan must provide Covered Services to Enrollees as required by each
Enrollee without regard to the frequency or cost of services relative to the
amount paid pursuant to the Contract.

B.
Service Requirements

 
1.
Inpatient Hospital Services

 
a.
Inpatient Hospital services are Medically Necessary Behavioral Health Services
provided in a Hospital setting (see Section V.7, Covered Services, Hospital
Services - Inpatient. Inpatient hospital services may be provided in a general
Hospital psychiatric unit or in a specialty Hospital. The inpatient care and
treatment services that an Enrollee receives must be under the direction of a
licensed physician with the appropriate Medicaid specialty requirements.

 
b.
A Hospital’s per diem (daily rate) for inpatient mental health hospital care and
treatment covers all services and items furnished during a 24-hour period. The
facilities, supplies, appliances, and equipment furnished by the Hospital during
the inpatient stay are included in the per diem as well as the related nursing,
social, and other services furnished by the Hospital during the inpatient stay.

 
c.
For all Child/Adolescent Enrollees, the Health Plan shall be responsible for the
provision of up to 365 days of behavioral health-related Hospital inpatient care
for each year.

 
d.
For all Enrollees, the Health Plan shall pay for inpatient mental health-related
Hospital days determined Medically Necessary by the Health Plan’s medical
director or designee, up to the maximum number of days required under the
Contract.

 
e.
If an Enrollee is admitted to a Hospital for a non-psychiatric diagnosis and
during the same hospitalization transfers to a psychiatric unit or receives
treatment for a psychiatric diagnosis, the Health Plan is at risk for the
Medically Necessary behavioral health treatment inpatient days up to the maximum
number of days required under this Contract.

 
f.
The Health Plan shall be responsible to cover the cost of all Enrollees’
Medically Necessary stays resulting from a mental health emergency, until such
time as the Health Plan can safely transport the Enrollee to a designated
facility.

 
g.
Crisis Stabilization Units may be used as a downward substitution for inpatient
psychiatric hospital care when determined medically appropriate. These bed days
are calculated on a two (2) for one (1) basis. Beds funded by the Department of
Children and Families, Substance Abuse and Mental Health (SAMH) cannot be used
for Enrollees if there are non-funded clients in need of the beds. If CSU beds
are at capacity, and some of the beds are occupied by Enrollees, and a
non-funded client presents in need of services, the Enrollees must be
transferred to an appropriate facility to allow the admission of the non-funded
client. Therefore, the Health Plan must demonstrate adequate capacity for
inpatient hospital care in anticipation of such transfers.

 
2.
Outpatient Hospital Services

 
a.
Outpatient Hospital services are Medically Necessary Behavioral Health Services
provided in a Hospital setting. The outpatient care and treatment services that
an Enrollee receives must be under the direction of a licensed physician with
the appropriate specialty.

 
3.
Physician Services

 
a.
Physician services are those services rendered by a licensed physician who
possesses the appropriate Medicaid specialty requirements when applicable. A
psychiatrist must be certified as a psychiatrist by the American Board of
Psychiatry and Neurology or the American Osteopathic Board of Neurology and
Psychiatry, or have completed a psychiatry residency accredited by the
Accreditation Council for Graduate Medical Education (ACGME) or the Royal
College of Physicians and Surgeons of Canada.

 
b.
Physician services include specialty consultations for evaluations. A physician
consultation shall include an examination and evaluation of the Enrollee with
information from family member(s) or significant others as appropriate. The
consultation shall include written documentation on an exchange of information
with the attending Provider. The components of the evaluation and management
procedure code and diagnosis code must be documented in the Enrollee's medical
record. A Hospital visit to an Enrollee in an acute care Hospital for a
behavioral health diagnosis must be documented with a behavioral health
procedure code and behavioral health diagnosis code. All procedures with a
minimum time requirement shall be documented in the Enrollee’s Medical Record to
show the time spent providing the service to the Enrollee. The Health Plan must
be responsive to requests for consultations made by the PCP.

 
c.
Physicians are required to coordinate Medically Necessary Behavioral Health
Services with the PCP and other Providers involved with the care of the
Enrollee. The Health Plan shall draft and implement a set of protocols that
indicate when such coordination is required.

 
4.
Community Mental Health Services

 
a.
General Provisions

 
(1)
Community mental health services include Behavioral Health Services that are
provided for the maximum reduction of the Enrollee’s behavioral health
disability and restoration to the best possible functional level. Community
mental health services are those services that can reasonably be expected to
improve the Enrollee’s condition or prevent further regression so that the
services will no longer be needed. The Health Plan shall provide community
mental health services that are Medically Necessary and are rendered or
recommended by a physician or psychiatrist and included in a treatment plan.
Medically Necessary community mental health services must be provided to
Enrollees of all ages from very young children through the geriatric population.
Because the provision of community mental health services at an early stage may
reduce the provision of expensive services later, the Health Plan is encouraged
to expand the criteria for some community mental health services and base the
criteria upon social necessity rather than strict Medical Necessity
requirements. Community mental health services should be age appropriate and
sensitive to the developmental level of the Enrollee. The term “community mental
health services” is not intended to suggest that the following services must be
provided by State funded “community mental health centers” or to preclude State
funded “community mental health centers” from providing these services.

 
(2)
The services provided must meet the intent of the services covered in the
Florida Medicaid Community Mental Health Services Coverage and Limitations
Handbook. Although the Health Plan can provide flexible services, the service
limits and medical necessity criteria cannot be more restrictive than those in
Medicaid policy as stated in Medicaid handbooks and this Contract. Additionally,
the Health Plan may have available additional services, but must have the core
services available as outlined and discussed below.

 
(3)
The health plan shall establish “Medical Necessity” criteria, including
admission criteria, continuing stay criteria, and discharge criteria for all
mandatory and optional services.

 
(a)
Criteria must be specific to Enrollee ages and diagnoses and must account for
orders for involuntary outpatient placement pursuant to 394.4655, F.S. These
criteria must be submitted for review by the Agency and approval.

 
(4)
Treatment Plan Development and Modification:

 
(a)
Treatment planning includes working with the Enrollee, their natural support
system, and all involved treating Providers to develop an individualized plan
for addressing identified clinical needs. A Behavioral Health Care Provider must
complete a face-to-face interview with the Enrollee during the development of
the plan. The individualized treatment plan should accurately reflect the
presenting problems of the Enrollee, identified strengths of the Enrollee,
family, and other natural support systems, and outcome-oriented objectives for
the Enrollee. The treatment plan shall also include an outcome-oriented schedule
of Behavioral Health Services that will be provided to meet the Enrollee’s
needs. Behavioral Health Services and service frequency shall be individualized
and reflect the needs, goals, and abilities of each Enrollee.

 
(b)
The Individualized Treatment Plan shall:

 
(i)
Be recovery-oriented and promote resiliency;

 
(ii)
Be Enrollee-directed;

 
(iii)
Accurately reflect the presenting problems of the Enrollee;

 
(iv)
Be based on the strengths of the Enrollee, family, and other natural support
systems;

 
(v)
Provide outcome-oriented objectives for the Enrollee;

 
(vi)
Include an outcome-oriented schedule of services that will be provided to meet
the Enrollee’s needs; and

 
(vii)
Include the coordination of services not covered by the Health Plan such as
school-based services, vocational rehabilitation, housing supports, Medicaid
fee-for-service substance abuse treatment, and physical health care.

 
(c)
Individualized Treatment Plan reviews shall be conducted at six (6) month
intervals to assure that the services being provided are effective and remain
appropriate for addressing individual Enrollee needs. Additionally, a review is
expected whenever clinically significant events occur. The provider is expected
to use the Individualized Treatment Plan review process in the utilization
management of Medically Necessary services. For further guidance see the most
recent Community Behavioral Health Services and Coverage Handbook.

 
(d)
Treatment plan reviews shall be conducted at appropriate time intervals to
assure that the services being provided are effective and remain appropriate for
addressing individual needs. A review is expected whenever a clinically
significant event occurs. The Health Plan is expected to use the treatment plan
review process in the Utilization Management of Medically Necessary services.

(e) Assessment Services:

 
(i)
Evaluation and testing services include psychological testing (standardized
tests) and evaluations that assess the Enrollee’s functioning in all areas.
Evaluations completed prior to provision of treatment must include a holistic
view of factors that underlie or may have contributed to the Enrollee’s need for
Behavioral Health Services. Evaluations that are completed for diagnostic
purposes are included in this category. Diagnostic evaluations must be
comprehensive and when completed must be used in the development of an
individualized treatment plan. All evaluations must be appropriate to the age,
developmental level and functioning of the Enrollee. All evaluations must
include a clinical summary that integrates all the information gathered and
identifies the Enrollee’s needs. The evaluation should prioritize the clinical
needs, evaluate the effectiveness of any prior treatment, and include
recommendations for interventions and mental health services to be provided. All
new Enrollees who appear for treatment services should receive an evaluation
unless there is sufficient collateral information that a new evaluation would
not be necessary.

 
(ii)
Evaluation services, when determined Medically Necessary must include assessment
of mutual status, functional capacity, strengths and service needs by trained
mental health staff. Also included in this category is the administration of
functional assessments that are required by the Agency, DCF or the Florida
Mental Health Institute Independent Evaluation.

 
(iii)
Prior to receiving any community mental health services, children ages 0-5 must
have a current assessment (within one year) of presenting symptoms and
behaviors; developmental and medical history; family psychosocial and medical
history; assessment of family functioning; a clinical interview with the primary
caretaker and an observation of the child’s interaction with the caretaker; and
an observation of the child’s language, cognitive, sensory, motor, self-care,
and social functioning.

 
(3)
Medical and Psychiatric Services:

 
(a)
These services include Medically Necessary interventions that require the skills
and expertise of a psychiatrist, psychiatric ARNP, or physician.

 
(b)
Medical psychiatric interventions include the prescribing and management of
medications, monitoring side effects associated with prescribed medications,
individual or group medical psychotherapy, psychiatric evaluation (for
diagnostic purposes and for initiating treatment), psychiatric review of
treatment records for diagnostic purposes, and psychiatric consultation with an
Enrollee’s family or significant others, PCPs, and other treatment providers.
Clinic visits are also a required service.

 
(c)
Interventions related to specimen collections, taking vital signs and
administering injections are also a Covered Service.

 
(d)
Treatment services are distinguished from the physician services outlined above
in that they are provided through a community mental health provider.
Psychiatric or physician services must be available at sites where substantial
amounts of community mental health services are provided.

 
(4)
Behavioral Health Therapy Services:

 
(a)
Therapy services include individual and family therapy, group therapy and
behavioral health day services. These services may include psychotherapy or
supportive counseling focused on assisting Enrollees with the problems or
symptoms identified in an assessment. The focus should be on identifying and
utilizing the strengths of the Enrollee, family, and other natural support
systems. Therapy services should be geared to the individual needs of the
Enrollee and should be sensitive to the age, developmental level, and functional
level of the Enrollee.

 
(b)
Family and marital therapy are also included in this category. Examples of
interventions include those that focus on resolution of a life crisis or an
adjustment reaction to an external stressor or developmental challenge.

 
(c)
Behavioral day services are designed to enable Enrollees to function
successfully in the community in the least restrictive environment and to
restore or enhance ability for social and prevocational life management
services. The primary functions of behavioral health day services are
stabilization of the symptoms related to a behavioral health disorder to reduce
or eliminate the need for more intensive levels of care, to provide transitional
treatment after an acute episode, or to provide a level of therapeutic intensity
not possible in a traditional outpatient setting.

 
(5)
Community Support and Rehabilitative services:

 
(a)
These services include: Psychosocial Rehabilitation Services and Clubhouse
services. Clubhouse services are excluded from the Health Plan’s Covered
Services. Psychosocial rehabilitation services may be provided in a facility,
home, or community setting. These services assist Enrollees in functioning
within the limits of a disability or disabilities resulting from a mental
illness. Services focus on restoration of a previous level of functioning or
improving the level of functioning. Services must be individualized and directly
related to goals for improving functioning within a major life domain.

 
(b)
The coverage must include a range of social, educational, vocational,
behavioral, and cognitive interventions to improve Enrollees’ potential for
social relationships, occupational/educational achievement and living skills
development. Skills training development is also included in this category and
includes activities aimed toward restoration of Enrollees’ skills/abilities that
are essential for managing their illness, actively participating in treatment,
and conducting the requirements of daily independent living. Providers must
offer the services in a setting best suited for desired outcomes, i.e., home or
community-based settings.

 
(c)
Psychosocial Rehabilitative Services may also be provided to assist Enrollees in
finding or maintaining appropriate housing arrangements or to maintain
employment. Interventions should focus on the restoration of skills/abilities
that are adversely affected by the mental health illness and supports required
to manage the Enrollee’s housing or employment needs. The provider must be
knowledgeable about the local TANF initiative and is responsible for Medically
Necessary mental health services that will assist the individual in finding and
maintaining employment.

 
(6)
Therapeutic Behavioral On-Site Services for Children and Adolescents (TBOS):

(a) Therapeutic Behavioral On-Site Services are community services and natural
supports for Children/Adoloscents with serious emotional disturbances. Clinical
services include the provision of a professional level therapeutic service that
may include the teaching of problem solving skills, behavioral strategies,
normalization activities and other treatment modalities that are determined to
be Medically Necessary. These services should be designed to maximize strengths
and reduce behavior problems or functional deficits stemming from the existence
of a mental health disorder. Social services include interventions designed for
the restoration, modification, and maintenance of social, personal adjustment
and basic living skills.

(b)  TBOS services are intended to maintain the Child/Adolescent in the home and
to prevent reliance upon a more intensive, restrictive, and costly mental health
placement. They are also focused on helping the Child/Adolescent possess the
physical, emotional, and intellectual skills to live, learn and work in their
own communities. Coverage must include the provision of these services outside
of the traditional office setting. The services must be provided where they are
needed, in the home, school, childcare centers or other community sites.

 
(7)
Day Treatment Services:

 
(a)
Adult day treatment services include therapy, rehabilitation, social
interactions, and other therapeutic services that are designed to redevelop,
maintain, or restore skills that are necessary for Enrollees to function in the
community. The Provider must have an array of available services designed to
meet the individualized needs of the Enrollee, and which address the following
primary functions:

 
(i)
Stabilize symptoms related to a behavioral health disorder to reduce or
eliminate the need for more intensive levels of care;

 
(ii)
Provide a level of therapeutic intensity between traditional outpatient and an
inpatient or partial Hospital setting;

 
(iii)
Provide a level of treatment that will assist Enrollees in transitioning from an
acute care or institutional settings;

 
(iv)
Assist Enrollees in redeveloping the skills required to maintain a living
environment, use community resources, and conduct activities of daily living;
and

 
(v)
Assist Enrollees in redeveloping or restoring skills that are needed to increase
an Enrollee’s ability to live independently in the community.

 
(b)
Children/Adolescent’s day treatment services include therapy, rehabilitation and
social interactions, and other therapeutic services that are designed to
redevelop, maintain, or restore skills that are necessary for
Children/Adolescents to function in their community. For Children/Adolescents,
the approach must take into consideration their developmental levels and delays
in development due to emotional disorders. If the Child/Adolescent is school
age, the services must be coordinated with the school system. All therapeutic
day treatment interventions for Children/Adolescents must have a component that
addresses caregiver participation and involvement. Services for all
Children/Adolescents should be coordinated with home care to the greatest extent
possible. Day treatment services must include an array of programs with the
following functions:

 
(i)
Stabilize the symptoms related to a behavioral health disorder to reduce or
eliminate the need for more intensive levels of care;

 
(ii)
Provide transitional treatment after an acute episode, admission to an inpatient
program, or discharge from a residential treatment setting;

 
(iii)
Provide a therapeutic intensity not possible in a traditional outpatient
setting; and

 
(iv)
Assist the Child/Adolescent in redeveloping the skills required to conduct
activities of everyday living in the community that are age appropriate.

 

 
(c)
Staff providing adult or Children/Adolescent’s day treatment services must have
appropriate training and experience. Behavioral Health Care Providers must be
available to provide clinical services when necessary.

 
(8)
Additional Community Mental Health Services for Children/Adolescents:

 
(a)
All of the community mental health services discussed above must be made
available to Children/Adolescents when Medically Necessary. The services
described in this section are two (2) additional core services that must be
available to Children/Adolescents when Medically Necessary. This coverage is
mandatory for Children/Adolescents with a serious emotional disturbance. These
services are intended to maintain the Child/Adolescent in the home and to
prevent reliance upon a more intensive, restrictive, and costly behavioral
health placement. They are also focused on helping the Child/Adolescent possess
the physical, emotional, and intellectual skills to live, learn and work in
their own communities. Coverage must include the provision of these services
outside of the traditional office setting. The services must be provided where
they are needed, in the home, school or other community sites.

 
(b)
Therapeutic behavioral on site services include the provision of a professional
level therapeutic service that may include the teaching of problem solving
skills, behavioral strategies, normalization activities and other treatment
modalities that are determined to be Medically Necessary. These services should
be designed to maximize strengths, reduce behavior problems or functional
deficits stemming from the existence of a behavioral health disorder. These
services shall not be office-based.

 
(9)
Services for Children Ages 0 through 5-Years

 

 
(a)
Services to these Enrollees include behavioral health day services and
Therapeutic Behavioral On-Site Services for Children Ages 0 through 5 years.

 
(b)
Prior to receiving these services, the Enrollees in this age group must meet the
criteria as stated in the Medicaid Community Behavioral Health Service Coverage
and Limitations Handbook.

 
(10)
Crisis Intervention Mental Health Services and Post-Stabilization Care Services

 
(a)
Crisis intervention services include intervention activities of less than
24-hour duration (within a 24-hour period) designed to stabilize an Enrollee in
a Psychiatric emergency.

(b) Post-stabilization care services include any of the mandatory services that
a treating physician views as Medically Necessary, that are provided after an
Enrollee is stabilized from an emergency mental health condition in order to
maintain the stabilized condition, or under the circumstances described in 42
CFR 438.114(e) to improve or resolve the Enrollee’s condition.

 
(11)
Substance Abuse Services

 
(a)
Health Plan Enrollees will receive Medicaid funded substance abuse services
through the fee-for-service system. The Health Plan shall develop methods of
coordinating and integrating mental health and substance abuse services for
Enrollees. The Health Plan shall be required to use the Florida Supplement to
the American Society of Addictions Medicine Patient Placement Criteria for the
coordination of mental health treatment with substance abuse providers as part
of the integration effort (Second Edition ASAM PPC-2, July 1998) the
coordination shall be reflected in their individualized Treatment Plan for
Enrollees with co-occurring disorder. The protocol for integrating mental health
services with substance abuse services shall be monitored through the Quality of
Care monitoring activities completed by the Agency’s EQRO contractor and the
Quality Improvement requirements in Section VIII.A., Quality Improvement.

 
5.
Behavioral Health Targeted Case Management

 
a.
The Health Plan must provide targeted Case Management services to
Children/Adolescents with serious emotional disturbances and adults with a
severe mental illness as defined below. The Health Plan shall meet the intent of
the services as outlined below and in the Medicaid Mental Health Targeted Case
Management Coverage and Limitations Handbook. The Health Plan shall set criteria
and clinical guidelines for Case Management services. Service limits and
criteria developed cannot be more restrictive than those in Medicaid policy and
as stated below.

 
(1)
At a minimum, case management services are to incorporate the principles of a
strengths-based approach. Strengths-based case management services are an
alternative service modality for working with individuals and families. This
method stresses building on the strengths of individuals that can be used to
resolve current problems and issues, countering more traditional approaches that
focus almost exclusively on individuals’ deficits or needs.

 
b.
Target Populations:

 
(1)
The Health Plan shall have Case Management services available to
Children/Adolescents who have a serious emotional disturbance, defined as: a
Child/Adolescent with a defined mental disorder; a level of functioning which
requires two (2) or more coordinated Behavioral Health Services to be able to
live in the community; and be at imminent risk of out of home behavioral health
treatment placement.

 
(2)
The Health Plan shall also have Case Management services available for adults
who:

 
(a)
Have been denied admission to a long-term mental health institution or
residential treatment facility or have been discharged from a long-term mental
health institution or residential treatment facility;

 
(b)
Require numerous services from different providers and also require advocacy and
coordination to implement or access services;

 
(c)
Would be unable to access or maintain consistent care within the service
delivery system without case management services; and/or

 
(d)
Do not possess the strengths, skills, or support system to allow them to access
or coordinate services;

 
(3)
The Health Plan will not be required to seek approval from the Department of
Children and Families, District Substance Abuse and Mental Health (SAMH) Office
for individual eligibility or mental health targeted case management agency or
individual provider certification. The staffing requirements for case management
services are listed in Section VII.E.7.

 
(4)
Behavioral health targeted Case Management services shall be available to all
Enrollees within the principles and guidelines described as follows:

 
(a)
Enrollees who require numerous services from different providers and also
require advocacy and coordination to implement or access services are
appropriate for Case Management services;

 
(b)
Enrollees who would be unable to access or maintain consistent care within the
service delivery system without Case Management services are appropriate for the
service;

 
(c)
Enrollees who do not possess the strengths, skills, or support system to allow
them to access or coordinate services are appropriate for Case Management
services;

 
(d)
Enrollees without the skills or knowledge necessary to access services may
benefit from Case Management. Case Management provides support in gaining skills
and knowledge needed to access services and enhances the Enrollee’s level of
independence.

 
c.
The Health Plan will not be required to seek approval from the SAMH Program
Office for client eligibility or behavioral health targeted Case Management
agency or individual provider certification. The staffing requirements for Case
Management services are found in Section VII.E.7, Provider Network, Behavioral
Health Services, in this Contract.

 
d.
Required Services

 
(1)
Behavioral health targeted Case Management services include working with the
Enrollee and the Enrollee’s natural support system to develop and promote a
needs assessment-based service plan. The service plan reflects the services or
supports needed to meet the needs identified in an individualized assessment of
the following areas: education or employment, physical health, mental health,
substance abuse, social skills, independent living skills, and support system
status. The approach used should identify and utilize the strengths, abilities,
cultural characteristics, and informal supports of the Enrollee, family, and
other natural support systems. Targeted case managers focus on overcoming
barriers by collaborating and coordinating with Providers and the Enrollee to
assist in the attainment of service plan goals. The targeted case manager takes
the lead in both coordinating services/treatment and assessing the effectiveness
of the services provided. A strengths-based approach to providing services is
consistent with the values of individuality and uniqueness and promotes
participant self-direction and choice. The planning process is vital to
achieving desired outcomes for the Enrollee. The Enrollee must have a sense of
ownership about his/her goals, and the goals must have true meaning and vitality
for him/her.

 
(2)
When targeted case management recipients enrolled in the Health Plan are
hospitalized in an acute care setting or held in a county jail or juvenile
detention facility, the Health Plan shall maintain contact with the Enrollee and
shall participate actively in the discharge planning processes.

 
(3)
Case managers are also responsible for coordination and collaboration with the
parents or guardians of Children/Adolescents who receive mental health targeted
Case Management services. The Health Plan shall make reasonable efforts to
assure that case managers include the parents or guardians of Enrollees in the
process of providing targeted Case Management services. Integration of the
parent’s input and involvement with the case manager and other Providers shall
be reflected in Medical Record documentation and monitored through the Health
Plan’s quality of care monitoring activities. Involvement with the
Child’s/Adolescent’s school and/or childcare center must also be a component of
case management with Children/Adolescents.

 
e.
Additional Requirements for Targeted Case Management

 
(1)
The Health Plan shall have a Case Management program, including clinical
guidelines and protocol that addresses the issues below:

 
(a)
Caseloads shall be set to achieve the desired results. Size limitations must
clearly state the ratio of Enrollees to each individual case manager. The limits
shall be specified for Children/Adolescents and adults, with a description of
the clinical rationale for determining each limitation. If the Health Plan
permits “mixed” caseloads, i.e., Children/Adolescents and adults, a separate
limitation is expected along with the rationale for the determination. Ratios
must be no greater than the requirements set forth in the Medicaid Mental Health
Targeted Case Management Coverage and Limitations Handbook.

 
(b)
A system shall be in place to manage caseloads when positions become vacant.

 
(c)
The modality of service provision, and the location that services will be
provided, shall be described.

 
(d)
Case Management protocol and clinical practice guidelines, which outline the
expected frequency, duration and intensity of the service, shall be available.

 
(e)
Clinical guidelines shall address issues related to recovery and self-care,
including services that will assist Enrollees in gaining independence from the
behavioral health and Case Management system.

 
(2)
The Case Management program shall have services available based on the
individual needs of the Enrollees receiving the service. The service should
reflect a flexible system that allows movement within a continuum of care that
addresses the changing needs and abilities of Enrollees.

 
(a)
Case management staff must have expertise and training necessary to competently
and promptly assist Enrollees in working with Social Security Administration or
Disability Determination in maintaining benefits from SSI and SSDI. For
Enrollees who wish to work, case management staff must have the expertise and
training necessary to assist Enrollees to access Social Security Work Incentives
including development of Plans for Achieving Self-Support (PASS).

 
(b)
At a minimum, case management services are to incorporate the principles of a
strengths-based approach. Strengths-based case management services are a
preferred service modality for work with individuals and families. This method
stresses building on the strengths of individuals and families that can be used
to resolve current problems and issues. This approach counters more traditional
approaches that focus almost exclusively on individuals’ deficits or needs.
Service limits and criteria developed cannot be more restrictive than those in
Medicaid policy.

 
6.
Intensive Case Management

 
a.
Intensive Case Management is intended to provide intensive team Case Management
to highly recidivistic adults who have a severe and persistent mental illness.
The service is intended to help Enrollees remain in the community and avoid
institutional care. Clinical care criteria for this level of Case Management
shall address the same elements required above, as well as expanded elements
related to access and twenty-four (24) hour coverage as described below.
Additionally, the intensive Case Management team composition shall be expanded
to include members of the team selected specifically to assist with the special
needs of this population. The Health Plan shall include the team composition and
how it will assist with special needs in the description of how this service
will be provided.

 
b.
The Health Plan shall provide this service for all Enrollees for whom the
service is determined to be Medically Necessary, to include Enrollees who meet
the following criteria:

 
(1)
Has resided in a state mental health treatment facility for at least six (6)
months in the past 36 months;

 
(2)
Resides in the community and has had two (2) or more admissions to a state
mental health treatment facility in the past 36 months;

 
(3)
Resides in the community and has had three (3) or more admissions to a crisis
stabilization unit, short-term residential facility, inpatient psychiatric unit,
or any combination of these facilities within the past twelve (12) months; or

 
(4)
Resides in the community and, due to a mental illness, exhibits behavior or
symptoms that could result in long-term hospitalization if frequent
interventions for an extended period of time were not provided.

 
c.
Intensive Case Management provides services through the use of a team of case
managers. The team can be expanded to include other specialists that are
qualified to address identified needs of the Enrollees receiving intensive Case
Management. This level of care for Case Management is the most intensive and
serves Enrollees with the most severe and disabling mental conditions. Services
are frequent and intense with a focus on assisting the Enrollee with attaining
the skills and supports needed to gain independent living skills. Case
Management services are provided primarily in the Enrollee’s residence and
include community-based interventions.

 
d.
The Health Plan shall provide this service in the least restrictive setting with
the goal of improving the Enrollee’s level of functioning, and providing ample
opportunities for rehabilitation, recovery, and self-sufficiency. Intensive Case
Management services shall be accessible twenty-four (24) hours per day, seven
(7) days per week. The Health Plan shall demonstrate adequate capacity to
provide this service for the targeted population within the guidelines outlined.

 
e.
Intensive Case Management teams shall provide the same coordination and Case
Management services for Enrollees admitted to inpatient facilities, State mental
Hospitals, and forensic or corrections facilities as those listed above for
behavioral health targeted Case Management services.

 
7.
Community Treatment of Patients Discharged from State Mental Hospitals 

 
a.
The Health Plan shall provide Medically Necessary Behavioral Health Services to
Enrollees who have been discharged from any State mental Hospital, including,
but not limited to, follow-up services and care. All Enrollees who have
previously received services at the State mental Hospital must receive follow up
care.

 
b.
The plan of care shall be aimed at encouraging Enrollees to achieve a high
quality of life while living in the community in the least restrictive
environment that is medically appropriate and reducing the likelihood that the
Enrollees will be readmitted to a State mental Hospital.

 
c.
The Health Plan shall follow the progress of all Enrollees enrolled in the
Health Plan prior to admission to a State mental Hospital until the one hundred
eightieth (180th) day after Disenrollment from the Health Plan. The Health Plan
shall use behavioral health targeted case managers to follow the progress of
Enrollees. The behavioral health targeted case manager must attend and
participate in the discharge planning activities at the facility. Targeted case
managers are responsible for working with the former Enrollee before discharge
from the State facility to assure that Benefits are reinstated as soon as
possible, and that the Enrollee receives community Behavioral Health Services
within twenty-four (24) hours of his/her discharge from the State facility.

 
d.
If the Enrollee remains in the State facility more than one hundred eighty (180)
days after Disenrollment, the Health Plan shall cooperate with DCF and the
Enrollee to ensure that the Enrollee is assigned a DCF funded Case Management
provider who will bear the responsibility of ongoing monthly follow-up care and
discharge planning until such time that the Enrollee is again eligible for, and
enrolled in, a Health Plan.

 
e.
The Health Plan shall develop a cooperative agreement with the behavioral health
care facility to enable the Health Plan to anticipate those Medicaid Recipients
who were Enrollees of the Health Plan prior to admission to the Facility, and
will be soon discharged from the Facility. The cooperative agreement must
address arrangements for Medicaid Recipients, whom the Facility is discharging,
but who are not eligible for immediate re-enrollment.

 
8.
Community Services for Medicaid Recipients Involved with the Corrections System

 
a.
The Health Plan shall provide Medically Necessary community-based services for
Health Plan Enrollees who have corrections involvement as follows:

 
(1)
Establish a linkage to pre-booking sites for assessment, screening or diversion
related to Behavioral Health Services;

 
(2)
Provide immediate access (within twenty-four (24) hours of release) for
psychiatric services upon release from jail, prison, juvenile detention
facility, or other corrections facility to assure that prescribed medications
are available for all Enrollees.

     

 
(3)
Establish a linkage to post-booking sites for discharge planning and assuring
that prior Health Plan Enrollees receive necessary services upon release from
the facility. Health Plan Enrollees must be linked to services and receive
routine care within seven (7) days from the date they are released.

 
(4)
Provide outreach to homeless and other populations of Health Plan Enrollees at
risk of corrections involvement, as well as those Health Plan Enrollees
currently involved in this system, to assure that services are accessible and
provided when necessary. This activity should be oriented toward preventive
measures to assess behavioral health needs and provide services that can
potentially prevent the need for future inpatient services or possible deeper
involvement in the forensic or corrections system.

 
(5)
The Health Plan shall develop a cooperative agreement with corrections
facilities to enable the Health Plan to anticipate Enrollees who were Health
Plan Enrollees prior to incarceration who will be released from these
institutions. The cooperative agreement must address arrangement for persons who
are to be released, but for whom re-Enrollment may not take effect immediately.
All Enrollees who were Health Plan Enrollees prior to incarceration and Medicaid
Recipients who are likely to enroll in the Health Plan upon return to the
community must receive a community Behavioral Health Service within twenty-four
(24) hours of discharge from the corrections facility.

 
9.
Treatment and Coordination of Care for Enrollees with Medically Complex
Conditions

 
a.
The Health Plan shall ensure that there are appropriate treatment resources
available to address the treatment of complex conditions that reflect both
mental health and physical health involvement. The following conditions must be
addressed:

 
(1)
Mental health disorders due to or involving a general medical condition,
specifically -9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89, and 310.1; and

 
(2)
Eating disorders - ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and 307.52.

 
b.
The Health Plan shall provide medically necessary community mental health
services to enrollees who exhibit the above diagnoses and shall develop a plan
of care that includes all appropriate collateral providers necessary to address
the complex medical issues involved. Clinical care criteria shall address
modalities of treatment that are effective for each diagnosis. The Health Plan’s
provider network must include appropriate treatment resources necessary for
effective treatment of each diagnosis within the required access time periods.

 
10.
Monitoring of Enrollees admitted to Children's Residential Treatment (Level I -
IV)

 
a.
The Health Plan shall maintain contact with Children/Adolescents who are
disenrolled from the Health Plan due to placement in a residential treatment
facility (Statewide Inpatient Psychiatric Program (SIPP), Therapeutic Group Care
Services (TGCS), or Behavioral Health Overlay Services (BHOS)). The Health Plan
shall participate in discharge planning, assist the Enrollee and their caregiver
to locate community-based services, and notify Medicaid when the enrollee is
discharged from the facility. The Health Plan’s contract manager or designee
shall re-enroll the Enrollee in the Health Plan upon notification of discharge
into the community.

 
b.
Children placed in SIPP, TGCS, or BHOS facilities will be disenrolled from the
Health Plan and then covered under Medicaid Fee-for-Service for mental health
services. The Medicaid contract manager or designee will be responsible for the
disenrollment process. The Department of Juvenile Justice, residential
providers, and/or the assigned Mental Health Targeted Case Management providers
will be responsible for notifying Medicaid of all admissions and discharges. A
specific agreement regarding the disenrollment and re-enrollment process will be
developed between the Agency, residential providers, and the departments.

 
c.
Upon notification of the Enrollee's discharge from the facility the Health Plan
shall notify the Choice Counselor/Enrollment Broker for re-Enrollment into the
Health Plan, if it is within six (6) months (180 days) from the disenrollment.

 
11.
Coordination of Children’s Services

 
a.
General Principles

 
(1)
The delivery and coordination of Children’s/Adolescent’s mental health services
shall be provided for all Children/Adolescents who exhibit the symptoms and
behaviors of an emotional disturbance. The delivery of services must address the
needs of any Child/Adolescent served in an SED or EH school program.
Developmentally appropriate early childhood mental health services must be
available to children age birth to five (5) years old and their families.

(2) The Health Plan shall deliver services for all Children/Adolescents within a
strengths-based, culturally competent service design. The service design shall
recognize and ensure that services are family-driven and include the
participation of family, significant others, informal support systems, school
personnel, and any State entities or other service providers involved in the
Child’s/Adolescent’s life. 

 
(3)
For all Children/Adolescents receiving services from the Health Plan, the
Provider shall work with the parents, guardians, or other responsible parties to
monitor the results of services and determine whether progress is occurring.
Active monitoring of the Child/Adolescent’s status shall occur to detect
potential risk situations and emerging needs or problems.

 
(4)
When the court mandates a parental behavioral health assessment, and the parent
is an Enrollee, the Provider must complete an assessment of the parent’s mental
health status and the effects on the child. Time frames for completion of this
service shall be determined by the mandates issued by the courts.

 
b.
Targeted Case Management

 
(1)
The Health Plan shall provide behavioral case management services to
Children/Adolescents in the care or custody of the State who need behavioral
health targeted Case Management services, as defined in the Health Plan’s
approved clinical protocols. These children shall not be transferred to the new
Medicaid Child Welfare Targeted Case Management program. The Health Plan shall
develop a cooperative agreement with DCF or their provider of community based
services, to address how to minimize duplication of case management services and
to promote the establishment of one case manager for the Child/Adolescent and
family whenever possible.

 
c.
Community Based Care Programs

 
(1)
If the community in which the Health Plan operates has a community-based care
program contracted by DCF for the provision of children’s protective services,
the Health Plan shall determine how to provide services to Enrollees served by
the community-based care program. The Health Plan shall develop, during the
implementation phase of the Contract, or upon notification that the department
has contracted with a Health Plan, a cooperative agreement between the Health
Plan and the community-based care program. Medicaid and DCF shall approve the
agreement. The Health Plan shall be prepared to provide services in a
collaborative manner in each county covered by the Health Plan.

 
12.
Evaluation and Treatment Services for Enrolled Children/Adolescents

 
a.
The Health Plan shall provide all Medically Necessary evaluation and treatment
services for Children/Adolescents referred to the Health Plan by DCF, DJJ and by
schools (elementary, middle, and secondary schools).

 
b.
The Health Plan shall provide Medically Necessary Children/Adolescent Behavioral
Health Services in such a way as to minimize disruption of services available to
high-risk populations served by DCF.

 
c.
The Health Plan shall promptly evaluate, provide psychological testing, and
deliver Behavioral Health Services to Children/Adolescents (including delinquent
and dependent Children/Adolescent) referred by DCF in accordance with Medical
Necessity. As well, the Health Plan shall adhere to the minimum staffing,
availability and access standards described in this Contract.

 
d.
The Health Plan shall provide court ordered evaluation and treatment required
for Children/Adolescents who are Enrollees. See specifications in the Medicaid
Community Behavioral Health Services Coverage & Limitations Handbook.

 
e.
The Health Plan must participate in all DCF or school staffings that may result
in the provision of Behavioral Health Services to an Enrolled Child/Adolescent.

 
f.
The Health Plan shall refer Children/Adolescents to DCF when residential
treatment is Medically Necessary. The Health Plan shall not be responsible for
providing any residential treatment for Children/Adolescents. The SAMH or DJJ
district office shall coordinate the placement of the Enrolled Child/Adolescent
with the Health Plan.

 
g.
The Health Plan's Case Management of Children/Adolescents shall include those
persons, schools, programs, networks and agencies that figure importantly in the
Child's/Adolescent's life.

 
h.
The Health Plan shall make determinations about care based on a comprehensive
evaluation, consultation with those persons, schools, programs, networks and
agencies that figure importantly in the Child's/Adolescent's life, and
appropriate protocols for admission and retention.

 
i.
The Health Plan shall monitor services for adequacy in conformity with the
cooperative agreement between the Health Plan and the facility.

 
13.
Assessment and Treatment of Mental Health Residents Who Reside in Assisted
Living Facilities (ALF) that hold a Limited Mental Health License

 
a.
The provider must develop and implement a plan to ensure compliance with Section
394.4574, F.S., related to services provided to residents of licensed assisted
living facilities that hold a limited mental health license. A cooperative
agreement, as defined in Section 400.402, F.S., must be developed by the ALF if
an Enrollee is a resident of an ALF. The provider must ensure that appropriate
assessment services are provided to Enrollees and that Medically Necessary
Behavioral Health Services are available to all Enrollees who reside in this
type of setting.

 
b.
A Community Living Support Plan, as defined in Section I, Definitions and
Acronyms, must be developed for each Enrollee who is a resident of an ALF, and
it must be updated annually. The Health Plan case manager is responsible for
ensuring that the community living support plan is implemented as written.

 
14.
Psychiatric Evaluations for Enrollees Applying for Nursing Home Admission

 
a.
The Health Plan, upon request from the SAMH district office, shall promptly
arrange for and authorize psychiatric evaluations for Enrollees applying for
admission to a Nursing Facility, and who, on the basis of a screening conducted
by CARES, are thought to need Behavioral Health Services, pursuant to OBRA,
1987. The examination shall be adequate to determine the need for "specialized
treatment" under the Act. Any of the Mental Health Professionals listed in
section 394.455, F.S., and make the observations as part of the evaluation,
although a psychiatrist must sign all evaluations. The examination shall be
adequate to determine the need for “specialized treatment” under the Act.
Evaluations must be completed within five (5) Business Days from the receipt of
the request from the DCF SAMH Program Office. The State has interpreted
regulations to permit any of the “mental health professionals” listed in Section
394.455, F.S. to make observations preparatory to the evaluation, although a
psychiatrist must sign such evaluations.

 
b.
The Health Plan shall not be responsible for annual resident reviews or for
providing services as a result of a Preadmission Screening Assessment Annual
Resident Review ("PASSAR") evaluation.

 
15.
Individuals with Special Health Care Needs

 
a.
The Health Plan shall implement mechanisms for identifying, assessing and
ensuring the existence of an Individualized Treatment Plan for Enrollees with
Special Health Care Needs, as defined in Section I, Definitions and Acronyms.
Mechanisms shall include evaluation of risk assessments, claims data, and
CPT/ICD-9 codes. Additionally, the Health Plan shall implement a process for
receiving and considering provider and Enrollee input.

 
b.
In accordance with this Contract and 42 CFR 438.208(c)(3), an Individualized
Treatment Plan for an Enrollee determined to need a course of treatment or
regular care monitoring must be:

 
(1)
Developed by the Enrollee's direct service mental health care professional with
Enrollee participation and in consultation with any specialists caring for the
Enrollee;

 
(2)
Approved by the Health Plan in a timely manner if this approval is required; and

 
(3)
Developed in accordance with any applicable Agency quality assurance and
utilization review standards.

 
c.
Pursuant to 42 CFR 438.208(c)(4), for Enrollees with Special Health Care Needs
determined through an assessment by appropriate mental health care professionals
(consistent with 42 CFR 438.208(c)(2)) to need a course of treatment or regular
care monitoring, the Health Plan must have a mechanism in place to allow
Enrollees to directly access a mental health care specialist (for example,
through a standing referral or an approved number of visits) as appropriate for
the Enrollee's condition and identified needs.

 
16.
Crisis Support/Emergency Services

 
a.
The Health Plan shall operate, as part of its Crisis Support/Emergency Services,
a crisis emergency hotline available to all Enrollees twenty-four (24) hours a
day, seven (7) days a week.

 
17.
Provision of Behavioral Health Services When Not Covered by the Health Plan

 
a.
If the Health Plan determines that an Enrollee is in need of Behavioral Health
Services that are not covered under the Contract, the Health Plan shall refer
the Enrollee to the appropriate provider. The Health Plan may request the
assistance of the Agency’s local field office or the local DCF District ADM
Office for referral to the appropriate service setting.

 
b.
Long term care institutional services in a nursing facility, an institution for
persons with developmental disabilities, specialized therapeutic foster care,
children's residential treatment services or State hospital services are not
covered by the Health Plan. For Enrollees requiring those services, the Health
Plan shall consult the Medicaid Field Office and/or the DCF District ADM Office
to identify appropriate methods of assessment and referral.

 
c.
The Health Plan is responsible for transition and referral of the Enrollee to
appropriate providers. The Health Plan shall request Disenrollment of all
Enrollees receiving the services described in this Section.

 
18.
Behavioral Health Services Care Coordination and Management

 
a.
The Health Plan shall be responsible for the coordination and management of
Behavioral Health Services and continuity of care for all Enrollees. At a
minimum, the Health Plan shall provide the following services to its Enrollees:

 
(1)
Minimize disruption to the Enrollee as a result of any change in Behavioral
Health Care Providers or Behavioral Health Care Case Managers that occur as a
result of this Contract. For new Enrollees who had been receiving Behavioral
Health Services, the Health Plan shall continue to authorize all valid claims
for services until the Health Plan has:

 
(a)
Reviewed the Enrollee's treatment plan;

 
(b)
Developed an appropriate written transition plan; and

 
(c)
Implemented the written transition plan.

 
(2)
If the previous Behavioral Health Care Provider is unable to allow the Health
Plan access to the Enrollee's Medical Records because the Enrollee refuses to
release his/her records, then the Health Plan shall provide:

 
(a)
Up to four (4) sessions of individual or group therapy;

 
(b)
One (1) psychiatric medical session;

 
(c)
Two (2) one-hour intensive therapeutic on-site sessions; or

 
(d)
Six (6) days of day treatment services.

 
(3)
Document all Emergency Behavioral Health Services received by an Enrollee, along
with any follow-up services, in the Enrollee's behavioral health Medical
Records. The Health Plan shall also assure the PCP receives the information
about the Emergency Behavioral Health Services for filing in the PCP's Medical
Record.

 
(4)
Document all referral services in the Enrollees’ behavioral health Medical
Records.

 
(5)
Monitor Enrollees admitted to State mental health institutions by participating
in discharge planning and community placement of Enrollees who are discharged
within sixty (60) days of losing their Health Plan enrollment due to State
institutionalization. The Agency shall sanction the Health Plan, as described in
Section XIV, Sanctions, for any inappropriate over-utilization of State mental
hospital services for its Enrollees.

 
(6)
Coordinate Hospital and institutional discharge planning for psychiatric
admissions and substance abuse detoxification to ensure inclusion of appropriate
post-discharge care.

 
(a)
Enrollees admitted to an acute care facility (inpatient Hospital or CSU) shall
receive appropriate services upon discharge from the acute care facility.

 
(b)
The Health Plan shall have follow-up services available to Enrollees within
twenty-four (24) hours of discharge from an acute care facility, provided the
acute care facility notified the Health Plan that it had provided services to
the Enrollee.

 
(c)
The Health Plan shall continue the medication prescribed by a State mental
health facility to the Enrollee for at least ninety (90) days after the State
mental health facility discharges the Enrollee, unless the Health Plan's
prescribing psychiatrist, in consultation and agreement with the State mental
health facility's prescribing physician, determines that the medications:

 
(i)
Are not Medically Necessary; or

 
(ii)
Are potentially harmful to the Enrollee.

 
g.
Provide appropriate referral of the Enrollee for non-covered services to the
appropriate service setting. The Health Plan shall request referral assistance,
as needed, from the Medicaid Field Office. The Health Plan is encouraged to use
the Florida Supplement to the American Society of Addictions Medicine Patient
Placement Criteria for coordination and treatment of substance abuse related
disorders with substance abuse providers. The Health Plan is encouraged to use
the Florida Supplement to the American Society of Addictions Medicine Placement
Criteria for coordination and treatment of substance-related disorders with
substance abuse Providers. The Health Plan shall provide coordination of care
with community-based substance abuse agencies as part of its policies and
procedures developed for continuity of care for Enrollees who are diagnosed with
mental illness and substance abuse or dependency.

 
h.
Provide court ordered mental health evaluations for Enrollees. The Health Plan
shall also provide expert behavioral health testimony for Enrollees.

 
i.
Provide appropriate screening, assessment, and crisis intervention in support of
Enrollees who are in the care and custody of the State. See Specifications
listed in the Medicaid Community Mental Health Services Coverage & Limitations
Handbook.

 
j..
Upon request from an ALF, the Health Plan shall provide procedures for the ALF
to follow should an emergent condition arise with an Enrollee that resides at
the ALF (see Section 409.912, F.S.).

 
k.
The Health Plan shall participate in the SAMH planning process in each DCF
district (see Section 394.75, F.S.).

 
l.
The Health Plan shall design and implement a Drug Utilization Review ("DUR")
program. Once the Health Plan's pharmacy utilization indicates that an Enrollee
is receiving an antipsychotic medication from a PCP or prescribing
non-psychiatrist physician, the Health Plan shall request a consultation with
the PCP or prescribing non-psychiatrist physician. Once the Health Plan's
pharmacy utilization indicates that an Enrollee, who is being treated by a
Behavioral Health Care Provider, receives medication for certain physical
conditions (such as hypertension, diabetes, neurological disorders, cardiac
problems, or any other serious medical condition) the Health Plan shall schedule
a consultation with the PCP or prescribing physician to discuss coordination of
care and concerns related to drug interactions. The Health Plan shall ensure
coordination with the PCP or prescribing physician with regards to drug
utilization and potential contraindications.

 
19.
Discharge Planning

 
a.
Discharge Planning is the evaluation of an Enrollee's medical care needs,
including Behavioral Health Service needs, substance abuse service needs, or
both, in order to arrange for appropriate care after discharge from one level of
care to another level of care. The Health Plan shall:

 
(1)
Monitor all Enrollee discharge plans from behavioral health inpatient admissions
to ensure that they incorporate the Enrollees’ needs for continuity in existing
behavioral health therapeutic relationships.

 
(2)
Ensure that Enrollees' family members, guardians, outpatient individual
practitioners and other identified supports are given the opportunity to
participate in Enrollee treatment to the maximum extent practicable and
appropriate, including behavioral health treatment team meetings and developing
the discharge plan. For adult Enrollees, family members and other identified
supports may be involved in the development of the Discharge Plan only if the
Enrollee consents to their involvement.

 
(3)
Designate staff members who are responsible for identifying Enrollees who remain
in the Hospital for non-clinical reasons (i.e., absence of appropriate treatment
setting availability, high demand for appropriate treatment setting, high-risk
Enrollees and Enrollees with multiple agency involvement).

 
(4)
Develop and implement a plan that monitors and ensures that clinically indicated
Behavioral Health Services are offered and available to Enrollees within
twenty-four (24) hours of discharge from an inpatient setting.

 
(5)
Ensure that a behavioral health program clinician provides medication management
to Enrollees requiring medication monitoring within twenty-four (24) hours of
discharge from a behavioral health program inpatient setting. The Health Plan
shall ensure that the behavioral health program clinician is duly qualified and
licensed to provide medication management.

 
(6)
Upon the admission of an Enrollee, the Health Plan shall make its best efforts
to ensure the Enrollee’s smooth transition to the next service or to the
community; and shall require that Behavioral Health Care Providers:

 
(a)
Assign a Behavioral Health Care Case Manager to oversee the care given to the
Enrollee;

 
(b)
Develop an individualized discharge plan, in collaboration with the Enrollee
where appropriate, for the next service or program or the Enrollee's discharge,
anticipating the Enrollee's movement along a continuum of services; and

 
(c)
Make best efforts to ensure a smooth transition to the next service or
community;

 
(d)
Document all significant efforts related to these activities, including the
Enrollee's active participation in discharge planning.

 
20.
Transition Plan

 
a.
A transition plan is a detailed description of the process of transferring
Enrollees from non-participating providers to the Health Plan's Behavioral
Health Care Provider network to ensure optimal continuity of care. The
transition plan shall include, but not be limited to, a timeline for
transferring Enrollees, description of provider medical record transfers,
scheduling of appointments, and propose prescription drug protocols and claims
approval for existing providers during the transition period. The Health Plan
shall document its efforts relating to the transition plan in the Enrollee’s
Medical Records.

 
b.
The Health Plan shall minimize the disruption of treatment by an Enrollee's
current behavioral health care provider by arranging for Enrollee use of
services outside of the Health Plan's network. For Enrollees who have received
Behavioral Health Services for at least six (6) months from a behavioral health
care provider, whether the provider is in the Health Plan’s network or not, the
Health Plan shall continue to authorize all valid claims until the Health Plan
reviews the Enrollee's treatment plan and implements an appropriate written
transition plan.

 
c.
During the first three (3) months that the Enrollee receives Behavioral Health
Services under this Contract, the Health Plan shall not deny requests for
Behavioral Health Services outside the network under the following conditions:

 
(1)
The Enrollee is a patient at a community behavioral health center and the center
has discussed the Enrollee's care with the Health Plan.

 
(2)
If, following contact with the Health Plan, there is no Behavioral Health Care
Provider readily available and the Enrollee's condition would not permit a delay
in treatment.

 
d.
If the previous treating provider is unable to allow the Health Plan access to
the Enrollee's Medical Records because the Enrollee refuses to release the
records, then the Health Plan shall approve the provider’s claims for:

 
(1)
Four (4) sessions of outpatient behavioral health counseling or therapy;

 
(2)
One (1) outpatient psychiatric physician session;

 
(3)
Two (2) one-hour intensive therapeutic on-site sessions; or

 
(4)
Six (6) days of day treatment services.

 
e.
Any disputes related to coverage of services necessary for the transition of
Enrollees from their current behavioral health care provider to a Behavioral
Health Care Provider shall follow the process set forth in Section IX, Grievance
System.

 
f.
The Health Plan shall approve claims from providers for authorized out-of-plan
non-emergency services, provided such claims are submitted within twelve (12)
months of the date of service. The Health Plan must process such claims within
the time period specified in Section 641.3155, F.S.

 
21.
Functional Assessments

 
a.
The Health Plan shall ensure that all Behavioral Health Care Providers
administer functional assessments using the Functional Assessment Rating Scales
(FARS) for all Enrollees over the age of eighteen (18) and Child Functional
Assessment Rating Scale (CFARS) for all Enrollees age eighteen (18) and under.

 
b.
The Health Plan shall ensure that all Behavioral Health Care Providers
administer and maintain the FARS and CFARS, according to the FARS and CFARS
manuals, to all Enrollees receiving Behavioral Health Services and upon
termination of providing such services.

 
c.
The results of the FARS and CFARS assessments shall be maintained in each
Enrollee's Medical Record, including a chart trending the results of the
functional assessments.

 
d.
The Health Plan shall submit the FARS/CFARS reports as required in Section XII,
Reporting Requirements.

 
22.
Outreach Program

 
a.
The Health Plan shall have an outreach program designed to encourage Enrollees
to seek Behavioral Health Services through the Health Plan when the Health Plan,
or Providers, perceive a need for Behavioral Health Services. In addition, the
outreach program, at a minimum, shall provide for the following:

 
(1)
Make available, by mail or at the request of an Enrollee/provider (participating
or non-participating), outreach program documentation that is written at the
fourth (4th) grade reading level and written in the primary language spoken by
the Enrollee;

 
(2)
A program to identify and manage Enrollees who are homeless.

 
(3)
A program, including referral and other resources, designed to assist PCP's in
the identification, management and treatment of:

 
(a)
Enrollees with severe and persistent mental illness;

 
(b)
Children/Adolescents with severe emotional disturbances; and

 
(c)
Enrollees with clinical depression.

 
23.
Behavioral Health Provider Contracts

 

 
a.
If the Health Plan subcontracts with a Managed Behavioral Health Organization
(MBHO) for the provision of Behavioral Health Services, the MBHO must be
accredited by at least one (1) of the recognized national accreditation
organizations.

 
a.
The Health Plan shall submit to the Agency the staff psychiatrist employment
contract, if any, and the model Provider Contracts for each Behavioral Health
Services specialist type or facility.

 
b.
All subcontracts and Provider Contracts must adhere to the requirements set
forth in this Contract.

 
24.
Optional Services

 
a.
The Health Plan is encouraged to provide additional services that will enhance
the Health Plan’s Covered Services for Enrollees. To the degree possible, the
Health Plan should use existing community resources. Below is a list of possible
optional services that could be provided with the savings achieved or as
downward substitutions. This list is not intended to be all-inclusive and the
Health Plan is encouraged to use creativity in developing new and innovative
services to expand the array of services and meet the needs of Enrollees.

 
(1)
Respite Care Services;

 
(2)
Prevention Services in the Community;

 
(3)
Supportive Living Services;

 
(4)
Supported Employment Services;

 
(5)
Foster Homes for Adults;

 
(6)
Parental Education Programs;

 
(7)
Drop-In Centers and other consumer operated programs (beyond the elements
provided under the Opportunities for Recovery and Reintegration component);

 
(8)
Intensive Therapeutic On-Site Services for Adults;

 
(9)
Home and Community Based Rehabilitation Services for Adults; and

 
(10)
Any other new and innovative interventions or services designed to benefit
Enrollees.

 
25.
Community Coordination and Collaboration

 
a.
The Health Plan must be or become a vital part of the community services and
support system. It must actively participate with and support community programs
and coalitions that promote school readiness, that assist persons to return to
work and provide for prevention programs. The Health Plan must have linkages
with numerous community programs that will assist Enrollees in obtaining
housing, economic assistance and other supports.

C.
Behavioral Health Managed Care Local Advisory Group

 
1.
There will be a local advisory group for the Health Plan that convenes quarterly
and reports to the Agency on advocacy and programmatic concerns. The local
advisory group is responsible for providing technical and policy advice to the
Agency regarding the Health Plan’s provision of services. The local advisory
group does not have access to Enrollee Medical Records.

 
2.
The role of the local advisory group is to report to the Agency information
related to practical and real events that occur related to the activities of
Medicaid health plans. Concerns about services, program changes, quality of
care, difficulties, advocacy issues, and reports about positive outcomes are
presented by members of the local advisory group and are addressed by the Agency
as part of the ongoing monitoring of the Health Plan. The Agency presents
information about actions taken related to issues presented by the group. If the
local advisory group determines that it is appropriate, the local advisory group
members also vote to present their issues to the Agency in writing.

 
3.
The local advisory group may request information to be presented at each meeting
that will keep the local advisory group up-to-date regarding the Contract and
activities of each Health Plan. Minutes of the meetings are kept and distributed
to all members and attendees. The voting membership of the local advisory group
is updated periodically.  This is a public meeting and may be attended by anyone
in the community.

     

 
4.
The local advisory group is coordinated by Agency area staff (who are not part
of the voting membership) and consists of providers, consumer representatives,
advocacy groups, and other relevant groups as identified by the Agency, which
represent the counties within the Service Area. Such relevant groups include the
Agency’s Medicaid Office, including Health Plan representatives; SAMH and Family
Safety representatives; representatives from any community based care Providers
contracted with DCF; the Florida Drop-In Center Association; the Human Rights
Advocacy Committee; the Alliance for the Mentally Ill; the Florida Consumer
Action Council; and the Substance Abuse and Mental Health Planning Council. In
addition, the Health Plan provides representation to the local advisory group.
The local advisory group elects a chairperson and vice-chairperson from the
voting membership, who facilitates the meetings and prepares any written
correspondence on behalf of the group.

 
5.
The Health Plan’s responsibility related to the local advisory group is as
follows:

 
a.
Assure representation at all scheduled meetings;

 
b.
Provide information requested by local advisory group members;

 
c.
Follow up on identified issues of concern related to the provision of services
or administration of the Health Plan; and

 
d.
Share pertinent information about Quality Improvement findings and outreach
activities with the local advisory group.

D.
Community Behavioral Health Services Annual 80/20 Expenditure Report 

 
1.
By April 1 of each year, Health Plans shall provide a breakdown of expenditures
related to the provision of community behavioral health services, using the
spreadsheet template provided by the Agency (see Section XII, Reporting
Requirements).  In accordance with Section 409.912, F.S., eighty percent (80%)
of the Capitation Rate paid to the Health Plan by the Agency shall be expended
for the provision of community behavioral health services.  In the event the
Health Plan expends less than eighty percent (80%) of the Capitation Rate, the
Health Plan shall return the difference to the Agency no later than May 1 of
each year.

 
a.  
For reporting purposes in accordance with this Section, ‘community behavioral
health services’ are defined as those services that the Health Plan is required
to provide as listed in the Community Mental Health Services Coverage and
Limitations Handbook and the Mental Health Targeted Case Management Coverage and
Limitations handbook.

   
b.  
For reporting purposes in accordance with this Section ‘expended’ means the
total amount, in dollars, paid directly or indirectly to community behavioral
health services providers solely for the provision of community behavioral
health services, not including administrative expenses or overhead of the plan.
 If the report indicates that a portion of the capitation payment is to be
returned to the Agency, the Health Plan shall submit a check for that amount
with the Behavioral Health Services Annual 80/20 Expenditure Report that the
Health Plan provides to the Agency.

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Section VII
 
Provider Network
 

A.
General Provisions

 
1.
The Health Plan shall have sufficient facilities, service locations, service
sites and personnel to provide the Covered Services described in Section V,
above, and Behavioral Health Care described in Section VI, above.

 
2.
The Health Plan shall provide the Agency with adequate assurances that the
Health Plan has the capacity to provide Covered Services to all Enrollees up to
the maximum enrollment level in each county, including assurances that the
Health Plan:

 
a.
Offers an appropriate range of services and accessible preventive and primary
care services such that the Health Plan can meet the needs of the maximum
enrollment level in each county, and

 
b.
Maintains a sufficient number, mix and geographic distribution of Providers,
including Providers who are accepting new Medicaid patients as specified in
Section 1932(b)(7) of the Social Security Act, as enacted by Section 4704(a) of
the Balanced Budget Act of 1997.

 
3.
By November 30, 2006, the Health Maintenance Organizations and other licensed
managed care organizations shall register all network providers with the
Agency’s Fiscal Agent, in the manner, and format determined by the Agency.

 
4.
Each Provider shall maintain Hospital privileges if Hospital privileges are
required for the delivery of Covered Services. The Health Plan may use admitting
panels to comply with this requirement.

 
5.
When designing the Provider network, the Health Plan shall take the following
into consideration as required by 42 CFR 438.206:

 
a.
The anticipated number of Enrollees;

 
b.
The expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented;

 
c.
The numbers and types (in terms of training, experience, and specialization) of
providers required to furnish the Covered Services;

 
d.
The numbers of network providers who are not accepting new Enrollees;

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

 
f.
There is to be no discrimination against particular providers that serve
high-risk populations or specialize in conditions that require costly
treatments.

 
6.
If the Health Plan is unable to provide Medically Necessary services to an
Enrollee, the Health Plan must cover these services by using providers and
services that are not providers in the Health Plan's network, in an adequate and
timely manner, for as long as the Health Plan is unable to provide the Medically
Necessary services within the Health Plan's network.

 
7.
The Health Plan shall allow each Enrollee to choose his or her Providers to the
extent possible and appropriate.

 
8.
The Health Plan shall require each Provider to have a unique Florida Medicaid
Provider number, in accordance with the requirement of Section X.C.jj., of this
Contract. By May 2007, the Health Plan shall require each Provider to have a
National Provider Identifier (NPI) in accordance with section 1173(b) of the
Social Security Act, as enacted by section 4707(a) of the Balanced Budget Act of
1997.

 
a.
The Health Plan need not obtain an NPI from the following Providers:

 
(1)
Individuals or organizations that furnish atypical or nontraditional services
that are only indirectly related to the provision of health care (examples
include taxis, home and vehicle modifications, insect control, habilitation and
respite services); and

 
(2)
Individuals or businesses that only bill or receive payment for, but do not
furnish, health care services or supplies (examples includes billing services,
repricers and value-added networks).

 
9.
The Health Plan shall provide the Agency with documentation of compliance with
access requirements:

 
a.
Upon the effective date of the Contract; and

 
b.
At any time there has been a significant change in the Health Plan's operations
that would affect adequate capacity and services, including, but not limited to,
the following:

 
(1)
Changes in Health Plan services or Service Area; and

 
(2)
Enrollment of a new population in the Health Plan.

 
10.
The Health Plan shall have procedures to inform Potential Enrollees and
Enrollees of any changes to service delivery and/or the Provider network
including the following:

 
a.
Inform Potential Enrollees and Enrollees of any restrictions to access to
Providers, including Providers who are not taking new patients, upon request
and, for Enrollees, at least on a six (6) month basis.

 
b.
An explanation to all Potential Enrollees that an enrolled family may choose to
have all family members served by the same PCP or they may choose different PCPs
based on each family member’s needs.

 
c.
Inform Potential Enrollees and Enrollees of objections to providing counseling
and referral services based on moral or religious grounds within ninety (90)
days after adopting the policy with respect to any service.

 
11.
The Health Plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider, whether participating or
nonparticipating, who is acting within the scope of the provider's license or
certification under applicable State law, solely on the basis of such license or
certification, in accordance with Section 1932(b) (7) of the Social Security Act
(as enacted by section 4704(a) of the Balanced Budget Act of 1997). The Health
Plan is not prohibited from including providers only to the extent necessary to
meet the needs of the Health Plan's Enrollees or from establishing any measure
designed to maintain quality and control costs consistent with the
responsibilities of the Health Plan. If the Health Plan declines to include
individual providers or groups of providers in its network, it must give the
affected providers written notice of the reason for its decision.

B.
Primary Care Providers 

 
1.
The Health Plan shall enter into Provider Contracts with a sufficient number of
PCPs to ensure adequate accessibility for Enrollees of all ages. The Health Plan
shall select and approve its PCPs. The Health Plan shall ensure its PCP Provider
Contracts provide for the following: 

 
a.
The PCP shall accept all associated Case Management responsibilities;

 
b.
The PCP shall provide, or arrange for coverage of services, consultation or
approval for referrals twenty four (24) hours per day, seven (7) days per week
by Medicaid enrolled providers who will accept Medicaid reimbursement. This
coverage must consist of an answering service, call forwarding, provider call
coverage or other customary means approved by the Agency. The chosen method of
twenty four (24) hour coverage must connect the caller to someone who can render
a clinical decision or reach the PCP for a clinical decision. The after hours
coverage must be accessible using the medical office’s daytime telephone number.
The PCP or covering medical professional must return the call within thirty (30)
minutes of the initial contact; and

c. The PCP shall arrange for coverage of primary care services during absences
due to vacation, illness or other situations which require the PCP to be unable
to provide services. Coverage must be provided by a Medicaid eligible PCP. 

 
2.
The Health Plan shall provide the following:

 
a.
At least one (1) FTE PCP per Service Area including, but not limited to, the
following specialties:

 
(1)
Family Practice;

 
(2)
General Practice;

 
(3)
Obstetrics or Gynecology;

 
(4)
Pediatrics; and

 
(5)
Internal Medicine.

 
b.
At least one (1) FTE PCP per 1,500 Enrollees. The Health Plan may increase the
ratio by 750 Enrollees for each FTE ARNP or FTE PA affiliated with a PCP.

 
c.
The Health Plan shall allow pregnant Enrollees to choose the Health Plan’s
obstetricians as their PCPs to the extent that the obstetrician is willing to
participate as a PCP.

 
3.
At least annually, the Health Plan shall review each PCP’s average wait times to
ensure services are in compliance with Section VII.D., Appointment Waiting Times
and Geographic Access Standards.

 
4.
The Health Plan shall assign a pediatrician or other appropriate PCP to all
pregnant Enrollees for the care of their newborn babies no later than the
beginning of the last trimester of gestation. If the Health Plan was not aware
that the Enrollee was pregnant until she presented for delivery, the Health Plan
shall assign a pediatrician or a PCP to the newborn baby within one (1) Business
Day after birth. The Health Plan shall advise all Enrollees of the Enrollees’
responsibility to notify their Health Plan and their DCF public assistance
specialists (case workers) of their pregnancies and the births of their babies.

C.
Minimum Standards

 
1.
Emergency Services and Emergency Services Facilities - The Health Plan shall
ensure the availability of Emergency Services and Care twenty-four (24) hours a
day, seven (7) days a week.

 
2.
General Acute Care Hospital - The Health Plan shall provide at least one (1)
fully accredited general acute care Hospital bed per 275 Enrollees. The Agency
may waive this accreditation requirement, in writing, for Rural areas.

 
3.
Birth Delivery Facility - The Health Plan shall provide at least one (1) birth
delivery facility, licensed under Chapter 383, F.S., or a Hospital with birth
delivery facilities, licensed under Chapter 383, F.S. The birth delivery
facility may be part of a Hospital or a freestanding facility.

 
4.
Birthing Center - The Health Plan shall provide a birthing center, licensed
under Chapter 383, F.S. that is accessible to low risk Enrollees.

 
5.
Regional Perinatal Intensive Care Centers (RPICC) - The Health Plan shall assure
access for Enrollees in one (1) or more of Florida's Regional Perinatal
Intensive Care Centers (RPICC), see Sections 383.15 through 383.21, F.S., or a
Hospital licensed by the Agency for Neonatal Intensive Care Unit (NICU) Level
III beds.

 
6.
Neonatal Intensive Care Unit (NICU) - The Health Plan shall ensure that care for
medically high risk perinatal Enrollees is provided in a facility with a NICU
sufficient to meet the appropriate level of need for the Enrollee.

 
7.
Certified Nurse Midwife Services - The Health Plan shall ensure access to
certified nurse midwife services or licensed midwife services for low risk
Enrollees, licensed in accordance with Section 641.31, F.S.

 
8.
Pharmacy - If the Health Plan elects to use a more restrictive pharmacy network
than the non-Medicaid Reform fee-for-service network, the Health Plan shall
provide at least one (1) licensed pharmacy per 2,500 Enrollees. The Health Plan
shall ensure that its contracted pharmacies comply with the Settlement Agreement
to Hernandez et al. v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA).

 
9.
Access for Persons with Disabilities - The Health Plan shall ensure that all
facilities have access for persons with disabilities.

 
10.
Health, Cleanliness and Safety - The Health Plan shall ensure adequate space,
supplies, proper sanitation, and smoke-free facilities with proper fire and
safety procedures in operation.

D.
Appointment Waiting Times and Geographic Access Standards

 
1.
The Health Plans must assure that PCP services and referrals to Participating
Specialists are available on a timely basis, as follows:

 
a.
Urgent Care — within one (1) day,

 
b.
Routine Sick Patient Care — within one (1) week, and

 
c.
Well Care Visit — within one (1) month.

 
2.
All PCP's and Hospital services must be available within an average of thirty
(30) minutes travel time from an Enrollee's residence. All Participating
Specialists and Ancillary Providers must be within an average of sixty (60)
minutes travel time from an Enrollee's residence. The Agency may waive this
requirement, in writing, for Rural Areas and for areas where there are no PCPs
or Hospitals within a thirty (30) minute average travel time.

 
3.
The Health Plan shall provide a designated emergency services facility within an
average of thirty (30) minutes travel time from an Enrollee's residence, that
provides care on a twenty-four (24) hours a day, seven (7) days a week basis.
Each designated emergency service facility shall have one (1) or more physicians
and one (1) or more nurses on duty in the facility at all times. The Agency may
waive the travel time requirement, in writing, in Rural areas.

     

 
4.
For Rural areas, if the Health Plan is unable to enter into an agreement with
specialty or ancillary service providers within the required sixty (60) minute
average travel time, the Agency may waive, in writing, the requirement.

 
5.
At least one (1) pediatrician or one (1) CHD, FQHC or RHC within an average of
thirty (30) minutes travel time from an Enrollee's residence, provided that this
requirement remains consistent with the other minimum time requirements of this
Contract. In order to meet this requirement, the pediatrician(s), CHD, FQHC,
and/or RHC must provide access to care on a twenty-four (24) hours a day, seven
(7) days a week basis. The Agency may waive this requirement, in writing, for
Rural areas and where there are no pediatricians, CHDs, FQHCs or RHCs within the
thirty (30) minute average travel time.

E.
Behavioral Health Services

 
1.
The Health Plan shall have at least one (1) certified adult psychiatrist and at
least one (1) board certified child psychiatrist (or one (1) child psychiatrist
who meets all education and training criteria for Board Certification) that is
available within thirty (30) minutes average travel time for Urban areas and
sixty (60) minutes average travel time for Rural areas of all Enrollees.

 
2.
For Rural areas, if the Health Plan does not have a Provider with the necessary
experience, the Agency may waive, in writing, the requirements in Section
VII.E.1, above.

 
3.
The Health Plan shall ensure that outpatient staff includes at least one (1) FTE
Direct Service Behavioral Health Provider per 1,500 Enrollees. The Agency
expects the Health Plan’s staffing pattern for direct service Providers to
reflect the ethnic and racial composition of the community.

 
4.
The Health Plan’s array of Direct Service Behavioral Health Providers for adults
and Children/Adolescents shall include Providers that are licensed or eligible
for licensure, and demonstrate two (2) years of clinical experience in the
following specialty areas or with the following populations:

 
a.
Adoption;

 
b.
Child protection or foster care;

 
c.
Dual diagnosis (mental illness and substance abuse);

 
d.
Dual diagnosis (mental illness and developmental disability);

 
e.
Developmental disabilities;

 
f.
Behavior analysis;

 
g.
Behavior management and alternative therapies for children/Adolescents;

 
h.
Separation and loss;

 
i.
Victims and perpetrators of sexual abuse (Children/Adolescents and adults);

 
j.
Victims and perpetrators of violence and violent crimes (Children/Adolescents
and adults);

 
k.
Court ordered mental health evaluations including assessment of parental mental
health issues and parental competency as it relates to mental health; and

 
l.
Expert witness testimony.

 
5.
All Direct Service Behavioral Health Providers and mental health targeted case
managers serving the Children/Adolescent population shall be certified by DCF to
administer CFARS (or other rating scale required by DCF or the Agency).

 
6.
The Health Plan shall not count Behavioral Health targeted case managers shall
not be counted as direct service Behavioral Health Providers.

 
7.
For Case Management services, the Health Plan shall provide staff that meets the
following minimum requirements:

 
a.
Have a baccalaureate degree from an accredited university, with major course
work in the areas of psychology, social work, health education or a related
human service field and, if working with Children/Adolescents, have a minimum of
one-(1) year full-time experience, or equivalent experience, working with the
target population. Prior experience is not required if working with the adult
population; or

 
b.
Have a baccalaureate degree from an accredited university and if working with
Children/Adolescents, have at least three (3) years full-time or equivalent
experience, working with the target population. If working with adults, the case
manager must have two (2) years of experience. (Note: case managers who were
certified by the Department prior to July 1, 1999, who do not meet the degree
requirements, may provide Case Management services if they meet the other
requirements; and

 
c.
Have completed a training program within six (6) months of employment. The
training program must be prior approved in writing by the Agency. The training
must include a review of the local resources and a thorough presentation of the
applicable State and federal statutes and promote the knowledge, skills, and
competency of all case managers through the presentation of key core elements
relevant to the target population. The case manager must also be able to
demonstrate an understanding of the Health Plan’s Case Management policies and
procedures.

 
8.
Case Management supervision must be provided by a person who has a master’s
degree in a human services field and three (3) years of professional full time
experience serving this target population or a person with a bachelor’s degree
and five (5) years of full time or equivalent Case Management experience. For
supervising case managers who work only with adults, two (2) years of full time
experience is required. The supervisors must have had the approved Health Plan
training in Case Management or have documentation that they have prior
equivalent training.

 
9.
The Health Plan shall have access to no less than one (1) fully accredited
psychiatric community Hospital bed per 2,000 Enrollees, as appropriate, for both
Children/Adolescents and adults. Specialty psychiatric Hospital beds may be used
to count toward this requirement when psychiatric community Hospital beds are
not available within a particular community. Additionally, the Health Plan shall
have access to sufficient numbers of accredited Hospital beds on a
medical/surgical unit to meet the need for medical detoxification treatment.

 
10.
The Health Plan’s facilities must be licensed, as required by law and rule,
accessible to the handicapped, in compliance with federal Americans with
Disabilities Act guidelines, and have adequate space, supplies, good sanitation,
and fire, safety, and disaster preparedness and recovery procedures in
operation.

 
11.
The Health Plan shall ensure that it has Providers that are qualified to serve
Enrollees and experienced in serving severely emotionally disturbed
Children/Adolescents and severely and persistent mentally ill adults. The Health
Plan shall maintain documentation of its Providers’ experience in the Providers'
credentialing file.

 
12.
The Health Plan shall adhere to the staffing ratio of at least one (1) FTE
Behavioral Health Care Case Manager for twenty (20) Children/Adolescents and at
least one (1) FTE Behavioral Health Care Case Manager per forty (40) adults.
Direct Service Behavioral Health Care Providers shall not count as Behavioral
Health Care Case Managers.

 
13.
Prior to commencement of Behavioral Health Services, the Health Plan shall enter
into agreements for coordination of care and treatment of Enrollees, jointly or
sequentially served, with county community mental health care center(s) that are
not a part of the Health Plan's Provider network. The Health Plan shall enter
into similar agreements with agencies funded pursuant to Chapter 394, F.S. The
Agency shall approve all model agreements between the Health Plan and county
community mental health center(s)/agencies before the Health Plan enters into
the agreement. This requirement shall not apply if the Health Plan provides the
Agency with documentation that shows the Health Plan has made a good faith
effort to contract with county community mental health center(s)/agencies, but
could not reach an agreement.

 
14.
The Health Plan shall request current behavioral health care provider
information from all new Enrollees upon enrollment. The Health Plan shall
solicit these behavioral health services providers to participate in the Health
Plan's network. The Health Plan may request in writing that the Agency grant
exemption to a Health Plan from soliciting a specific behavioral health services
provider on a case-by-case basis.

 
15.
To the maximum extent possible, the Health Plan shall contract for the provision
of Behavioral Health Services with the State's community mental health centers
designated by the Agency and DCF.

F.
Specialists and Other Providers

 
1.
In addition to the above requirements, the Health Plan shall assure the
availability of the following specialists, as appropriate for both adults and
pediatric Enrollees, on at least a referral basis. The Health Plan shall use
Participating Specialists with pediatric expertise for Children/Adolescents when
the need for pediatric specialty care is significantly different from the need
for adult specialty care (for example a pediatric cardiologist for
Children/Adolescents with congenital heart defects).

a. Allergist,

b. Cardiologist,

c. Endocrinologist,

d. General Surgeon,

e. Obstetrical/Gynecology (OB/GYN),

f. Neurologist,

g. Nephrologist,

h. Orthopedist,

i. Urologist,

j. Dermatologist,

k. Otolaryngologist,

l. Pulmonologist,

m. Chiropractic Physician,

n. Podiatrist,

o. Ophthalmologist,

p. Optometrist,

q. Neurosurgeon,

r. Gastroenterologist,

s. Oncologist,

t. Radiologist,

u. Pathologist,

v. Anesthesiologist,

w. Psychiatrist,

x. Oral surgeon,

y. Physical, respiratory, speech and occupational therapists, and

z. Infectious disease specialist.

 
2.
If the infectious disease specialist does not have expertise in HIV and its
treatment and care, then the Health Plan must have another Provider with such
expertise.

 
3.
The Health Plan shall make a good faith effort to execute memoranda of agreement
with the local CHDs to provide services which may include, but are not limited
to, family planning services, services for the treatment of sexually transmitted
diseases, other public health related diseases, tuberculosis, immunizations,
foster care emergency shelter medical screenings, and services related to
Healthy Start prenatal and post-natal screenings. The Health Plan shall provide
documentation of its good faith effort upon the Agency’s request.

 
4.
Notwithstanding Section VIII.B.2, Certain Public Providers, of this Contract,
the Health Plan shall pay, without prior authorization, at the contracted rate
or the Medicaid fee-for-service rate, all valid claims initiated by any CHD for
office visits, prescribed drugs, laboratory services directly related to DCF
emergency shelter medical screening, and tuberculosis. The Health Plan must
reimburse the CHD when the CHD notifies the Health Plan and provides the Health
Plan with copies of the appropriate Medical Records and provides the Enrollee's
PCP with the results of any tests and associated office visits.

 
5.
The Health Plan shall make a good faith effort to execute a contract with a
Federally Qualified Health Center (FQHC) and, if applicable, a Rural Health
Clinic (RHC). The Health Plan shall reimburse FQHCs and RHCs at rates comparable
to those rates paid for similar services in the FQHC's or RHC's community. The
Health Plan shall report to the Agency, on a quarterly basis, the payment rates
and the payment amounts made to FQHCs and RHCs for contractual services provided
by these entities.

 
6.
The Health Plan shall permit female Enrollees to have direct access to a women's
health specialist within the network for Covered Services necessary to provide
women's routine and preventive health care services. This is in addition to an
Enrollee's designated PCP, if that Provider is not a women's health specialist.

G.
Continuity of Care 

 
1.
The Health Plan shall allow Enrollees in active treatment to continue care with
a terminated treating provider when such care is Medically Necessary, through
completion of treatment of a condition for which the Enrollee was receiving care
at the time of the termination, until the Enrollee selects another treating
Provider, or during the next Open Enrollment period. None of the above may
exceed six (6) months after the termination of the Provider's contract.

 
2.
The Health Plan shall allow pregnant Enrollees who have initiated a course of
prenatal care, regardless of the trimester in which care was initiated, to
continue care with a terminated treating provider until completion of postpartum
care.

 
3.
Notwithstanding the provisions in this subsection, a terminated provider may
refuse to continue to provide care to an Enrollee who is abusive or
noncompliant.

 
4.
For continued care under this subsection, the Health Plan and the terminated
provider shall continue to abide by the same terms and conditions as existed in
the terminated contract.

 
5.
The requirements set forth in this subsection shall not apply to providers who
have been terminated from the Health Plan for Cause.

 
6.
The Health Plan shall develop and maintain policies and procedures for the above
requirements.

H.
Network Changes 

 
1.
The Health Plan shall notify the Agency within seven (7) Business Days of any
significant changes to the Health Plan network. A significant change is defined
as:

 
a.
A decrease in the total number of PCPs by more than five percent (5%);

 
b.
A loss of all Participating Specialists in a specific specialty where another
Participating Specialist in that specialty is not available within sixty (60)
minutes;

 
c.
A loss of a Hospital in an area where another Health Plan Hospital of equal
service ability is not available within thirty (30) minutes; or

 
d.
Other adverse changes to the composition of the network which impair or deny the
Enrollee's adequate access to Providers.

 
2.
The Health Plan shall have procedures to address changes in the Health Plan
network that negatively affect the ability of Enrollees to access services,
including access to a culturally diverse Provider network. Significant changes
in network composition that negatively impact Enrollee access to services may be
grounds for Contract termination or Agency determined sanctions.

 
3.
The Health Plan shall make a good faith effort to give written notice of
termination within fifteen (15) days after receipt of a termination notice to
each Enrollee who received his or her primary care from, or was seen on a
regular basis by, a terminated provider.

 
a.
If an Enrollee is in a Prior Authorized ongoing course of treatment with any
other Provider who becomes unavailable to continue to provide services, the
Health Plan shall notify the Enrollee in writing within ten (10) Calendar Days
from the date the Health Plan becomes aware of such unavailability.

 
b.
These requirements to provide notice prior to the effective dates of termination
shall be waived in instances where a Provider becomes physically unable to care
for Enrollees due to illness, a Provider dies, the Provider moves from the
Service Area and fails to notify the Health Plan, or when a Provider fails
credentialing. Under these circumstances, notice shall be issued immediately
upon the Health Plan becoming aware of the circumstances.

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Section VIII
 
Quality Management
 

A.
Quality Improvement

1.  
General Requirements

 
a.
The Health Plan shall have an ongoing Quality Improvement Program (QIP) that
objectively and systematically monitors and evaluates the quality and
appropriateness of care and services rendered, thereby promoting quality of care
and quality patient outcomes in service performance to its Enrollees.

 
b.
The Health Plan’s written policies and procedures shall address components of
effective health care management including, but not limited to anticipation,
identification, monitoring, measurement, evaluation of Enrollee’s health care
needs, and effective action to promote quality of care.

 
c.
The Health Plan shall define and implement improvements in processes that
enhance clinical efficiency, provide effective utilization, and focus on
improved outcome management achieving the highest level of success.

 
d.
The Health Plan and its QIP shall demonstrate in its care management, specific
interventions to better manage the care and promote healthier Enrollee outcomes.

 
e.
The Health Plan shall cooperate with the Agency and the External Quality Review
Organization (EQRO). The Agency will set methodology and standards for Quality
Improvement (QI) with advice from the EQRO.

 
f.
Prior to implementation, the Agency and/or the EQRO shall review the Health
Plan’s QIP.

 
g.
The Health Plan must submit its QIP to the Agency no later than the execution
date of the Contract. The QIP must be approved, in writing, by the Agency no
later than three (3) months following the execution of this Contract.

 
2.
Specific Required Components of the QIP

 
a.
The Health Plan’s governing body shall oversee and evaluate the QIP. The role of
the Health Plan’s governing body shall include providing strategic direction to
the QIP, as well as ensuring the QIP is incorporated into the operations
throughout the Health Plan.

 
b.
The Health Plan shall have a QIP Committee. The Health Plan’s Medical Director
shall serve as either the Chairman or Co-Chairman of the QIP Committee.
Appropriate Health Plan staff representing the various departments of the
organization shall have membership on the Committee. The Committee shall meet on
a regular periodic basis. Its responsibilities shall include the following:

 
(1)
Development and implementation of a written QI plan, which incorporates the
strategic direction provided by the governing body.

 
(2)
The QI plan shall reflect a coordinated strategy to implement the QIP including
planning, decision making, intervention, and assessment of results.

 
(3)
The QI plan shall include a description of the Health Plan staff assigned to the
QIP; their specific training regarding Medicaid; how they are organized; and
their responsibilities.

 
(4)
The QI plan shall describe the role of its Providers in giving input to the QIP,
whether that is by membership on the Committee, its Sub-Committees, or other
means.

 
(5)
The Health Plan is encouraged to include an advocate representative on the QIP
Committee.

 
(6)
The Health Plan shall submit its written QI plan to the Agency for written
approval within thirty (30) days of the execution of the Contract.

 
c.
Direct and review QI activities, including, but not limited to:

 
(1)
Assure that QIP activities take place throughout the Health Plan;

 
(2)
Review and suggest new and/or improved QI activities;

 
(3)
Direct task forces/committees to review areas of concern in the provision of
health care services to Enrollees;

 

 
(4)
Designate evaluation and study design procedures;

 
(5)
Report findings to appropriate executive authority, staff, and departments
within the Health Plan; and

 
(6)
Direct and analyze periodic reviews of Enrollees' service utilization patterns.

     

 
d.
Maintain minutes of all Committee and Sub-Committee meetings.

 
3.
Health Plan QI Activities

The Health Plan shall monitor and evaluate the quality and appropriateness of
care and service delivery (or the failure to provide care or deliver services)
to Enrollees through performance improvement projects (PIPs), medical record
audits, performance measures, surveys, and related activities.

 
a.
PIPs

The Health Plan shall perform no less than six (6) Agency approved performance
improvement projects.

 
(1)
Each PIP must include a statistically significant sample of Enrollees.

 
(2)
At least one (1) of the PIPs must focus on Language and Culture, Clinical Health
Care Disparities, or Culturally and Linguistically Appropriate Services.

 
(3)
At least two (2) of the PIPs must relate to Behavioral Health Services.

 
(4)
All PIPs by the Health Plan must achieve, through ongoing measurements and
intervention, significant improvement to the quality of care and service
delivery, sustained over time, in both clinical care and non-clinical care areas
that are expected to have a favorable effect on health outcomes and Enrollee
satisfaction.

 
(5)
The PIPs must be completed in a reasonable time period so as to allow the Health
Plan to evaluate the information drawn from them and to use the results of the
analysis to improve quality of care and service delivery every year.

 
(6)
Within three (3) months of the execution of this Contract, the Health Plan shall
submit, in writing, a description of each of the PIPs to the Agency for written
approval. The detailed description shall include:

 
(a)
An overview explaining how and why the project was selected, as well as its
relevance to the Health Plan’s Enrollees and Providers;

(b) The study question;

(c) The study population;

 
(d)
The quantifiable measures to be used, including a goal or benchmark;

(e) Baseline methodology;

(f) Data sources;

(g) Data collection methodology;

(h) Data collection cycle;

(i) Data analysis cycle;

(j) Results with quantifiable measures;

(k) Analysis with time period and the measures covered;

 
(l)
Analysis and identification of opportunities for improvement; and

(m) An explanation of all interventions to be taken.

 
b.
Behavioral Health QI Requirements

 
(1)
The Health Plan's QIP shall include a Behavioral Health component in order to
monitor and assure that the Health Plan's Behavioral Health Services are
sufficient in quantity, of acceptable quality and meet the needs of the
Enrollees.

 
(2)
Treatment plans must:

(a) Identify reasonable and appropriate objectives;

(b) Provide necessary services to meet the identified objectives; and

 
(c)
Include retrospective reviews that confirm that the care provided, and its
outcomes, were consistent with the approved treatment plans and appropriate for
the Enrollees' needs.

 
(3)
In determining if Behavioral Health Services are acceptable according to current
treatment standards, the Health Plan shall:

 
(a)
Perform a quarterly review of a random selection of ten percent (10%) or fifty
(50) Medical Records, whichever is more, of Enrollees who received Behavioral
Health Services during the previous quarter; and

(b) Elements of these reviews shall include, but not be limited to:

 
(i)
Management of specific diagnoses;

 
(ii)
Appropriateness and timeliness of care;

 
(iii)
Comprehensiveness of, and compliance with, the plan of care;

 
(iv)
Evidence of special screening for high risk Enrollees and/or conditions; and

 
(v)
Evidence of appropriate coordination of care.

 
(4)
In areas in which there is not an established local advisory group, the Health
Plan is responsible for the development of local advisory group meetings within
sixty (60) days of the effective date of the Contract.

 
(5)
In areas where there is more than one (1) Health Plan authorized to provide
Behavioral Health Services, the Health Plans shall work together in establishing
an area local advisory group.

 
(6)
Composition of local advisory groups shall follow the requirements set forth in
Section VI.C., Behavioral Health Managed Care Local Advisory Group.

 
(7)
The Health Plan shall send representation to the local advisory group’s meetings
that convene quarterly and report to the Agency on the behavioral health
advocacy and programmatic concerns.

 
(8)
Local advisory groups shall provide technical and policy advice to the Agency
regarding Behavioral Health Services.

c. Performance Measures (PMs) 

 
(1)
Quality and performance measures shall be evaluated at least once annually at
dates to be determined by the Agency, or as otherwise specified by this
Contract. The Health Plan will implement an enhanced quality improvement and
performance measurement system to provide for the delivery of quality care with
the primary goal of improving the health status of Enrollees.

 
(2)
The Health Plan, in conjunction with the Agency, will participate in workgroups
to plan further quality improvement strategies and learning to use best practice
methods for enhancing quality of health care.

 
(3)
If CAHPS, the AHCA quality indicators, the annual medical record audit or the
EQR indicate that the Health Plan's performance is not acceptable, then the
Agency may restrict the Health Plan’s Enrollment activities, including, but not
limited to, termination of Automatic Assignments.

 
(4)
For Health Plan performance that is not acceptable, the Agency shall require the
Health Plan to submit a corrective action plan (CAP). Failure to provide a CAP
within the time specified shall be cause for the Agency to immediately terminate
all Enrollment activities and Automatic Assignments. When considering whether to
impose a limitation on Enrollment activities or Automatic Assignments, the
Agency may consider the Health Plan’s cumulative performance on all quality and
performance measures.

 
(5)
The Health Plan shall collect data on patient outcome PMs, as defined by the
Health Plan Employee Data and Information Set (HEDIS) or otherwise defined by
the Agency and report the results of the measures to the Agency annually. The
Agency may add or remove reporting requirements with thirty (30) days advance
notice.

(6) At a minimum, the following PMs shall be measured by the Health Plan:

(a) Breast Cancer Screening;

(b) Cervical Cancer Screening;

(c) Colorectal Cancer Screening;

(d) Well Child Visits in the First 15 Months of Life;

(e) Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life;

(f) Adolescent Well Care Visits;

(g) Childhood Immunization Status;

(h) Adolescent Immunization Status;

(i) Preventive and Total Dental Visits for Children/Adolescents Between Three
Years and Eleven Years and for Children/Adolescents Between Twelve Years and
Twenty Years of Age;

(j) Average number of days spent in the community by all Enrollees receiving
behavioral health intensive case management services;

(k) Number of Enrollees admitted to a State Mental Hospital;

(l) Amount of time between discharge from a State Mental Hospital and first date
of service received from a Provider; and

(m) Number of Enrollees who receive a psychiatric evaluation within the required
time frames prior to admission to a nursing facility.

 
d.
Consumer Assessment of Health Plans Survey (CAHPS)

 
(1)
At the end of the first (1st) year under this Contract, the Agency shall conduct
an annual Consumer Assessment of Health Plans Survey (CAHPS). The CAHPS survey
shall be done on an annual basis thereafter. The Health Plan shall provide an
action plan to address the results of the CAHPS Survey within two (2) months of
receipt of the written request from the Agency.

 
e.
Medical Record Review

 
(1)
If the Health Plan is not accredited, or if the Health Plan is accredited by an
entity, that does not review the Medical Records of the Health Plan's PCPs, then
the Health Plan shall conduct reviews of Enrollees’ Medical Records to ensure
that PCPs provide high quality health care that is documented according to
established standards.

 
(2)
The standards, which must include all Medical Record documentation requirements
addressed in this Contract, must be distributed to all Providers.

 
(3)
The Health Plan must conduct these reviews at all PCP sites that serve fifty
(50) or more Enrollees.

 
(4)
Practice sites include both individual offices and large group facilities.

 
(5)
The Health Plan must review each practice site at least one (1) time during each
two (2) year period.

 
(6)
The Health Plan must review a reasonable number of records at each site to
determine compliance. Five (5) to ten (10) records per site is a
generally-accepted target, though additional reviews must be completed for large
group practices or when additional data is necessary in specific instances.

 
(7)
The Health Plan shall report the results of all Medical Record reviews to the
Agency within thirty (30) Calendar Days of the review.

 
(8)
The Health Plan must submit to the Agency for written approval and maintain a
written strategy for conducting Medical Record reviews. The strategy must
include, at a minimum, the following:

 
(a)
Designated staff to perform this duty;

 
(b)
The method of case selection;

 
(c)
The anticipated number of reviews by practice site;

 
(d)
The tool that the Health Plan will use to review each site; and

 
(e)
How the Health Plan will link the information compiled during the review to
other Health Plan functions (e.g., QI, credentialing, Peer Review, etc.).

 
f.
Peer Review

 
(1)
The Health Plan shall have a Peer Review process which:

 
(a)
Reviews a Provider's practice methods and patterns, morbidity/mortality rates,
and all Grievances filed against the Provider relating to medical treatment.

 
(b)
Evaluates the appropriateness of care rendered by Providers.

 
(c)
Implements corrective action(s) when the Health Plan deems it necessary to do
so.

 
(d)
Develops policy recommendations to maintain or enhance the Quality of care
provided to Enrollees.

 
(e)
Conducts reviews which include the appropriateness of diagnosis and subsequent
treatment, maintenance of a Provider's Medical Records, adherence to standards
generally accepted by a Provider's peers and the process and outcome of a
Provider's care.

 
(f)
Appoints a Peer Review Committee, as a Sub-Committee to the QIP Committee, to
review provider performance when appropriate. The Medical Director or his/her
designee shall chair the Peer Review Committee, and its membership shall be
drawn from the Provider Network and include peers of the Provider being
reviewed.

 
(g)
Receive and review all written and oral allegations of inappropriate or aberrant
service by a Provider.

 
(h)
Educate Enrollees and Health Plan staff about the Peer Review process, so that
Enrollees and the Health Plan staff can notify the Peer Review authority of
situations or problems relating to Providers.

 
g.
Credentialing and Recredentialing

 
(1)
The Health Plan shall be responsible for the credentialing and recredentialing
of its Provider network. Hospital ancillary Providers are not required to be
independently credentialed if those Providers only provide services to the
Health Plan Enrollees through the Hospital.

 
(2)
The Health Plan shall establish and verify credentialing and recredentialing
criteria for all professional Providers that, at a minimum, meet the Agency's
Medicaid participation standards. The Agency’s criteria includes:

 
(a)
A copy of each Provider's current medical license pursuant to Section 641.495,
F.S

 
(b)
No receipt of revocation or suspension of the Provider's State License by the
Division of Medical Quality Assurance, Department of Health.

 
(c)
No ongoing investigation(s) by Medicaid Program Integrity, other governmental
entities.

 
(d)
Conduct a background check with the Florida Department of Law Enforcement (FDLE)
for all treating providers not currently enrolled in Medicaid’s Fee-for-Service
program.

 
(i)
If exempt from the criminal background screening requirements, a copy of the
screen print of the Provider’s current Department of Health licensure status and
exemption reason must be included.

 
(ii)
The Health Plan shall not contract with any Provider who has a record of illegal
conduct; i.e., found guilty of, regardless of adjudication, or who entered a
plea of nolo contendere or guilty to any of the offenses listed in Section
435.03, F.S.

 
(e)
Proof of the Provider's medical school graduation, completion of residency and
other postgraduate training. Evidence of board certification shall suffice in
lieu of proof of medical school graduation, residency and other postgraduate
training.

(f) Evidence of specialty board certification, if applicable.

(g) Evidence of the Provider's professional liability claims history.

 
(h)
Any sanctions imposed on the Provider by Medicare or Medicaid.

 
(3)
The Health Plan's credentialing and recredentialing files must document the
education, experience, prior training and ongoing service training for each
staff member or Provider rendering Behavioral Health Services.

 
(4)
The Health Plan's credentialing and recredentialing policies and procedures
shall be in writing and include the following:

(a) Formal delegations and approvals of the credentialing process.

(b) A designated credentialing committee.

(c) Identification of Providers who fall under its scope of authority.

 
(d)
A process which provides for the verification of the credentialing and
recredentialing criteria required under this Contract.

 
(e)
Approval of new Providers and imposition of sanctions, termination, suspension
and restrictions on existing Providers.

 
(f)
Identification of quality deficiencies which result in the Health Plan's
restriction, suspension, termination or sanctioning of a Provider.

 
(5)
The credentialing and recredentialing processes must also include verification
of the following additional requirements for physicians and must ensure
compliance with 42 CFR 438.214:

 
(a)
Good standing of privileges at the Hospital designated as the primary admitting
facility by the PCP or if the PCP does not have admitting privileges, good
standing of privileges at the Hospital by another Provider with whom the PCP has
entered into an arrangement for Hospital coverage.

 
(b)
Valid Drug Enforcement Administration (DEA) certificates, where applicable.

 
(c)
Attestation that the total active patient load (all populations with Medicaid
FFS, CMS Network, HMO, Health Plan, Medicare and commercial coverage) is no more
than 3,000 patients per PCP. An active patient is one that is seen by the
Provider a minimum of three (3) times per year.

 
(d)
A good standing report on a site visit survey. For each PCP and OB/GYN Provider,
documentation in the Health Plan’s credentialing files regarding the site survey
shall include the following:

 
(i)
Evidence that the Health Plan has evaluated the Provider's facilities using the
Health Plan's organizational standards.

 
(ii)
Evidence that the Health Plan has evaluated the Provider's medical record
keeping practices at each site to ensure conformity with the Health Plan's
organizational standards.

 
(iii)
Evidence that the Health Plan has determined that the following documents are
posted in the Provider's waiting room/reception area: the Agency’s statewide
consumer call center telephone number, including hours of operation and a copy
of the summary of Florida’s Patient’s Bill of Rights and Responsibilities, in
accordance with Section 381.026, F.S.; the Provider has a complete copy of the
Florida Patient’s Bill of Rights and Responsibilities, available upon request by
an Enrollee, at each of the Provider's offices.

 
(iv)
The Provider's waiting room/reception area has a consumer assistance notice
prominently displayed in the reception area in accordance with Section 641.511,
F.S.

 
(e)
Attestation to the correctness/completeness of the Provider's application.

 
(f)
Statement regarding any history of loss or limitation of privileges or
disciplinary activity as described in Section 456.039, F.S.

 
(g)
A statement from each Provider applicant regarding the following:

 
(i)
Any physical or mental health problems that may affect the Provider's ability to
provide health care;

(ii) Any history of chemical dependency/substance abuse;

 
(iii)
Any history of loss of license and/or felony convictions; and

(iv) The Provider is eligible to become a Medicaid provider.

 
(h)
Current curriculum vitae, which includes at least five (5) years of work
history.

 
(6)
The Health Plan shall recredential its Providers at least every three (3) years.

 
(7)
The Health Plan shall develop and implement an appeal procedure for Providers
against whom the Health Plan has imposed sanctions, restrictions, suspensions
and/or terminations.

 
(8)
The Health Plan shall submit a Provider Network for initial or expansion review
to the Agency for approval only when the Health Plan has satisfactorily
completed the minimum standards required in Section VII, Provider Network and
the minimum credentialing steps required in Section VIII.A.3.h(2), and i.(5) and
(6).

 
4.
Agency Oversight

 
a.
The Agency shall evaluate the Health Plan’s QIP and PMs at least one (1) time
per year at dates to be determined by the Agency, or as otherwise specified by
this Contract.

 
b.
The Health Plan, in conjunction with the Agency, shall participate in workgroups
to design additional QI strategies and to learn to use the best practice methods
for enhancing the quality of health care provided to Enrollees.

 
c.
If the PIPs, CAHPS, the PMs, the annual Medical Record audit or the EQRO
indicate that the Health Plan's performance is not acceptable, then the Agency
may restrict the Health Plan’s Enrollment activities including, but not limited
to, termination of Mandatory Assignments.

 
d.
If the Agency determines that the Health Plan’s performance is not acceptable,
the Agency shall require the Health Plan to submit a corrective action plan
(CAP). If the Health Plan fails to provide a CAP within the time specified by
the Agency, the Agency shall sanction the Health Plan, in accordance with the
provisions of Section XIV, Sanctions, and may immediately terminate all
Enrollment activities and Mandatory Assignments. When considering whether to
impose a limitation on Enrollment activities or Mandatory Assignments, the
Agency may take into account the Health Plan’s cumulative performance on all QI
activities.

 
e.
Annual Medical Record Audit

 
(1)
The Health Plan shall furnish specific data requested by the Agency in order to
conduct the Medical Record audit.

 
(2)
If the Medical Record audit indicates that quality of care is not acceptable,
pursuant to contractual requirements, the Agency shall sanction the Health Plan,
in accordance with the provisions of Section XIV, Sanctions, and may immediately
terminate all Enrollment activities and Mandatory Assignments, until the Health
Plan attains an acceptable level of quality of care as determined by the Agency.

 
f.
Independent Medical Record Review by an EQRO

 
(1)
The Health Plan shall provide all information requested by the EQRO and/or the
Agency, including, but not limited to quality outcomes concerning timeliness of,
and Enrollee access to, Covered Services.

 
(2)
The Health Plan shall cooperate with the EQRO during the Medical Record review,
which will be done at least one (1) time per year.

 
(3)
If the EQRO indicates that the Quality of care is not within acceptable limits
set forth in this Contract, the Agency shall sanction the Health Plan, in
accordance with the provisions of Section XIV, Sanctions and may immediately
terminate all Enrollment activities and Mandatory Assignments until the Health
Plan attains a satisfactory level of Quality of care as determined by the EQRO.

B.
Utilization Management (UM)

 
1.
General Requirements

The UM program shall be consistent with 42 CFR 456 and include, but not be
limited to:

 
a.
Procedures for identifying patterns of over-utilization and under-utilization by
Enrollees and for addressing potential problems identified as a result of these
analyses.

 
b.
The Health Plan shall report Fraud and Abuse information identified through the
Utilization Management program to the Agency’s contract manager, MPI and MFCU as
described in Section X, and referenced in 42 CFR 455.1(a)(1).

 
c.
A procedure for Enrollees to obtain a second medical opinion and that the Health
Plan shall be responsible for authorizing claims for such services in accordance
with Section 641.51, F.S.

 
d.
Service Authorization protocols for Prior Authorization and denial of services;
the process used to evaluate prior and con-current authorization; mechanisms to
ensure consistent application of review criteria for authorization decisions;
consultation with the requesting Provider when appropriate, Hospital discharge
planning, physician profiling; and a retrospective review of both inpatient and
ambulatory claims, meeting the predefined criteria below. The Health Plan shall
be responsible for ensuring the consistent application of review criteria for
authorization decisions and consulting with the requesting Provider when
appropriate.

 
(1)
The Health Plan must have written approval from the Agency for its Service
Authorization protocols and for any changes to the original protocols.

 
(2)
The Health Plan's Service Authorization systems shall provide the authorization
number and effective dates for authorization to Providers and non-participating
providers.

 
(3)
The Health Plan's Service Authorization systems shall provide written
confirmation of all denials of authorization to providers (See 42 CFR
438.210(c)).

 
(a)
The Health Plan may request to be notified, but shall not deny claims payment
based solely on lack of notification, for the following:

 
(i)
Inpatient emergency admissions (within ten (10) days);

 
(ii)
Obstetrical care (at first visit);

 
(iii)
Obstetrical admissions exceeding forty-eight (48) hours for vaginal delivery and
ninety-six (96) hours for caesarean section; and

 
(iv)
Transplants.

 
(b)
The Health Plan shall ensure that all decisions to deny a Service Authorization
request, or limit a service in amount, duration, or scope that is less than
requested, are made by Health Care Professionals who have the appropriate
clinical expertise in treating the Enrollee’s condition or disease (see 42 CFR
438.210(b)(3)).

 
(4)
Only a licensed psychiatrist may authorize a denial for an initial or concurrent
authorization of any request for Behavioral Health Services. The psychiatrist's
review shall be part of the UM process and not part of the clinical review,
which may be requested by a Provider or the Enrollee, after the issuance of a
denial.

 
(5)
The Health Plan shall provide post authorization to CHDs for the provision of
emergency shelter medical screenings provided for clients of DCF.

 
(6)
Health Plans with automated authorization systems may not require paper
authorization as a condition of receiving treatment.

 
2.
Certain Public Providers

 
a.
The Health Plan shall authorize all claims, from a CHD, a migrant health center
funded under Section 329 of the Public Health Services Act or a community health
center funded under Section 330 of the Public Health Services Act, without Prior
Authorization for the following:

 
(1)
The diagnosis and treatment of sexually transmitted diseases and other
communicable diseases, such as tuberculosis and human immunodeficiency syndrome;

 
(2)
The provision of immunizations;

 
(3)
Family planning services and related pharmaceuticals;

 
(4)
School health services listed in (1), (2) and (3) above, and for services
rendered on an urgent basis by such providers; and,

 
(5)
In the event that a vaccine-preventable disease emergency is declared, the
Health Plan shall authorize claims from the CHD for the cost of the
administration of vaccines.

 
b.
The providers specified in Section VIII.B.2.a., above, shall attempt to contact
the Health Plan before providing health care services to Enrollees. Such
providers shall provide the Health Plan with the results of the office visit,
including test results.

 
c.
The Health Plan shall not deny claims for services delivered by the providers
specified in Section VIII.B.2.a., above solely based on the period between the
date of service and the date of clean claim submission, unless that period
exceeds 365 Calendar Days, and shall be reimbursed by the Health Plan at the
rate negotiated between the Health Plan and the public provider or the Medicaid
Fee-for-Service rate.

 
3.
Notice of Action

 
a.
The Health Plan shall notify the Enrollee, in writing, using language at, or
below the fourth (4th) grade reading level, of any Action taken by the Health
Plan to deny a Service Authorization request, or limit a service in an amount,
duration, or scope that is less than requested.

 
b.
The Health Plan must provide notice to the Enrollee as set forth below (see 42
CFR 438.404(a) and (c) and 42 CFR 438.210(b) and (c)):

 
(1)
The Action the Health Plan has taken or intends to take;

 
(2)
The reasons for the Action, customized for the circumstances of the Enrollee;

 
(3)
The Enrollee’s or the Provider's (with written permission of the Enrollee) right
to file an Appeal;

 
(4)
The procedures for filing an Appeal;

 
(5)
The circumstances under which expedited resolution is available and how to
request it; and

 
(6)
The Enrollee’s rights to request that Benefits continue pending the resolution
of the Appeal, how to request that Benefits be continued, and the circumstances
under which the Enrollee may be required to pay the costs of these services.

 
c.
The Health Plan must provide the notice of Action within the following time
frames:

 
(1)
At least ten (10) Calendar Days before the date of the Action or fifteen (15)
Calendar Days if the notice is sent by Surface Mail (five [5] Calendar Days if
the Health Plan suspects Fraud on the part of the Enrollee). See 42 CFR 431.211,
42 CFR 431.213 and 42 CFR 431.214.

 
(2)
For denial of the claim, at the time of any Action affecting the claim.

 
(3)
For standard Service Authorization decisions that deny or limit services, as
quickly as the Enrollee’s health condition requires, but no later than fourteen
(14) Calendar Days following receipt of the request for service (see 42 CFR
438.201(d)(1)).

 
(4)
If the Health Plan extends the time frame for notification, it must:

 
(a)
Give the Enrollee written notice of the reason for the extension and inform the
Enrollee of the right to file a Grievance if the Enrollee disagrees with the
Health Plan’s decision to extend the time frame; and

 
(b)
Carry out its determination as quickly as the Enrollee's health condition
requires, but in no case later than the date upon which the fourteen (14)
Calendar Day extension period expires (see 42 CFR 438.210(d)(1)).

 
(5)
If the Health Plan fails to reach a decision within the time frames described
above, the failure on the part of the Health Plan shall be considered a denial
and is an Action adverse to the Enrollee (See 42 CFR 438.210(d)).

 
(6)
For expedited Service Authorization decisions, within three (3) Business Days
(with the possibility of a fourteen (14) Calendar Day extension). See 42 CFR
438.210(d)(2).

 
(7)
The Health Plan shall provide timely approval or denial of authorization of
out-of-network use through the assignment of a Prior Authorization number, which
refers to and documents the approval. The Health Plan shall provide written
follow-up documentation of the approval or the denial to the out-of-network
provider within five (5) Business Days from the request for approval.

 
(8)
The Health Plan shall determine when exceptional referrals to out-of-network
specially qualified providers are needed to address the unique medical needs of
an Enrollee (e.g., when an Enrollee’s medical condition requires testing by a
geneticist). The Health Plan shall develop and maintain policies and procedures
for such referrals.

 
4.
Care Management

 
a.
The Health Plan shall be responsible for the management of medical care and
continuity of care for all Enrollees. The Health Plan shall maintain written
Case Management and continuity of care protocols that include the following
minimum functions:

 
(1)
Appropriate referral and scheduling assistance of Enrollees needing specialty
health care/Transportation Services, including those identified through Child
Health Check-Up Program (CHCUP) Screenings;

 
(2)
Determination of the need for Non-Covered Services and referral of the Enrollee
for assessment and referral to the appropriate service setting (to include
referral to WIC and Healthy Start) utilizing assistance as needed by the area
Medicaid office;

 
(3)
Case Management follow-up services for Children/Adolescents, who the Health Plan
identifies through blood Screenings as having abnormal levels of lead;

 
(4)
Coordinated Hospital/institutional discharge planning that includes
post-discharge care, including skilled, short-term, skilled nursing facility
care, as appropriate; and

 
(5)
A mechanism for direct access to specialists for Enrollees identified as having
special health care needs, as is appropriate for their condition and identified
needs.

 
(6)
The Health Plan shall have an outreach program and other strategies for
identifying every pregnant Enrollee. This shall include case management, claims
analysis, and use of health risk assessment, etc. The Health Plan shall require
its participating Providers to notify the Health Plans of any Medicaid Enrollee
who is identified as being pregnant.

 
(7)
Documentation of referral services in Enrollees’ Medical Records, including
results.

 
(8)
Monitoring of Enrollees with ongoing medical conditions and coordination of
services for high utilizers such that the following functions are addressed as
appropriate: acting as a liaison between the Enrollee and Providers, ensuring
the Enrollee is receiving routine medical care, ensuring that the Enrollee has
adequate support at home, assisting Enrollees who are unable to access necessary
care due to their medical or emotional conditions or who do not have adequate
community resources to comply with their care, and assisting the Enrollee in
developing community resources to manage the Enrollee’s medical condition.

 
(9)
Documentation of emergency care encounters in Enrollees’ Medical Records with
appropriate medically indicated follow-up.

 
(10)
Coordination of hospital/institutional discharge planning that includes
post-discharge care, including skilled short-term rehabilitation, and skilled
nursing facility care, as appropriate.

 
(11)
Share with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its
identification and assessment of any Enrollee with special health care needs so
that those activities need not be duplicated.

 
(12)
Ensure that in the process of coordinating care, each Enrollee's privacy is
protected consistent with the confidentiality requirements in 45 CFR parts 160
and 164. 45 CFR Part 164 specifically describes the requirements regarding the
privacy of individually identifiable health information.

 
5.
New Enrollee Procedures

 
a.
The Health Plan shall not delay Service Authorization if written documentation
is not available in a timely manner.

 
b.
The Health Plan shall contact each new Enrollee at least two (2) times, if
necessary, within ninety (90) Calendar Days of the Enrollee's Enrollment to
schedule the Enrollee's initial appointment with his/her PCP for the purpose of
obtaining a health risk assessment and/or CHCUP Screening. For this subsection,
"contact" is defined as mailing a notice to, or telephoning, an Enrollee at the
most recent address or telephone number available.

 
c.
The Health Plan shall urge Enrollees to see their PCPs within 180 Calendar Days
of Enrollment.

 
d.
The Health Plan shall contact each new Enrollee within thirty (30) Calendar Days
of Enrollment to request that the Enrollee authorize the release of his or her
Medical Records (including those related to Behavioral Health Services) to the
Health Plan, or the Health Plan's health services Subcontractor, from those
providers who treated the Enrollee prior to the Enrollee's Enrollment with the
Health Plan. Also, the Health Plan shall request or assist the Enrollee's new
PCP by requesting the Enrollee's Medical Records from the Enrollee’s previous
providers.

 
e.
The Health Plan shall use the Enrollee's health risk assessments and/or released
Medical Records to identify Enrollees who have not received CHCUP Screenings in
accordance with the Agency approved periodicity schedule.

 
f.
The Health Plan shall contact, up to two (2) times if necessary, any Enrollee
more than two (2) months behind in the Agency approved periodicity Screening
schedule to urge those Enrollees, or their legal representatives, to make an
appointment with the Enrollees' PCPs for a Screening visit.

 
g.
Within thirty (30) Calendar Days of Enrollment, the Health Plan shall notify
Enrollees of, and ensure the availability of, a Screening for all Enrollees
known to be pregnant or who advise the Health Plan that they may be pregnant.
The Health Plan shall refer Enrollees who are, or may be, pregnant to the
appropriate Provider stating that the Enrollee can obtain appropriate prenatal
care.

 
h.
The Health Plan shall honor any written documentation of Prior Authorization of
ongoing Covered Services for a period of thirty (30) Business Days after the
effective date of Enrollment, or until the Enrollee's PCP reviews the Enrollee's
treatment plan for the following types of Enrollees:

 
(1)
Enrollees who voluntarily enrolled; and

 
(2)
Those Enrollees who were automatically reenrolled after regaining Medicaid
eligibility.

 
i.
For Mandatory Assignment Enrollees, the Health Plan shall honor any written
documentation of Prior Authorization of ongoing services for a period of one (1)
month after the effective date of Enrollment or until the Mandatory Assignment
Enrollee's PCP reviews the Enrollee's treatment plan, whichever comes first.

 
j.
For all Enrollees, written documentation of Prior Authorization of ongoing
services includes the following, provided that the services were prearranged
prior to Enrollment with the Health Plan:

 
(1)
Prior existing orders;

 
(2)
Provider appointments, e.g. dental appointments, surgeries, etc.; and

 
(3)
Prescriptions (including prescriptions at non-participating pharmacies).

 
k.
The Health Plan shall not delay Service Authorization if written documentation
is not available in a timely manner. The Health Plan is not required to approve
claims for which it has received no written documentation.

 
l.
The Health Plan shall not deny claims submitted by an out-of-network provider
solely based on the period between the date of service and the date of clean
claim submission, unless that period exceeds 365 days.

m. The Enrollee's guardian, next of kin or legally authorized responsible person
is permitted to act on the Enrollee's behalf in matters relating to the
Enrollee's Enrollment, plan of care, and/or provision of services, if the
Enrollee: 

 
(1)
Was adjudicated incompetent in accordance with the law;

 
(2)
Is found by his or her Provider to be medically incapable of understanding his
or her rights; or

 
(3)
Exhibits a significant communication barrier.

 
n.
The Health Plan shall take immediate action to address any identified urgent
medical needs. "Urgent medical needs" means any sudden or unforeseen situation
which requires immediate action to prevent hospitalization or nursing home
placement. Examples include hospitalization of spouse or caregiver or increased
impairment of an Enrollee living alone who suddenly cannot manage basic needs
without immediate help, hospitalization or nursing home placement.

 
6.
Incentive Programs

 
a.
The Health Plan may offer incentives for Enrollees to receive preventive care
services. The Health Plan shall receive written approval from the Agency before
offering any incentives. The Health Plan shall make all incentives available to
all Enrollees. The Health Plan shall not use incentives to direct individuals to
select a particular Provider.

 
b.
The Health Plan may inform Enrollees, once they are enrolled, about the specific
incentives available.

 
c.
The Health Plan shall not include the provision of gambling, alcohol, tobacco or
drugs in any of the Health Plan's incentives.

 
d.
The Health Plan's incentives shall have some health or child development related
function (e.g., clothing, food, books, safety devices, infant care items,
magazine subscriptions to publications which devote at least ten percent (10%)
of their copy to health related subjects, membership in clubs advocating
educational advancement and healthy lifestyles, etc.). Incentive dollar values
shall be in proportion to the importance of the health service to be utilized
(e.g., a T-shirt for attending one (1) prenatal class, but a car seat for
completion of a series of classes).

 
e.
Incentives shall be limited to a dollar value of ten dollars ($10.00), except in
the case of incentives for the completion of a series of services, health
education classes or other educational activities, in which case the incentive
shall be limited to a dollar value of fifty dollars ($50.00). The Agency will
allow a special exception to the dollar value relating to infant car seats,
strollers, and cloth baby carriers or slings.

 
f.
The Health Plan shall not include in the dollar limits on incentives any money
spent on the transportation of Enrollees to services or child care provided
during the provision of services.

 
g.
The Health Plan may offer an Agency approved program for pregnant women in order
to encourage the commencement of prenatal care visits in the first (1st)
trimester of pregnancy. The Health Plan’s prenatal and postpartum care Incentive
Program must be aimed at promoting early intervention and prenatal care to
decrease infant mortality and low birth weight and to enhance healthy birth
outcomes. The prenatal and postpartum incentives may include the provision of
maternity and health related items and education.

 
h.
The Health Plan's request for approval of all incentives shall contain a
detailed description of the incentive and its mission.

 
7.
Practice Guidelines

 
a.
The Health Plan shall 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 a particular field;

 
(2)
Consider the needs of the Enrollees;

 
(3)
Are adopted in consultation with Providers; and

 
(4)
Are reviewed and updated periodically, as appropriate (See 42 CFR 438.236(b)).

 
b.
The Health Plan shall disseminate any revised practice guidelines to all
affected Providers and, upon request, to Enrollees and Potential Enrollees.

 
c.
The Health Plan shall ensure consistency with regard to all decisions relating
to UM, Enrollee education, Covered Services and other areas to which the
practice guidelines apply.

9.  Changes to Utilization Management Components 

 
a.
The Health Plan shall provide no less than thirty (30) Calendar Days written
notice before making any changes to the administration and/or management
procedures and/or authorization, denial or review procedures, including any
delegations, as described in this section.

 
10.
Out-of-Plan Use of Non-Emergency Services

 
a.
Unless otherwise specified in this Contract, where an Enrollee utilizes services
available under the Health Plan other than Emergency Services from a
non-participating provider, the Health Plan shall not be liable for the cost of
such utilization unless the Health Plan referred the Enrollee to the
non-participating provider or authorized such out-of-network utilization. The
Health Plan shall provide timely approval or denial of authorization of
out-of-network use through the assignment of a prior authorization number, which
refers to and documents the approval. The Health Plan may not require paper
authorization as a condition of receiving treatment if the Health Plan has an
automated authorization system. Written follow up documentation of the approval
must be provided to the out-of-network provider within one (1) Business Day from
the request for approval. The Enrollee shall be liable for the cost of such
unauthorized use of Covered Services from non-participating providers.

 
b.
In accordance with Section 409.912, F.S., the Health Plan shall reimburse any
hospital or physician that is outside the Health Plan’s authorized Service Area
for Health Plan authorized services provided by the hospital or physician to
Enrollees at a rate negotiated with the hospital or physician for the provision
of services or according to the lesser of the following:

 
(1)
The usual and customary charge made to the general public by the hospital or
physician; or

 
(2)
The Florida Medicaid reimbursement rate established for the hospital or
physician.

 
c.
The Health Plan shall reimburse all out-of-network providers pursuant to Section
641.3155, F.S.

 
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Section IX
Grievance System

 
A.
General Requirements

 

 
1.
The Health Plan shall have a Grievance System in place that includes a Grievance
process, an Appeal process and access to the Medicaid Fair Hearing system. The
Health Plan’s Grievance System shall comply with the requirements set forth in
Section 641.511, F.S., if applicable and with all applicable federal and State
laws and regulations, including 42 CFR 431.200 and 42 CFR 438, Subpart F,
“Grievance System.”

 
2.
The Health Plan must develop and maintain written policies and procedures
relating to the Grievance System and must provide its Grievance Procedures to
the Agency for approval. Before implementation, the Agency must give the Health
Plan written approval of the Health Plan’s Grievance System policies and
procedures.

 
3.
The Health Plan shall refer all Enrollees and/or providers, on behalf of the
Enrollee, (whether the provider is a participating Provider or a
nonparticipating provider) who are dissatisfied with the Health Plan or its
Actions to the Health Plan’s Grievance/Appeal Coordinator for processing and
documentation in accordance with this Contract and the Health Plan's
Agency-approved policies and procedures.

 
4.
The Health Plan's Grievance System must include an additional grievance
resolution process, as set forth in Section 408.7056, F.S., and referred to in
this Contract as the Subscriber Assistance Program (SAP).

 
5.
The Health Plan must give Enrollees reasonable assistance in completing forms
and other procedural steps, including, but not limited to, providing interpreter
services and toll-free numbers with TTY/TDD and interpreter capability.

 
6.
The Health Plan must acknowledge, in writing, receipt of Appeal, unless the
Enrollee or provider requests an expedited resolution.

 
7.
The Health Plan shall ensure that none of the decision makers on a Grievance or
Appeal were involved in any of the previous levels of review or decision-making
and that all decision makers are health care professionals with clinical
expertise in treating the Enrollee's condition or disease when deciding any of
the following:

a. An Appeal of a denial that is based on lack of Medical Necessity;

 
b.
A Grievance regarding the denial of an expedited resolution of an Appeal; and

c. A Grievance or Appeal that involves clinical issues.

 
8.
The Health Plan shall allow the Enrollee, and/or the Enrollee's representative,
an opportunity to examine the Enrollee's case file before and during the Appeal
process, including all medical records and any other documents and records.

 
9.
The Health Plan shall consider the Enrollee, the Enrollee's representative or
the representative of a deceased Enrollee's estate as parties to the
Grievance/Appeal.

 
10.
The Health Plan shall include information (including all related policies,
procedures and time frames) regarding Grievances, Appeals and Medicaid Fair
Hearings in the Health Plan's Provider Manual. The Health Plan shall provide a
copy of the Provider Manual to all Providers/Subcontractors at the time the Plan
enters into agreements with said Providers/Subcontractors.

 

 
11.
The Enrollee Handbook and the Provider Manual must clearly specify all necessary
procedural steps for filing Grievances, Appeals and Medicaid Fair Hearings, as
set forth in Section IV.A.2. and 4., above, including:

 
a.
Enrollee rights to file Grievances and Appeals and all requirements and time
frames for filing Grievances and Appeals.

 
b.
The Health Plan's Grievances and Appeals Coordinator’s address, toll-free
telephone number and office hours.

 
c.
The availability of assistance to Enrollees in filing Grievances, Appeals and
Medicaid Fair Hearings.

 
d.
Enrollee rights to a Medicaid Fair Hearing and the method for obtaining a
Medicaid Fair Hearing, including the address for pursuing a Medicaid Fair
Hearing:

Office of Public Assistance Appeals Hearings
1317 Winewood Boulevard, Building 5, Room 203
Tallahassee, FL 32399-0700

 
e.
The rules that govern representation at the Medicaid Fair Hearing.

 
f.
A statement explaining the Enrollee's right to request a continuation of
benefits during an Appeal and/or Medicaid Fair Hearing and a statement that if
the Health Plan's Action is upheld in any Medicaid Fair Hearing, the Health Plan
may hold the Enrollee liable for the cost of any continued Benefits.

 
g.
A detailed explanation of the proper procedure for an Enrollee to request a
continuation of benefits during an Appeal and/or Medicaid Fair Hearing.

 
h.
An explanation regarding the Enrollee's rights to appeal to the Agency and the
SAP after exhausting the Health Plan's Appeal/Grievance process, with the
following exception: pursuant to Sections 408.7056 and 641.511, F.S., the SAP
will not consider a Grievance or Appeal taken to a Medicaid Fair Hearing.

 
i.
The information set forth in the Enrollee Handbook and the Provider Manual must
explain that an Enrollee must request a review by the SAP within one (1) year of
receipt of the final decision letter from the Health Plan, must explain how to
initiate a review by the SAP and must include the SAP's address and telephone
number:

Agency for Health Care Administration
Subscriber Assistance Program
Building 1, MS #26
2727 Mahan Drive, Tallahassee, Florida 32308
(850) 921-5458
(888) 419-3456 (toll-free)

 
12.
The Health Plan shall maintain a record/log of all Grievances, Appeals and
Medicaid Fair Hearings in accordance with the terms of this Contract and to
fulfill the reporting requirements as set forth in Section XII, Reporting
Requirements.

B.
The Grievance Process

 
1.
The Grievance process is the Health Plan's procedure for addressing Enrollee
Grievances, which are expressions of dissatisfaction about any matter other than
Action.

 
2.
An Enrollee may file a Grievance, or a provider (whether a participating
Provider or a nonparticipating provider), acting on behalf of the Enrollee and
with the Enrollee's written consent, may file a Grievance.

 
3.
The Health Plan must complete the Grievance process in time to permit the
Enrollee's disenrollment to be effective in accordance with the time frames
specified in 42 CFR 438.56(e)(1).

 
4.
General Health Plan Duties

a. The Health Plan must:

 
(1)
Resolve each Grievance within State-established time frames not to exceed ninety
(90) Calendar Days from the day the Health Plan received the initial Grievance
request, be it oral or in writing;

 
(2)
Notify the Enrollee, in writing, within ninety (90) Calendar Days of the
resolution of the Grievance. The notice of disposition shall include the results
and date of the resolution of the Grievance, and for decisions not wholly in the
Enrollee's favor, the notice of disposition shall include:

 
(a)
Notice of the right to request a Medicaid Fair Hearing if applicable;

 
(b)
Information necessary to allow the Enrollee/provider to request a Medicaid Fair
Hearing, including the contact information necessary to pursue a Medicaid Fair
Hearing (see Section IX.D., below);

 
(3)
Provide the Agency with a copy of the written notice of disposition upon
request; and

 
(4)
Ensure that no punitive action is taken against a provider who files a Grievance
on behalf of an Enrollee, or supports an Enrollee's Grievance.

 
b.
The Health Plan may extend the Grievance resolution time frame by up to fourteen
(14) Calendar Days if the Enrollee requests an extension, or the Health
Plan documents that there is a need for additional information and that the
delay is in the Enrollee's best interest.

 
(1)
If the extension is not requested by the Enrollee, the Health Plan must give the
Enrollee written notice of the reason for the delay.

c. Filing Requirements

 
(1)
The Enrollee or provider may file a Grievance within one (1) year after the date
of occurrence that initiated the Grievance.

 
(2)
The Enrollee or provider may file a Grievance either orally or in writing. An
oral request may be followed up with a written request, however the timeframe
for resolution begins the date the plan receives the oral request.

C.
The Appeal Process 

 
1.
The Appeal process is the Health Plan's procedure for addressing Enrollee
Appeals, which are requests for review of an Action.

 
2.
An Enrollee, or a provider (whether a participating Provider or a
nonparticipating provider) acting on behalf of an Enrollee and with the
Enrollee's written consent, may file an Appeal.

 
3.
The Appeal procedure must be the same for all Enrollees.

 
4.
General Health Plan Duties

a. The Health Plan shall:

 
(1)
Confirm in writing all oral inquiries seeking an Appeal, unless the Enrollee or
provider requests an expedited resolution;

 
(2)
If the resolution is in favor of the Enrollee, provide the services as quickly
as the Enrollee's health condition requires;

 
(3)
Provide the Enrollee or provider with a reasonable opportunity to present to
evidence and allegations of fact or law, in person and/or in writing;

 
(4)
Allow the Enrollee, and/or the Enrollee's representative, an opportunity, before
and during the Appeal process, to examine the Enrollee's case file, including
all Medical Records and any other documents and records;

 
(5)
Consider the Enrollee, the Enrollee's representative or the representative of a
deceased Enrollee's estate as parties to the Appeal;

 
(6)
Continue the Enrollee's Benefits if:

 
(a)
The Enrollee files the Appeal in a timely manner, meaning on or before the later
of the following:

 
(i)
Within ten (10) Business Days of the date on the notice of Action (add five [5]
Business Days if the notice is sent via Surface Mail); or

 
(ii)
The intended effective date of the Health Plan’s proposed Action.

 
(b)
The Appeal involves the termination, suspension or reduction of a previously
authorized course of treatment;

 
(c)
The services were ordered by an authorized provider;

     

 
(d)
The authorization period has not expired; and/or

 
(e)
The Enrollee requests extension of Benefits.

 
(7)
Provide written notice of the resolution of the Appeal, including the results
and date of the resolution within two (2) business days after the resolution.
For decisions not wholly in the Enrollee's favor, the notice of resolution shall
include:

 
(a)
Notice of the right to request a Medicaid Fair Hearing;

 
(b)
Information about how to request a Medicaid Fair Hearing, including the DCF
address necessary for pursuing a Medicaid Fair Hearing, as set forth in Section
IX.D., below;

 
(c)
Notice of the right to continue to receive Benefits pending a Medicaid Fair
Hearing;

 
(d)
Information about how to request the continuation of Benefits;

 
(e)
Notice that if the Health Plan's Action is upheld in a Medicaid Fair Hearing,
the Enrollee may be liable for the cost of any continued Benefits; and

 
(f)
Pursuant to Section 408.7056, F.S., the Health Plan must notify the
Enrollee/provider that if the Appeal is not resolved to the satisfaction of the
Enrollee/provider, the Enrollee/provider has one (1) year from the date of the
occurrence that initiated the Appeal in which to request review of the Health
Plan's decision concerning the Appeal by the SAP. The notice must explain how to
initiate such a review and include the address and toll-free telephone numbers
of the Agency and the SAP, as provided in Section IX.A.11(i), above.

 
(8)
Provide the Agency with a copy of the written notice of disposition upon
request; and

 
(9)
Ensure that punitive action is not taken against a provider who files an Appeal
on behalf of an Enrollee or supports an Enrollee's Appeal.

 
b.
If the Health Plan continues or reinstates the Enrollee’s Benefits while the
Appeal is pending, the Health Plan must continue providing the Benefits until
one (1) of the following occurs:

(1) The Enrollee withdraws the Appeal;

 
(2)
Ten (10) Business Days pass from the date of the Health Plan's notice of
resolution of the appeal if the resolution is adverse to the enrollee and if the
Enrollee has not requested a Medicaid Fair Hearing with continuation of Benefits
until a Medicaid Fair Hearing decision is reached.

(3) The Medicaid Fair Hearing panel's decision is adverse to the Enrollee; or

 
(4)
The authorization to provide services expires, or the Enrollee meets the
authorized service limits.

 
c.
If the final resolution of the Appeal is adverse to the Enrollee, the Health
Plan may recover the costs of the services furnished from the Enrollee while the
Appeal was pending, to the extent that the services were furnished solely
because of the requirements of this Section.

 
d.
If services were not furnished while the Appeal was pending and the Appeal panel
reverses the Plan's decision to deny, limit or delay services, the Health Plan
must authorize or provide the disputed services promptly and as quickly as the
Enrollee's health condition requires.

 
e.
If the services were furnished while the Appeal was pending and the Appeal panel
reverses the Plan's decision to deny, limit or delay services, the Health Plan
must pay for disputed services in accordance with State policy and regulations.

5. Filing Requirements

 
a.
The Enrollee/provider must file an Appeal within thirty (30) Calendar Days of
receipt of the notice of the Health Plan's Action

 
b.
The Enrollee/provider may file an Appeal either orally or in writing. If the
filing is oral, the Enrollee/provider must also file a written, signed Appeal
within thirty (30) Calendar Days of the oral filing. The Health Plan shall
notify the requesting party that it must file the written request within ten
(10) Business Days after receipt of the oral request. For oral filings, time
frames for resolution of the Appeal begin on the date the Health Plan receives
the oral filing.

 
c.
The Health Plan shall resolve each Appeal within State-established time frames
not to exceed forty-five (45) Calendar Days from the day the Plan received the
initial Appeal request, whether oral or in writing.

 
d.
If the resolution is in favor of the Enrollee, the Health Plan shall provide the
services as quickly as the Enrollee's health condition requires.

 
e.
The Health Plan may extend the resolution time frames by up to fourteen (14)
Calendar Days if the Enrollee requests an extension, or the Health Plan
documents that there is a need for additional information and that the delay is
in the Enrollee's best interest.

 
(1)
If the extension is not requested by the Enrollee, the Health Plan must give the
Enrollee written notice of the reason for the delay.

 
(2)
The Health Plan must provide written notice of the extension to the Enrollee
within five (5) Business Days of determining the need for an extension.

6. Expedited Process

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

 
b.
The Enrollee/provider may file an expedited Appeal either orally or in writing.
No additional written follow-up on the part of the Enrollee/provider is required
for an oral request for an expedited Appeal.

c. The Health Plan must:

 
(1)
Inform the Enrollee of the limited time available for the Enrollee to present
evidence and allegations of fact or law, in person and in writing;

 
(2)
Resolve each expedited Appeal and provide notice to the Enrollee, as quickly as
the Enrollee's health condition requires, within State established time frames
not to exceed seventy-two (72) hours after the Health Plan receives the Appeal
request, whether the Appeal was made orally or in writing;

 
(3)
Provide written notice of the resolution in accordance with Section IX. C.7. of
the expedited Appeal to the Enrollee;

 
(4)
Make reasonable efforts to provide oral notice of disposition to the Enrollee
immediately after the Appeal panel renders a decision; and

 
(5)
Ensure that punitive action is not taken against a provider who requests an
expedited resolution on the Enrollee's behalf or supports an Enrollee's request
for expedited resolution of an Appeal.

 
d.
If the Health Plan denies a request for an expedited resolution of an Appeal,
the Health Plan must:

 
(1)
Transfer the Appeal to the standard time frame of no longer than forty-five (45)
Calendar Days from the day the Health Plan received the request for Appeal (with
a possible fourteen [14] day extension);

 
(2)
Make all reasonable efforts to provide immediate oral notification of the Health
Plan's denial for expedited resolution of the Appeal;

 
(3)
Provide written notice of the denial of the expedited Appeal within two (2)
Calendar Days; and

(4) Fulfill all requirements set forth in Section IX.C.1 - 5, above.

 
7.
Submission to the Subscriber Assistance Program (SAP)

 
(1)
Before filing with the SAP, the Enrollee/provider must complete the Health
Plan’s Appeal process.

 
(2)
The Enrollee/provider must submit the Appeal to the SAP within one (1) year of
the date of the occurrence that initiated the Appeal.

 
(3)
The SAP will not consider a Grievance or Appeal taken to a Medicaid Fair
Hearing.

D.
Medicaid Fair Hearing System

 
1.
As set forth in Rule 65-2.042, FAC, the Health Plan's Grievance Procedure and
Appeal and Grievance processes shall state that the Enrollee has the right to
request a Medicaid Fair Hearing, in addition to, and at the same time as,
pursuing resolution through the Health Plan's Grievance and Appeal processes.

 
a.
A provider must have an Enrollee's written consent before requesting a Medicaid
Fair Hearing on behalf of an Enrollee.

 
b.
The parties to a Medicaid Fair Hearing include the Health Plan, as well as the
Enrollee, his/her representative or the representative of a deceased Enrollee's
estate.

2. Filing Requirements

 
a.
The Enrollee/provider may request a Medicaid Fair Hearing within ninety (90)
days of the date of the notice of the Health Plan's resolution of the Enrollee’s
Grievance/Appeal by contacting DCF at:

The Office of Appeal Hearings
1317 Winewood Boulevard, Building 5, Room 203
Tallahassee, Florida 32399-0700

3. General Health Plan Duties

a. The Health Plan must:

 
(1)
Continue the Enrollee's Benefits while the Medicaid Fair Hearing is pending if:

 
(a)
The Medicaid Fair Hearing is filed timely, meaning on or before the later of the
following:

 
(i)
Within ten (10) Business Days of the date on the notice of Action (add five [5]
Business Days if the notice is sent via Surface Mail);

 
(ii)
The intended effective date of the Health Plan's proposed Action.

 
(b)
The Medicaid Fair Hearing involves the termination, suspension or reduction of a
previously authorized course of treatment;

(c) The services were ordered by an authorized provider;

(d) The authorization period has not expired; and/or

(e) The Enrollee requests extension of Benefits.

 
(2)
Ensure that punitive action is not taken against a provider who requests a
Medicaid Fair Hearing on an Enrollee's behalf or supports an Enrollee's request
for a Medicaid Fair Hearing.

 
b.
If the Health Plan continues or reinstates Enrollee Benefits while the Medicaid
Fair Hearing is pending, the Health Plan must continue said Benefits until one
(1) of the following occurs:

 
(1)
The Enrollee withdraws the request for a Medicaid Fair Hearing;

 
(2)
Ten (10) Business Days pass from the date of the Health Plan's notice of
resolution of the appeal if the resolution is adverse to the enrollee and the
Enrollee has not requested a Medicaid Fair Hearing with continuation of benefits
until a Medicaid Fair Hearing decision is reached (add five [5] Business Days if
the Health Plan sends the notice of Action by Surface Mail);

     

 
(3)
The Medicaid Fair Hearing officer renders a decision that is adverse to the
Enrollee; and/or

 
(4)
The Enrollee's authorization expires or the Enrollee reaches his/her authorized
service limits.

 
4.
If the final resolution of the Medicaid Fair Hearing is adverse to the Enrollee,
the Health Plan may recover the costs of the services furnished while the
Medicaid Fair Hearing was pending, to the extent that the services were
furnished solely because of the requirements of this Section.

 
5.
If services were not furnished while the Medicaid Fair Hearing was pending, and
the Medicaid Fair Hearing resolution reverses the Health Plan's decision to
deny, limit or delay services, the Health Plan must authorize or provide the
disputed services as quickly as the Enrollee's health condition requires.

 
6.
If the services were furnished while the Medicaid Fair Hearing was pending, and
the Medicaid Fair Hearing resolution reverses the Plan's decision to deny, limit
or delay services, the Health Plan must pay for disputed services in accordance
with State policy and regulations.

 
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Section X
 
Administration and Management
 

A.
General Provisions

 
1.
The Health Plan’s governing body shall set forth policy and has overall
responsibility for the organization of the Health Plan. The Health Plan shall be
responsible for the administration and management of all aspects of this
Contract, including all Subcontracts, employees, agents and services performed
by anyone acting for or on behalf of the Health Plan. The Health Plan shall have
a centralized executive administration, which shall serve as the contact point
for the Agency, except as otherwise specified in this Contract.

 
2.
The Health Plan shall be responsible for the administration and management of
all aspects of this Contract, such as, but not limited to, the delivery of
services, Provider network, Provider education, and claims resolution and
assistance.

 
3.
The Health Plan must provide that compensation to individuals or entities that
conduct utilization management activities is not structured so as to provide
incentives for the individual or entity to deny, limit, or discontinue Medically
Necessary services to any Enrollee.

B.
Staffing

 
1.
Minimum Staffing Requirements

 
a.
Contract Manager: The Health Plan shall designate a Contract Manager to work
directly with the Agency. The Contract Manager shall be a full-time employee of
the Health Plan with the authority to revise processes or procedures and assign
additional resources as needed to maximize the efficiency and effectiveness of
services required under the Contract. The Health Plan shall meet in person, or
by telephone, at the request of Agency representatives, but at least monthly, to
discuss the status of the Contract, Health Plan performance, benefits to the
State, necessary revisions, reviews, reports and planning. Summary reports shall
be developed and presented to the Agency, or its Agent, as specified.

 
b.
Full-Time Administrator: The Health Plan shall have a Full-Time Administrator
specifically identified to administer the day-to-day business activities of this
Contract. The Health Plan may designate the same person as the Contract Manager,
the Full-time Administrator, or the Medical Director, The Health Plan may
designate the same person as the Contract Manager, the Full-time Administrator,
or the Medical Director, but such person cannot be designated to any other
position in this section, including in other lines of business within the Health
Plan, unless otherwise approved by the Agency.

 
c.
Medical and Professional Support Staff: The Health Plan shall have Medical and
Professional Support Staff sufficient to conduct daily business in an orderly
manner, including having Enrollee services staff directly available during
business hours for Enrollee services consultation, as determined through
management and medical reviews. The Health Plan shall maintain sufficient
medical staff, available twenty-four (24) hours per day, seven (7) days per
week, to handle Emergency Services and Care inquiries. The Health Plan shall
maintain sufficient Medical and Professional Support Staff during non-business
hours, unless the Health Plan's computer system automatically approves all
Emergency Services and Care claims relating to Screening and treatment.

 
d.
Medical Director: The Health Plan shall have a full-time licensed physician to
serve as Medical Director to oversee and be responsible for the proper provision
of Covered Services to Enrollees, the Quality Management Program and the
Grievance System. The Medical Director shall be licensed in accordance with
Chapter 458 or 459, F.S. The Medical Director cannot be designated to serve in
any other non-administrative position. The Medical Director cannot be designated
to serve in any other non-administrative position.

 
e.
Medical Records Review Coordinator: A designated person, qualified by training
and experience, to ensure compliance with the Medical Records requirements as
described in this Contract. The Medical Records Review Coordinator shall
maintain Medical Record standards and conduct Medical Record reviews according
to the terms of this Contract.

 
f.
Data Processing and Data Reporting Coordinator: The Health Plan shall have a
person trained and experienced in data processing, data reporting, and claims
resolution, as required, to ensure that computer system reports that that the
Health Plan provides to the Agency and its Agents are accurate, and that
computer systems operate in an accurate and timely manner.

 
g.
Marketing Oversight Coordinator: If the Health Plan engages in Marketing, the
Health Plan shall have a designated person, qualified by training and
experience, to assure the Health Plan adheres to the marketing requirements of
this Contract.

 
h.
QI and UM Professional: The Health Plan shall have a designated person,
qualified by training and experience in QI and UM and who holds the appropriate
clinical certification and/or license.

 
i.
Grievance System Coordinator: The Health Plan shall have a designated person,
qualified by training and experience, to process and resolve Appeals and
Grievances and to be responsible for the Grievance System.

 
j.
Compliance Officer: The Health Plan shall have a designated person qualified by
training and experience, to oversee a Fraud and Abuse program to prevent and
detect potential Fraud and Abuse activities pursuant to State and federal rules
and regulations.

 
k.
Case Management Staff: The Health Plan shall have sufficient Case Management
Staff, qualified by training, experience and certification/licensure to conduct
the Health Plan's Case Management functions.

 
l.
Claims/Encounter Manager: The Health Plan shall have a designated person
qualified by training and experience to oversee claims and encounter submittal
and processing and to ensure the accuracy, timeliness and completeness of
processing payment and reporting.

 
2.
Behavioral Health Staff Requirements

 
a.
The Health Plan must name a staff member to maintain oversight responsibility
for Behavioral Health Services and to act as a liaison to the Agency.

 
b.
The Health Plan's Medical Director shall appoint a board certified, or board
eligible, licensed psychiatrist (staff psychiatrist) to oversee the provision of
Behavioral Health Services to Enrollees. The Health Plan may delegate this duty,
by way of a written Subcontract, to a third party.

 
c.
The Agency shall review and approve the Health Plan's Behavioral Health Services
staff and any Subcontracted Behavioral Health Care Providers in order to
determine the Health Plan's compliance with all licensure requirements.

C.
Provider Contract Requirements

 
1.
The Health Plan shall comply with all Agency procedures for Provider Contract
review and approval submission.

 
a.
All Provider Contracts must comply with 42 CFR 438.230.

 
b.
If the Health Plan is a capitated health plan, it shall ensure that all
Providers are eligible for participation in the Medicaid program. If a Provider
was involuntarily terminated from the Florida Medicaid program, other than for
purposes of inactivity, that Provider is not considered an eligible Medicaid
provider.

 
c.
The Health Plan shall not employ or contract with individuals on the State or
federal exclusions list.

 
d.
No Provider Contract which the Health Plan enters into with respect to
performance under Contract shall in any way relieve the Health Plan of any
responsibility for the provision of services duties under this Contract. The
Health Plan shall assure that all services and tasks related to the Provider
Contract are performed in accordance with the terms of this Contract. The Health
Plan shall identify in its Provider Contract any aspect of service that may be
subcontracted by the Provider.

 
e.
All model Provider Contracts and amendments must be submitted by the Health Plan
to the Agency for approval and the Health Plan must receive written approval by
the Agency prior to use.

 
2.
All Provider Contracts and amendments executed by the Health Plan must be in
writing, signed, and dated by the Health Plan and the Provider. All model and
executed Provider Contracts and amendments shall meet the following
requirements:

 
a.
Prohibit the Provider from seeking payment from the Enrollee for any Covered
Services provided to the Enrollee within the terms of the Contract;

 
b.
Require the Provider to look solely to the Health Plan for compensation for
services rendered, with the exception of nominal cost sharing, pursuant to the
State Medicaid Plan and the Florida Coverages and Limitations Handbooks,

 
c.
If there is a Health Plan physician incentive plan, include a statement that the
Health Plan shall make no specific payment directly or indirectly under a
physician incentive plan to a Provider as an inducement to reduce or limit
Medically Necessary services to an Enrollee, and that all incentive plans shall
not contain provisions which provide incentives, monetary or otherwise, for the
withholding of Medically Necessary care;

 
d.
Specify that any contracts, agreements, or subcontracts entered into by the
Provider for the purposes of carrying out any aspect of this Contract must
include assurances that the individuals who are signing the contract, agreement
or subcontract are so authorized and that it includes all the requirements of
this Contract;

 
e.
Require the Provider to cooperate with the Health Plan's peer review, grievance,
QIP and UM activities, and provide for monitoring and oversight, including
monitoring of services rendered to Enrollees, by the Health Plan (or its
Subcontractor) and for the Provider to provide assurance that all licensed
Providers are Credentialed in accordance with the Health Plan’s and the Agency’s
Credentialing requirements as found in Section VIII.A.3.h Credentialing and
Recredentialing, of this Contract, if the Health Plan has delegated the
Credentialing to a Subcontractor;

 
f.
Include provisions for the immediate transfer to another PCP or Health Plan if
the Enrollee's health or safety is in jeopardy;

 
g.
Not prohibit a Provider from discussing treatment or non-treatment options with
Enrollees that may not reflect the Health Plan's position or may not be covered
by the Health Plan;

 
h.
Not prohibit a Provider from acting within the lawful scope of practice, from
advising or advocating on behalf of an Enrollee for the Enrollee's health
status, medical care, or treatment or non-treatment options, including any
alternative treatments that might be self-administered;

 
i.
Not prohibit a Provider from advocating on behalf of the Enrollee in any
Grievance System or UM process, or individual authorization process to obtain
necessary health care services;

 
j.
Require Providers to meet appointment waiting time standards pursuant to this
Contract;

 
k.
Provide for continuity of treatment in the event a Provider Contract terminates
during the course of an Enrollee's treatment by that Provider;

 
l.
Prohibit discrimination with respect to 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 such
license or certification. This provision should not be construed as a willing
Provider law, as it does not prohibit the Health Plan from limiting provider
participation to the extent necessary to meet the needs of the Enrollees. This
provision does not interfere with measures established by the Health Plan that
are designed to maintain quality and control costs;

 
m.
Prohibit discrimination against Providers serving high-risk populations or those
that specialize in conditions requiring costly treatments;

 
n.
Require an adequate record system be maintained for recording services, charges,
dates and all other commonly accepted information elements for services rendered
to the Health Plan.

 
o.
Require that records be maintained for a period not less than five (5) years
from the close of the Contract, and retained further if the records are under
review or audit until the review or audit is complete. (Prior approval for the
disposition of records must be requested and approved by the Health Plan if the
Provider Contract is continuous.)

 
p.
Specify that DHHS, the Agency, MPI and MFCU, shall have the right to inspect,
evaluate, and audit all of the following related to this Contract:

 
(1)
Pertinent books,

 
(2)
Financial records,

 
(3)
Medical Records, and

 
(4)
Documents, papers, and records of any Provider involving financial transactions;

 
q.
Specify Covered Services and populations to be served under the Provider
Contract;

 
r.
Require that Providers comply with the Health Plan's cultural competency plan;

 
s.
Require that any marketing materials related to this Contract that are
distributed by the Provider be submitted to the Agency for written approval
before use;

 
t.
Provide for submission of all reports and clinical information required by the
Health Plan, including Child Health Check-Up reporting (if applicable);

 
u.
Require Providers of transitioning Enrollees to cooperate in all respects with
providers of other Health Plans to assure maximum health outcomes for Enrollees;

 
v.
Require Providers to submit notice of withdrawal from the network at least
ninety (90) Calendar Days prior to the effective date of such withdrawal;

 
w.
Require that all Providers agreeing to participate in the network as PCPs fully
accept and agree to perform the Case Management responsibilities and duties
associated with the PCP designation;

 
x.
Require all Providers to notify the Health Plan in the event of a lapse in
general liability or medical malpractice insurance, or if assets fall below the
amount necessary for licensure under Florida Statutes;

 
y.
Require Providers to offer hours of operation that are no less than the hours of
operation offered to commercial HMO members or comparable Medicaid FFS
Recipients if the Provider serves only Medicaid Recipients.

 
z.
Require safeguarding of information about Enrollees according to 42 CFR, Part
438.224.

 
aa.
Require compliance with HIPAA privacy and security provisions.

 
bb.
Require an exculpatory clause, which survives Provider agreement termination,
including breach of Provider Contract due to insolvency, that assures that
Medicaid Recipients nor the Agency shall be held liable for any debts of the
Provider.

 
cc.
Contain a clause indemnifying, defending and holding the Agency and the Health
Plan’s Enrollees harmless from and against all claims, damages, causes of
action, costs or expense, including court costs and reasonable attorney fees to
the extent proximately caused by any negligent act or other wrongful conduct
arising from the Provider Contract:

 
(1)
This clause must survive the termination of the Provider Contract, including
breach due to Insolvency, and

 
(2)
The Agency may waive this requirement for itself, but not Health Plan Enrollees,
for damages in excess of the statutory cap on damages for public entities if the
Provider is a public health entity with statutory immunity (all such waivers
must be approved in writing by the Agency);

 
dd.
Require that the Provider secure and maintain during the life of the Provider
Contract worker's compensation insurance (complying with the Florida's Worker's
Compensation Law) for all of its employees connected with the work under this
Contract unless such employees are covered by the protection afforded by the
Health Plan;

 
ee.
Make provisions for a waiver of those terms of the Provider Contract, which, as
they pertain to Medicaid Recipients, are in conflict with the specifications of
this Contract;

ff.  
Contain no provision that in any way prohibits or restricts the Provider from
entering into a commercial contract with any other health plan (see Section
641.315, F.S.);

gg.  
Contain no provision requiring the Provider to contract for more than one (1)
HMO product or otherwise be excluded (see Section 641.315, F.S.); and

hh.  
Contain no provision that prohibits the Provider from providing inpatient
services in a contracted Hospital to an Enrollee if such services are determined
to be Medically Necessary and Covered Services under this Contract;

 
ii.
Require all Providers to apply for a National Provider Identification number
(NPI) no later than May 1, 2007. Providers can obtain their NPIs through the
National Plan and Provider Enumerator System located at:
https://nppes.cms.hhs.gov/NPPES/Welcome.do. Additionally, the Provider Contract
shall require the Provider to submit all NPIs for its physicians and other
health care providers to the Health Plan within fifteen (15) Business Days of
receipt. The Health Plan shall report the Providers’ NPIs as part of its
Provider Network Report, in a manner to be determined by the Agency, and in its
Provider Directory, to the Agency or its Choice Counselor/Enrollment Broker, as
set forth in Section XII, Reporting Requirements.

(1) The Health Plan need not obtain an NPI from the following Providers:

 
(a)
Individuals or organizations that furnish atypical or nontraditional services
that are only indirectly related to the provision of health care (examples
include taxis, home and vehicle modifications, insect control, habilitation and
respite services); and

 
(b)
Individuals or businesses that only bill or receive payment for, but do not
furnish, health care services or supplies (examples include billing services,
repricers and value-added networks).

 
jj.
Require Providers to cooperate fully in any investigation by the Agency,
Medicaid Program Integrity (MPI), or Medicaid Fraud Control Unit (MFCU), or any
subsequent legal action that may result from such an investigation.

D.
Provider Termination 

 
1.
The Health Plan shall comply with all State and federal laws regarding Provider
termination. In its Provider contracts, the Health Plan shall:

 
a.
Specify that in addition to any other right to terminate the Provider contract,
and not withstanding any other provision of this Contract, the Agency or the
Health Plan may request immediate termination of a Provider contract if, as
determined by the Agency, a Provider fails to abide by the terms and conditions
of the Provider contract, or in the sole discretion of the Agency, the Provider
fails to come into compliance with the Provider contract within fifteen (15)
Calendar Days after receipt of notice from the Health Plan specifying such
failure and requesting such Provider abide by the terms and conditions thereof;
and

 
b.
Specify that any Provider whose participation is terminated pursuant to the
Provider Contract for any reason shall utilize the applicable appeals procedures
outlined in the Provider Contract. No additional or separate right of appeal to
the Agency or the Health Plan is created as a result of the Health Plan's act of
terminating, or decision to terminate any Provider under this Contract.
Notwithstanding the termination of the Provider Contract with respect to any
particular Provider, this Contract shall remain in full force and effect with
respect to all other Providers; and

 
2.
The Health Plan shall notify the Agency at least ninety (90) Calendar Days prior
to the effective date of the suspension, termination, or withdrawal of a
Provider from participation in the Health Plan network. If the termination was
for "Cause" the Health Plan shall provide to the Agency the reasons for
termination; and

 
3.
The Health Plan shall notify Enrollees in accordance with the provisions of this
Contract; and

 
4.
The Health Plan shall provide sixty (60) Calendar Days’ advance written notice
to the Provider before canceling, without cause, the Contract with the Provider,
except in a case in which a patient's health is subject to imminent danger or a
physician's ability to practice medicine is effectively impaired by an action by
the Board of Medicine or other governmental Agency, in which case notification
shall be provided to the Agency immediately. A copy of the notice shall be
submitted simultaneously to the Agency.

E.
Provider Services

 
1.
General Provisions

 
a.
The Health Plan shall provide sufficient information to all Providers in order
to operate in full compliance with this Contract and all applicable federal and
State laws and regulations.

 
b.
The Health Plan shall monitor Provider knowledge and understanding of Provider
requirements, and take corrective actions to ensure compliance with such
requirements.

 
c.
The Health Plan shall submit to the Agency for written approval all materials
and information to be distributed and/or made available to Providers.

 
2.
Provider Handbooks

 
a.
The Health Plan shall develop and issue a Provider Handbook to all Providers at
the time the Provider Contract is signed. The Health Plan may choose not to
distribute the Provider Handbook via Surface Mail, provided it submits a written
notification to all Providers that explains how to obtain the Provider Handbook
from the Health Plan’s website. This notification shall also detail how the
Provider can request a hard-copy from the Health Plan at no charge to the
Provider. All Provider Handbooks and bulletins shall be in compliance with State
and federal laws. The Provider Handbook shall serve as a source of information
regarding Health Plan Covered Services, policies and procedures, statutes,
regulations, telephone access and special requirements to ensure all Contract
requirements are met. At a minimum, the Provider Handbook shall include the
following information:

 
(1)
Description of the program;

 
(2)
Covered Services;

 
(3)
Emergency Service responsibilities;

 
(4)
Child Health Check-Up program services and standards;

 
(5)
Policies and procedures that cover the Provider complaint system. This
information shall include, but not be limited to, specific instructions
regarding how to contact the Health Plan’s Provider services to file a Provider
complaint and which individual(s) has/have the authority to review a Provider
complaint;

 
(6)
Information about the Grievance System, the timeframes and requirements, the
availability of assistance in filing, the toll-free numbers and the Enrollee’s
right to request continuation of Benefits while utilizing the Grievance System;

 
(7)
Medical Necessity standards and practice guidelines;

 
(8)
Practice protocols, including guidelines pertaining to the treatment of chronic
and complex conditions;

 
(9)
PCP responsibilities;

 
(10)
Other Provider or Subcontractor responsibilities;

 
(11)
Prior Authorization and referral procedures;

 
(12)
Medical Records standards;

 
(13)
Claims submission protocols and standards, including instructions and all
information necessary for a clean or complete claim;

 
(14)
Notice that Provider complaints regarding claims payment should be sent to the
Health Plan;

 

 
(15)
The Health Plan’s cultural competency plan;

 
(16)
Enrollee rights and responsibilities (see 42 CFR 438.100); and

 
(17)
The Health Plan shall disseminate bulletins as needed to incorporate any needed
changes to the Provider Handbook.

 
3.
Education and Training

 
a.
The Health Plan shall offer training to all Providers and their staff regarding
the requirements of this Contract and special needs of Enrollees. The Health
Plan shall conduct initial training within thirty (30) Calendar Days of placing
a newly contracted Provider, or Provider group, on active status. The Health
Plan shall also conduct ongoing training, as deemed necessary by the Health Plan
or the Agency, in order to ensure compliance with program standards and this
Contract.

 
b.
The Health Plan shall submit the Provider training manual and training schedule
to the Agency for written approval.

 
4.
Provider Relations

The Health Plan shall establish and maintain a formal Provider relations
function to timely and adequately respond to inquiries, questions and concerns
from network Providers. The Health Plan shall implement policies addressing the
compliance of Providers with the requirements of this Contract, institute a
mechanism for Provider dispute resolution and execute a formal system of
terminating Providers from the Health Plan’s network.

 
5.
Toll-free Provider Telephone Help Line

 
a.
The Health Plan shall operate a toll-free telephone help line to respond to
Provider questions, comments and inquiries.

 
b.
The Health Plan shall develop telephone help line policies and procedures that
address staffing, personnel, hours of operation, access and response standards,
monitoring of calls via recording or other means, and compliance with standards.

 
c.
The Health Plan shall submit these telephone help line policies and procedures,
including performance standards, to the Agency for written approval.

 
d.
The Health Plan’s call center systems shall have the capability to track call
management metrics identified in Section IV.A.7., Toll-free Enrollee Help Line.

 
e.
The Health Plan shall staff the telephone help line twenty-four (24) hours a
day, seven (7) days a week to respond to Prior Authorization requests. The
Health Plan shall staff the telephone help line so that the Health Plan can
respond to Provider questions in all other areas, including the Provider
complaint system, Provider responsibilities, etc., between the hours of 8:00 am
and 7:00 pm EST or EDT as appropriate, Monday through Friday, excluding State
holidays.

 
f.
The Health Plan shall develop performance standards and monitor telephone help
line performance by recording calls and employing other monitoring activities.
All performance standards shall be submitted to the Agency for written approval.

 
g.
The Health Plan shall ensure that after regular business hours the Provider
services line (not the Prior Authorization line) is answered by an automated
system with the capability to provide callers with information about operating
hours and instructions about how to verify Enrollment for an Enrollee with an
Emergency or Urgent Medical Condition. The requirement that the Health Plan
shall provide information to providers about how to verify Enrollment for an
Enrollee with an Emergency or Urgent Medical Condition shall not be construed to
mean that the provider must obtain verification before providing Emergency
Services and Care.

 
6.
Provider Complaint System

 
a.
The Health Plan shall establish a Provider complaint system that permits a
Provider to dispute the Health Plan’s policies, procedures, or any aspect of a
Health Plan’s administrative functions, including proposed Actions.

 
b.
The Health Plan shall submit its Provider complaint system policies and
procedures to the Agency for written approval.

 

 
c.
The Health Plan shall include its Provider complaint system policies and
procedures in its Provider handbook as described above.

 
d.
The Health Plan shall also distribute the Provider complaint system policies and
procedures to out of network providers upon written or oral request. The Health
Plan may distribute a summary of these policies and procedures, if the summary
includes information about how the provider may access the full policies and
procedures on the Health Plan’s Web site. This summary shall also detail how the
provider can request a hard-copy from the Health Plan at no charge to the
provider.

 
e.
As a part of the Provider complaint system, the Health Plan shall:

 
(1)
Allow providers forty-five (45) Calendar Days to file a written complaint;

 
(2)
Have dedicated staff for providers to contact via telephone, electronic mail, or
in person, to ask questions, file a provider complaint and resolve problems;

 
(3)
Identify a staff person specifically designated to receive and process provider
complaints;

 
(4)
Thoroughly investigate each provider complaint using applicable statutory,
regulatory, Contractual and Provider contract provisions, collecting all
pertinent facts from all parties and applying the Health Plan’s written policies
and procedures; and

 
(5)
Ensure that Health Plan executives with the authority to require corrective
action are involved in the provider complaint process.

 
f.
In the event the outcome of the review of the provider complaint is adverse to
the provider, the Health Plan shall provide a written notice of adverse action
to the provider.

 
g.
The Health Plan shall ensure that claims are processed and comply with the
federal and State requirements set forth in 42 CFR 447.45 and 447.46 and Chapter
641, F.S., whichever is more stringent.

F.
Medical Records Requirements

 
1.
The Health Plan shall maintain Medical Records for each Enrollee in accordance
with this Section. Medical Records shall include the quality, quantity,
appropriateness, and timeliness of services performed under this Contract.

 
a.
The Health Plan must include/follow the Medical Record standards set forth below
for each Enrollee's Medical Records, as appropriate:

 
(1)
The Enrollee’s identifying information, including name, Enrollee identification
number, date of birth, sex and legal guardianship (if any);

 
(2)
Each record must be legible and maintained in detail;

 
(3)
A summary of significant surgical procedures, past and current diagnoses or
problems, allergies, untoward reactions to drugs and current medications;

 
(4)
All entries must be dated and signed by the appropriate party;

 
(5)
All entries must indicate the chief complaint or purpose of the visit, the
objective, diagnoses, medical findings or impression of the provider;

 
(6)
All entries must indicate studies ordered (e.g., laboratory, x-ray, EKG) and
referral reports;

 
(7)
All entries must indicate therapies administered and prescribed;

 
(8)
All entries must include the name and profession of the provider rendering
services (e.g., MD, DO, OD), including the signature or initials of the
provider;

 
(9)
All entries must include the disposition, recommendations, instructions to the
Enrollee, evidence of whether there was follow-up and outcome of services;

 
(10)
All records must contain an immunization history;

 
(11)
All records must contain information relating to the Enrollee’s use of tobacco
products and alcohol/substance abuse;

 
(12)
All records must contain summaries of all Emergency Services and Care and
Hospital discharges with appropriate medically indicated follow up;

 
(13)
Documentation of referral services in Enrollees' Medical Records;

 
(14)
All services provided by providers. Such services must include, but not
necessarily be limited to, family planning services, preventive services and
services for the treatment of sexually transmitted diseases;

 
(15)
All records must reflect the primary language spoken by the Enrollee and any
translation needs of the Enrollee;

 
(16)
All records must identify Enrollees needing communication assistance in the
delivery of health care services; and

 
(17)
All records must contain documentation that the Enrollee was provided with
written information concerning the Enrollee’s rights regarding Advance
Directives (written instructions for living will or power of attorney) and
whether or not the Enrollee has executed an Advance Directive. Neither the
Health Plan, nor any of its Providers shall, as a condition of treatment,
require the Enrollee to execute or waive an Advance Directive. The Health Plan
must maintain written policies and procedures for Advance Directives.

 
b.
Confidentiality of Medical Records

 
(1)
The Health Plan shall have a policy to ensure the confidentiality of Medical
Records in accordance with 42 CFR, Part 431, Subpart F. This policy shall also
include confidentiality of a minor’s consultation, examination, and treatment
for a sexually transmissible disease in accordance with section 384.30(2), F.S.

 
(2)
The Health Plan shall have a policy to ensure compliance with the Privacy and
Security provisions of the Health Insurance Portability and Accountability Act
(HIPAA).

 
2.
The Health Plan shall maintain a behavioral health Medical Record for each
Enrollee. Each Enrollee's behavioral health Medical Record shall include:

 
a.
Documentation sufficient to disclose the quality, quantity, appropriateness and
timeliness of Behavioral Health Services performed;

 
b.
Must be legible and maintained in detail consistent with the clinical and
professional practice which facilitates effective internal and external peer
review, medical audit and adequate follow-up treatment; and

 
c.
For each service provided, clear identification as to:

 
(1)
The physician or other service provider;

 
(2)
Date of service;

 
(3)
The units of service provided; and

 
(4)
The type of service provided.

G.
Claims Payment

 
1.
The Health Plan shall reimburse providers for the delivery of authorized
services pursuant to Section 641.3155 F.S., including, but not limited to:

 
a.
Claims are considered received on the date the claims are received by the Health
Plan at its designated claims receipt location.

 
b.
The provider must mail or electronically transfer (submit) the claim to the
Health Plan within six (6) months of:

 
(1)
The date of service or discharge from an inpatient setting; or

 
(2)
The provider has been furnished with the correct name and address of the
Enrollee’s Health Plan.

 
c.
When the Health Plan is the secondary payor, the provider must submit the claim
to the Health Plan within ninety (90) days of the final determination of the
primary payor.

 
2.
The Health Plan shall reimburse providers for Medicare deductibles and
co-insurance payments for Medicare dually eligible members according to the
lesser of the following:

 
a.
The rate negotiated with the provider; or

 
b.
The reimbursement amount as stipulated in Section 409.908 F.S.

 
3.
In accordance with Section 409.912 F.S., the Health Plan shall reimburse any
Hospital or physician that is outside the Health Plan’s authorized geographic
service area for Health Plan authorized services provided by the Hospital or
physician to Enrollees:

 
a.
At a rate negotiated with the Hospital or physician; or

 
b.
The lesser of the following:

 
(1)
The usual and customary charge made to the general public by the Hospital or
physician; or

 
(2)
The Florida Medicaid reimbursement rate established for the Hospital or
physician.

 
4.
The Health Plan shall have a process for handling and addressing the resolution
of provider complaints concerning claims issues. The process shall be in
compliance with Section 641 .3155 F.S.

 
5.
The Health Plan shall have claims processing and payment performance metrics
including those for quality, accuracy and timeliness and include a process for
measurement and monitoring, and for the development and implementation of
interventions for improvement. These metrics must be approved in writing by the
Agency.

 
6.
The Health Plan shall ensure that claims are processed and payment systems
comply with the federal and State requirements set forth in 42 CFR 447.45, 42
CFR 447.46, and Chapter 641, F.S., as applicable.

H.
Encounter Data 

 
1.
The Agency is developing a Medicaid Encounter Data System (MEDS) to collect all
encounter data from health plans reimbursed on a capitated basis. Encounter data
collection will be required from all Florida capitated health plans for all
health care services rendered to its members.

 
2.
The information required to support encounter reporting and submission will be
defined by the Agency in the MEDS Companion Guide and MEDS Operations Manual.
Other information contained within the MEDS Companion Guide and MEDS Operations
Manual will be Managed Care Organization testing requirements for SFY 06-07 and
thereafter. The Companion Guide and Operations Manual will be distributed to
Health Plans in a manner that makes them easily accessible.

 
3.
Upon the request of the Agency, Health Plans shall be prepared to submit
encounter data to the Agency or its designee. Health Plans shall have a
comprehensive automated and integrated Encounter Data System that is capable of
meeting the requirements listed below:

 
a.
All encounters shall be submitted in the standard HIPAA transaction formats,
namely the ANSI X12N 837 Transaction formats (P - Professional, I -
Institutional, and D - Dental), and the National Council for Prescription Drug
Programs NCPDP format (for Pharmacy services).

 
b.
Health Plans shall collect and submit to the Agency or its designee, enrollee
service level encounter data for all covered services. Health Plans will be held
responsible for errors or noncompliance resulting from their own actions or the
actions of an agent authorized to act on their behalf.

 
c.
Health Plans shall have the capability to convert all information that enters
their claims systems via hard copy paper claims to encounter data to be
submitted in the appropriate HIPAA compliant formats.

d. Complete and accurate encounters shall be provided to the Agency. Health
Plans will implement review procedures to validate encounter data submitted by
providers. The historical encounter data submission shall be retained for a
period not less than five years following generally accepted retention
guidelines. 

 
e.
Health Plans shall require each Provider to have a unique Florida Medicaid
Provider number, in accordance with the requirement of Section X, C. jj. of this
Contract.

 
f.
Health Plans will designate sufficient IT and staffing resources to perform
these encounter functions as determined by generally accepted best industry
practices.

I.
Fraud Prevention

1.  
The Health Plan shall establish functions and activities governing program
integrity in order to reduce the incidence of Fraud and Abuse and shall comply
with all State and federal program integrity requirements, including the
applicable provisions of 42 CFR 438.608, 42 CFR 455(a)(2), Chapters 358, 414,
641 and 932, F.S. and Sections 409.912 (21) and (22), F.S.

2.  
The Health Plan shall designate a compliance officer with sufficient experience
in health care, who shall have the responsibility and authority for carrying out
the provisions of the Fraud and Abuse policies and procedures. The Health Plan
shall have adequate staffing and resources to investigate unusual incidents and
develop and implement corrective action plans to assist the Health Plan in
preventing and detecting potential Fraud and Abuse activities.

 
3.
The Health Plan shall have internal controls and policies and procedures in
place that are designed to prevent, detect and report known or suspected Fraud
and Abuse activities.

 
4.
The Health Plan shall submit its Fraud and Abuse policies and procedures to the
Bureau of Managed Health Care (BMHC) for written approval before implementation.
At a minimum, the Health Plan’s Fraud and Abuse policies and procedures shall:

 
a.
Ensure that all officers, directors, managers and employees know and understand
the provisions of the Health Plan’s Fraud and Abuse policies and procedures;

 
b.
Include procedures designed to prevent and detect potential or suspected abuse
and fraud in the administration and delivery of services under this Contract.
Nothing in this Contract shall require that the Health Plan assure that
non-participating providers are compliant with this Contract or State and/or
federal law, but the Health Plan is responsible for reporting suspected abuse
and fraud by non-participating providers when detected, in accordance with the
Health Plan’s policies and procedures.

 
c.
Incorporate a description of the specific controls in place for prevention and
detection of potential or suspected Fraud and Abuse, including, but not limited
to:

 
(1)
Claims edits;

 
(2)
Post-processing review of claims;

 
(3)
Provider profiling and credentialing, including a review process for claims that
shall include Providers and non-participating providers:

 
(a)
Who consistently demonstrate a pattern of submitting falsified encounter or
service reports;

 
(b)
Who consistently demonstrate a pattern of overstated reports or up-coded levels
of service;

 
(c)
Who alter, falsify or destroy clinical record documentation;

 
(d)
Who make false statements relating to credentials;

 
(e)
Who misrepresent medical information to justify Enrollee referrals;

 
(f)
Who fail to render Medically Necessary Covered Services that they are obligated
to provide according to their Provider contracts; and

 
(g)
Who charge Enrollees for Covered Services.

 
(4)
Prior Authorization;

 
(5)
Utilization Management;

 
(6)
Relevant Subcontract and Provider contract provisions; and

 
(7)
Pertinent provisions from the Provider handbook and the Enrollee handbook.

 
d.
Contain provisions for the confidential reporting of Health Plan violations to
the Health Plan’s analyst with the Bureau of Managed Health Care, MPI and MFCU;

 
e.
Include provisions for the investigation and follow-up of any reports;

 
f.
Ensure that the identities of individuals reporting acts of Fraud and Abuse are
protected;

 
g.
Require all instances of provider or Enrollee Fraud and Abuse under State and/or
federal law be reported to the Health Plan's analyst with the Bureau of Managed
Health Care and MPI. The Health Plan shall not cease an investigation or resolve
the suspicion, knowledge or action without first informing the Agency and MPI.
Additionally, any final resolution must include a written statement that
provides notice to the provider or enrollee that the resolution in no way binds
the State of Florida nor precludes the State of Florida from taking further
action for the circumstances that brought rise to the matter;

 
h.
The Health Plan and all Providers, upon request, and as required by State and/or
federal law, shall:

 
(1)
Make available to the Agency, MPI and/or MFCU any and all administrative,
financial and Medical Records relating to the delivery of items or services for
which Medicaid monies are expended; and

(2)  
Allow access to the Agency, MPI and/or MFCU to any place of business and all
Medical Records, as required by State and/or federal law. The Agency, MPI and
MFCU shall have access during normal business hours, except under special
circumstances when the Agency, MPI and MFCU shall have after hour admission. The
Agency, MPI and/or MFCU shall determine the need for special circumstances.

 
i.
The Health Plan shall cooperate fully in any investigation by the Agency, MPI,
MFCU or any subsequent legal action that may result from such an investigation.

 
j.
Ensure that the Health Plan does not retaliate against any individual who
reports violations of the Health Plan’s Fraud and Abuse policies and procedures
or suspected Fraud and Abuse.

 
k.
The Health Plan shall provide for the use of the List of Excluded Individuals
and Entities (LEIE), or its equivalent, to identify excluded parties during the
process of an engaging the services of new Providers to ensure that the
Providers are not in a nonpayment status or sanctioned from participation in
federal health care programs. The Health Plan shall not engage the services of a
provider if that provider is in nonpayment status or is excluded from
participation in federal health care programs under Sections 1128 and 1128A of
the Social Security Act. The Health Plan shall not employ or contract the
services of excluded Providers and must terminate the Provider contract
immediately between the Health Plan and a Provider that becomes an excluded
provider.

 
5.
The Health Plan shall comply with all reporting requirements as set forth in
Section XII., Reporting Requirements.

 
6.
The Health Plan shall meet with the Agency periodically, at the Agency’s
request, to discuss Fraud, Abuse, Neglect and Overpayment issues. For purpose of
this Section, the Health Plan Compliance Officer shall be the point of contact
for the Health Plan and the Agency’s Medicaid Fraud and Abuse Liaison shall be
the point of contact for the Agency.

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Section XI
 
Information Management and Systems 
 

 
A.
General Provisions

 
1.
Systems Functions. The Health Plan shall have Information management processes
and Information Systems that enable it to meet Agency and federal reporting
requirements and other Contract requirements and that are in compliance with
this Contract and all applicable State and federal laws, rules and regulations,
including HIPAA.

 
2.
Systems Capacity. The Health Plan’s Systems shall possess capacity sufficient to
handle the workload projected for the begin date of operations and will be
scaleable and flexible so they can be adapted as needed, within negotiated
timeframes, in response to changes in Contract requirements, increases in
Enrollment estimates, etc.

 
3.
E-Mail System. The Health Plan shall provide a continuously available electronic
mail communication link (E-mail system) with the Agency. This system shall be:

 
a.
Available from the workstations of the designated Health Plan contacts; and

 
b.
Capable of attaching and sending documents created using software products other
than Health Plan’s systems, including the Agency’s currently installed version
of Microsoft Office and any subsequent upgrades as adopted.

 
4.
Participation in Information Systems Work Groups/Committees. The Health Plan
shall meet as requested by the Agency, to coordinate activities and develop
cohesive systems strategies across vendors and agencies.

 
5.
Connectivity to the Agency/State Network and Systems. The Health Plan shall be
responsible for establishing connectivity to the Agency’s/State’s wide area data
communications network, and the relevant information systems attached to this
network, in accordance with all applicable Agency and/or State policies,
standards and guidelines.

B.
Data and Document Management Requirements

 
1.
Adherence to Data and Document Management Standards

a.  
The Health Plan’s Systems shall conform to the standard transaction code sets
specified in Section XI.I.

b.  
The Health Plan’s Systems shall conform to HIPAA standards for data and document
management that are currently under development within one hundred twenty (120)
Calendar Days of the standard’s effective date or, if earlier, the date
stipulated by CMS or the Agency.

c.  
The Health Plan shall partner with the Agency in the management of standard
transaction code sets specific to the Agency. Furthermore, the Health Plan shall
partner with the Agency in the development and implementation planning of future
standard code sets not specific to HIPAA or other federal efforts and shall
conform to these standards as stipulated in the plan to implement the standards.

 
2.
Data Model and Accessibility. Health Plan Systems shall be Structured Query
Language (SQL) and/or Open Database Connectivity (ODBC) compliant.
Alternatively, the Health’s Plan Systems shall employ a relational data model in
the architecture of its databases in addition to a relational database
management system (RDBMS) to operate and maintain them.

 
3.
Data and Document Relationships. The Health Plan shall house indexed images of
documents used by Enrollees and providers to transact with the Health Plan in
the appropriate database(s) and document management systems so as to maintain
the logical relationships between certain documents and certain data.

 

 
4.
Information Retention. Information in the Health Plan’s Systems shall be
maintained in electronic form for three (3) years in live Systems and, for audit
and reporting purposes, for five (5) years in live and/or archival Systems.

 
5.
Information Ownership. All Information, whether data or documents, and reports
that contain or make references to said Information, involving or arising out of
this Contract is owned by the Agency. The Health Plan is expressly prohibited
from sharing or publishing the Agency information and reports without the prior
written consent of the Agency. In the event of a dispute regarding the sharing
or publishing of information and reports, the Agency’s decision on this matter
shall be final and not subject to change.

C.
System and Data Integration Requirements

 
1.
Adherence to Standards for Data Exchange

 
a.
The Health Plan’s Systems shall be able to transmit, receive and process data in
HIPAA-compliant formats that are in use as of the Contract execution date; these
formats are detailed in Section XI.J.

 
b.
The Health Plan’s Systems shall be able to transmit, receive and process data in
the Agency-specific formats and/or methods that are in use on the Contract
execution date, as specified in Section XI.J.

 
c.
Health Plan Systems shall conform to future federal and/or Agency specific
standards for data exchange within one hundred twenty (120) Calendar Days of the
standard’s effective date or, if earlier, the date stipulated by CMS or the
Agency. The Health Plan shall partner with the Agency in the management of
current and future data exchange formats and methods and in the development and
implementation planning of future data exchange methods not specific to HIPAA or
other Federal effort. Furthermore, the Health Plan shall conform to these
standards as stipulated in the plan to implement such standards.

 
2.
HIPAA Compliance Checker

All HIPAA-conforming exchanges of data between the Agency and the Health Plan
shall be subjected to the highest level of compliance as measured using an
industry-standard HIPAA compliance checker application.

 
3.
Data and Report Validity and Completeness

The Health Plan shall institute processes to ensure the validity and
completeness of the data, including reports, it submits to the Agency. At its
discretion, the Agency will conduct general data validity and completeness
audits using industry-accepted statistical sampling methods. Data elements that
will be audited include but are not limited to: Enrollee ID, date of service,
assigned Medicaid Provider ID, category and sub category (if applicable) of
service, diagnosis codes, procedure codes, revenue codes, date of claim
processing, and (if and when applicable) date of claim payment. Control totals
shall also be reviewed and verified.

 
4.
State/Agency Website/Portal Integration

Where deemed that the Health Plan’s Web presence will be incorporated to any
degree to the Agency’s or the State’s Web presence (also known as a portal), the
Health Plan shall conform to any applicable Agency or State standard for Website
structure, coding and presentation.

 
5.
Connectivity to and Compatibility/Interoperability with Agency Systems and IT
Infrastructure.

The Health Plan shall be responsible for establishing connectivity to the
Agency’s/State’s wide area data communications network, and the relevant
information systems attached to this network, in accordance with all applicable
Agency and/or State policies, standards and guidelines.

 
6.
Functional Redundancy with FMMIS.

The Health Plan’s Systems shall be able to transmit and receive transaction data
to and from FMMIS as required for the appropriate processing of claims and any
other transaction that could be performed by either System.

 
7.
Data Exchange in Support of the Agency’s Program Integrity and Compliance
Functions.

The Health Plan’s System(s) shall be capable of generating files in the
prescribed formats for upload into Agency Systems used specifically for program
integrity and compliance purposes.

 
8.
Address Standardization.

The Health Plan’s System(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.

9. Eligibility and Enrollment Data Exchange Requirements

a.  
The Health Plan shall receive, process and update enrollment files sent daily by
the Agency or its Agent.

b.  
The Health Plan shall update its eligibility/Enrollment databases within
twenty-four (24) hours of receipt of said files.

c.  
The Health Plan shall transmit to the Agency or its Agent, in a periodicity
schedule, format and data exchange method to be determined by the Agency,
specific data it may garner from an Enrollee including third party liability
data.

d.  
The Health Plan shall be capable of uniquely identifying a distinct Medicaid
Recipient across multiple Systems within its Span of Control.

D.
Systems Availability, Performance and Problem Management Requirements

     

1. Availability of Critical Systems Functions

The Health Plan shall ensure that critical systems functions available to
Enrollees and providers, functions that if unavailable would have an immediate
detrimental impact on Enrollees and providers, are available twenty-four (24)
hours a day, seven (7) days a week, except during periods of scheduled System
Unavailability agreed upon by the Agency and the Health Plan. Unavailability
caused by events outside of a Health Plan’s Span of Control is outside the scope
of this requirement. The Health Plan shall make the Agency aware of the nature
and availability of these functions prior to extending access to these functions
to Enrollees and/or providers.

2. Availability of Data Exchange Functions 

The Health Plan shall ensure that the systems and processes within its Span of
Control associated with its data exchanges with the Agency and/or its Agent(s)
are available and operational according to specifications and the data exchange
schedule.

3. Availability of Other Systems Functions 

The Health Plan shall ensure that at a minimum all other System functions and
Information are available to the applicable System users between the hours of
7:00 a.m. and 7:00 p.m., EST or EDT as appropriate, Monday through Friday.

4. Problem Notification

a.  
Upon discovery of any problem within its Span of Control that may jeopardize or
is jeopardizing the availability and performance of all Systems functions and
the availability of information in said Systems, including any problems
impacting scheduled exchanges of data between the Health Plan and the Agency
and/or its Agent(s), the Health Plan shall notify the applicable Agency staff
via phone, fax and/or electronic mail within fifteen (15) minutes of such
discovery. In its notification the Health Plan shall explain in detail the
impact to critical path processes such as enrollment management and claims
submission processes.

b.  
The Health Plan shall provide to appropriate Agency staff information on System
Unavailability events, as well as status updates on problem resolution. At a
minimum these up-dates shall be provided on an hourly basis and made available
via electronic mail and/or telephone.

5. Recovery from Unscheduled System Unavailability

Unscheduled System unavailability caused by the failure of systems and
telecommunications technologies within the Health Plan’s Span of Control will be
resolved, and the restoration of services implemented, within forty-eight (48)
hours of the official declaration of System Unavailability.
 
6. Exceptions to System Availability Requirement 

The Health Plan shall not be responsible for the availability and performance of
systems and IT infrastructure technologies outside of the Health Plan’s Span of
Control.

7. Corrective Action Plan 

Full written documentation, that includes a Corrective Action Plan, that
describes how problems with critical Systems functions will be prevented from
occurring again, shall be delivered within five (5) Business Days of the System
Unavailability/problem’s occurrence.

8. Business Continuity-Disaster Recovery (BC-DR) Plan

 
a.
Regardless of the architecture of its Systems, the Health Plan shall develop,
and be continually ready to invoke, a business continuity and disaster recovery
(BC-DR) plan that is reviewed and prior-approved by the Agency.

 
b.
At a minimum the Health Plan’s BC-DR plan shall address the following scenarios:
(1) the central computer installation and resident software are destroyed or
damaged; (2) System interruption or failure resulting from network, operating
hardware, software, or operational errors that compromise the integrity of
transactions that are active in a live system at the time of the outage; (3)
System interruption or failure resulting from network, operating hardware,
software or operational errors that compromise the integrity of data maintained
in a live or archival system; (4) System interruption or failure resulting from
network, operating hardware, software or operational errors that do not
compromise the integrity of transactions or data maintained in a live or
archival system, but does prevent access to the System, i.e. causes unscheduled
System Unavailability.

c.  
The Health Plan shall periodically, but no less than annually, perform
comprehensive tests of its BC-DR plan through simulated disasters and lower
level failures in order to demonstrate to the Agency that it can restore System
functions per the standards outlined elsewhere in this Section of the Contract.

d.  
In the event that the Health Plan fails to demonstrate in the tests of its BC-DR
plan that it can restore system functions per the standards outlined in this
Contract, the Health Plan shall be required to submit to the Agency a Corrective
Action Plan in accordance with Section XIV, Sanctions, that describes how the
failure will be resolved. The Corrective Action Plan shall be delivered within
ten (10) Business Days of the conclusion of the test.

E. System Testing and Change Management Requirements 

1. Notification and Discussion of Potential System Changes.

The Health Plan shall notify the applicable Agency staff person of the following
changes to Systems within its Span of Control within at least ninety (90)
Calendar Days of the projected date of the change; if so directed by the Agency,
the Health Plan shall discuss the proposed change with the applicable Agency
staff: (1) software release updates of core transaction Systems: claims
processing, eligibility and Enrollment processing, service authorization
management, Provider enrollment and data management; (2) conversions of core
transaction management Systems.

 
2.
Response to Agency Reports of Systems Problems not Resulting in System
Unavailability.

 
a.
The Health Plan shall respond to Agency reports of System problems not resulting
in System Unavailability according to the following timeframes:

 
(1)
Within seven (7) Calendar Days of receipt, the Health Plan shall respond in
writing to notices of system problems.

 
(2)
Within twenty (20) Calendar Days, the correction will be made or a Requirements
Analysis and Specifications document will be due.

 
(3)
The Health Plan will correct the deficiency by an effective date to be
determined by the Agency.

3. Valid Window for Certain System Changes.

Unless otherwise agreed to in advance by the Agency as part of the activities
described in this Section, scheduled System Unavailability to perform System
maintenance, repair and/or upgrade activities shall not take place during hours
that could compromise or prevent critical business operations.

4. Testing

a.  
The Health Plan shall work with the Agency pertaining to any testing initiative
as required by the Agency.

b.  
Upon the Agency’s written request, the Health Plan shall provide details of the
test regions and environments of its core production Information Systems,
including a live demonstration, to enable the Agency to corroborate the
readiness of the Health Plan’s Information Systems.

F. Information Systems Documentation Requirements 

1. Types of Documentation

The Health Plan shall develop, prepare, print, maintain, produce, and distribute
distinct System Process and Procedure Manuals, User Manuals and Quick/Reference
Guides, and any updates thereafter, for the Agency and other applicable Agency
staff.

2. Content of System Process and Procedure Manuals

The Health Plan shall ensure that written System Process and Procedure Manuals
document and describe all manual and automated system procedures for its
information management processes and Information Systems.

 
3.
Content of System User Manuals 

The System User Manuals shall contain information about, and instructions for,
using applicable System functions and accessing applicable system data.

 
4.
Changes to Manuals

a.  
When a System change is subject to the Agency’s written approval, the Health
Plan shall draft revisions to the appropriate manuals prior to Agency approval
of the change.

b.  
Updates to the electronic version of these manuals shall occur in real time;
updates to the printed version of these manuals shall occur within ten (10)
Business Days of the update taking effect.

 
5.
Availability of/Access to Documentation

All of the aforementioned manuals and reference guides shall be available in
printed form and/or on-line. If so prescribed, the manuals will be published in
accordance with the appropriate Agency and/or State standard.

G.
Reporting Requirements - Specific to Information Management and Systems
Functions and Capabilities - and Technological Capabilities 

 
1.
Reporting Requirements. 

If the Health Plan is extending access to “critical systems functions” to
providers and Enrollees as described in Section XI.D.1., above, it shall submit
a monthly Systems Availability and Performance Report to the Agency as described
in Section XII, Reporting Requirements, otherwise this reporting requirement is
not applicable.

2. Reporting Capabilities.

The Health Plan shall provide Systems-based capabilities, such as a data
warehouse, that enables authorized Agency personnel, or the Agency’s Agent, on a
secure and read-only basis, to build and generate reports for management use.

H.
Other Requirements

 
1.
Community Health Record/Electronic Medical Record and Related Efforts 

 
a.
At such times that the Agency requires, the Health Plan shall participate and
cooperate with the Agency to implement, within a reasonable timeframe, a secure,
Web-accessible, Community Health Records for Enrollees.

 
b.
The design of the vehicle(s) for accessing the Community Health Record, the
health record format and design shall comply with all HIPAA and related
regulations.

 
c.
The Health Plan shall also cooperate with the Agency in the continuing
development of the State’s health care data site (FloridaHealthStat).

I.
Compliance with Standard Coding Schemes

1. Compliance with HIPAA-Based Code Sets. 

 
a.
A Health Plan System that is required to or otherwise contain the applicable
data type shall conform to the following HIPAA-based standard code sets; the
processes through which the data are generated should conform to the same
standards as needed:

 
(1)
Logical Observation Identifier Names and Codes (LOINC);

 
(2)
Health Care Financing Administration Common Procedural Coding System (HCPCS);

 
(3)
Home Infusion EDI Coalition (HEIC) Product Codes;

 
(4)
National Drug Code (NDC);

 
(5)
National Council for Prescription Drug Programs (NCPDP);

 
(6)
International Classification of Diseases (ICD-9);

 
(7)
Diagnosis Related Group (DRG);

 
(8)
Claim Adjustment Reason Codes; and

 
(9)
Remittance Remarks Codes.

 
2.
Compliance with Other Code Sets 

 
a.
A Health Plan System that is required to or otherwise contains the applicable
data type shall conform to the following non-HIPAA-based standard code sets:

 
(1)
As described in all AHCA Medicaid Reimbursement Handbooks, for all "Covered
Entities", as defined under HIPAA, and which submit transactions in paper format
(non-electronic format).

 
(2)
As described in all AHCA Medicaid Reimbursement Handbooks for all "Non-covered
Entities", as defined under HIPAA.

J.
Data Exchange and Formats and Methods Applicable to Health Plans

 

 
1.
HIPAA-Based Formatting Standards 

 
a.
Health Plan Systems shall conform to the following HIPAA-compliant standards for
information exchange effective the first day of operations in the applicable
service region:

 
(1)
Batch transaction types

 
(a)
ASC X12N 834 Enrollment and Audit Transaction

 
(b)
ASC X12N 835 Claims Payment Remittance Advice Transaction

 
(c)
ASC X12N 837I Institutional Claim/Encounter Transaction

 
(d)
ASC X12N 837P Professional Claim/Encounter Transaction

 
(e)
ASC X12N 837D Dental Claim/Encounter Transaction

(f) NCPDP 1.1 Pharmacy Claim/Encounter Transaction

   
 

 
(2)
Online transaction types

 
(a)
ASC X12N 270/271 Eligibility/Benefit Inquiry/Response

 
(b)
ASC X12N 276 Claims Status Inquiry

 
(c)
ASC X12N 277 Claims Status Response

 
(d)
ASC X12N 278/279 Utilization Review Inquiry/Response

 
(e)
NCPDP 5.1 Pharmacy Claim/Encounter Transaction

 
2.
Methods for Data Exchange

The Health Plan and the Agency and/or its Agent shall made predominant use of
Secure File Transfer Protocol (SFTP) and Electronic Data Interchange (EDI) in
their exchanges of data.
 

 
3.
Agency-Based Formatting Standards and Methods 

 
a.
Health Plan Systems shall exchange the following data with the Agency and/or its
Agent in a format to be jointly agreed upon by the Health Plan and the Agency: 

 
(1)
Provider network data;

 
(2)
Case Management fees; and

 
(3)
Administrative payments.

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Section XII
 
Reporting Requirements
 

 
A.
Health Plan Reporting Requirements

 
1.
The Health Plan shall comply with all Reporting Requirements set forth by the
Agency in this Contract.

 
a.
The Health Plan is responsible for assuring the accuracy, completeness, and
timely submission of each report.

 

 
b.
The Health Plan’s chief executive officer (CEO), chief financial officer (CFO),
or an individual who reports to the CEO or CFO and who has delegated authority
to certify the Health Plan’s reports, must attest, based on his/her best
knowledge, information, and belief, that all data submitted in conjunction with
the reports and all documents requested by the Agency are accurate, truthful,
and complete (see 42 CFR 438.606(a) and (b)).

 

 
c.
The Health Plan must submit its certification at the same time it submits the
certified data reports (see 42 CFR 438.606(c)). The certification page should be
scanned and submitted it electronically.

 
d.
Before October 1 of each year, the Health Plan shall deliver to the Agency a
certification by an Agency-approved independent auditor that the Performance
Measure data reported for the previous calendar year are fairly and accurately
presented.

 
e.
Deadlines for report submission referred to in this Contract specify the actual
time of receipt at the Agency, not the date the file was postmarked or
transmitted.

 
f.
If a reporting due date falls on a weekend, the report shall be due to the
Agency on the following Business Day.

 
g.
All reports filed on a quarterly basis shall be filed on a calendar year
quarter.

 
2.
The Agency shall furnish the Health Plan with the appropriate reporting
formats, templates, instructions, submission timetables, and technical
assistance, as required.

 
3.
The Agency reserves the right to modify the Reporting Requirements, with a
ninety (90) Calendar Day notice to allow the Health Plan to complete
implementation, unless otherwise required by law.

 
4.
The Agency shall provide the Health Plan with written notification of any
modifications to the Reporting Requirements.

5. The Reporting Requirements specifications are outlined in detail below.

 
6.
If the Health Plan fails to submit the required reports accurately and within
the timeframes specified below, the Agency shall fine or otherwise sanction the
Health Plan in accordance with Section XIV, Sanctions.

7.  
The Health Plan must use the following naming convention for all submitted
reports. Unless otherwise noted, each report will have an 8-digit file name,
constructed as follows:

 

Digit 1
Report Identifier
Indicates the report type. See Digit 1 Report Identifiers table below.
Digits 2, 3, and 4
Plan Identifier
Indicates the specific Health Plan submitting the data by the use of three (3)
unique alpha digits. Comports to the Health Plan identifier used in exchanging
data with the Choice Counselor/Enrollment Broker.
Digits 5 and 6
Year
Indicates the year. For example, reports submitted in 2006 should indicate 06.
Digits 7 and 8
Time Period
For reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4. For reports
submitted monthly, use the appropriate month, such as 01, 02, 03, etc.

 

Digit 1 Report Identifiers
R
Marketing Representative
I
Information Systems Availability
G
Grievance System Reporting
F
Financial Reporting
C
Claims Inventory
T
Transportation
S
Critical Incident Summary
E
Behavioral Health Encounter Data
B
Behavioral Health Pharmacy Encounter Data
P
Behavioral Health Required Staff/Providers
O
FARS/CFARS

 

8. Unless otherwise specified, these files can be:

a. Mailed to the following address:

Agency for Health Care Administration
Bureau of Managed Health Care
2727 Mahan Drive, MS #26
Tallahassee, FL 32308

or

 
b.
Transmitted electronically to the Agency at the following address:

MMCDATA@ahca.myflorida.com

 
c.
PHI information has to be submitted to the AHCA SFTP site.

 
9.
For financial reporting, the Health Plan shall complete the spreadsheets and
mail the CD or DVD to the address indicated above or transmit it electronically
to the Agency at the email address noted below:

MMCFIN@ahca.myflorida.com

10.  
For Claims Inventory Summary reporting, the Health Plan shall complete the
template and mail the CD or DVD to the address indicated above or transmit it
electronically to the Agency at the e-mail address noted below:

MMCCLMS@ahca.myflorida.com

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Table 1
SUMMARY OF REPORTING REQUIREMENTS
Health Plan Reports Required by AHCA
Report
Specific Data Elements
Format
Frequency Requirements
Submit to:
Suspected Fraud Reporting
See Section X.J.
Narrative
Immediately upon occurrence
Electronic mail to Bureau of Managed Health Care and MPI
Critical Incidents
See Section XII.F.
Code 15 Report
Immediately upon occurrence
Electronic mail and Surface Mail to the Health Plan’s analyst at the Bureau of
Managed Health Care
Enrollment/Disenrollment
See Section XII.B.
Enrollee Level as needed
First Thursday of the Month
File Transfer Protocol (FTP) to the Agency or its Agent via a secure Internet
site
Provider Network Report
(***REFPROVYYYYMMDD.dat)
See Section XII.D. Table 3
Fixed record length ASCII flat file (.dat)
Monthly - Due on the first Thursday of the month (optional weekly submissions on
each Thursday for the remainder of the month)
FTP to Choice Counselor vendor
Marketing Representative Report
(R***YYMM.xls)
See Section XII.E. Table 4
Electronic template provided by the Agency
Monthly If applicable
Electronic mail to mmcdata@ahca.myflorida.com
Information Systems Availability and Performance Report (I***YYMM.xls)
See Section XII.K. Table 5
Electronic template provided by the Agency
Monthly - If applicable
Electronic mail to mmcdata@ahca.myflorida.com
Minority Reporting
See Section XII.X.
Narrative
Monthly - Due fifteen (15) days after the end of the month being reported
Electronic Mail to the Contract Manager or his/her designee
Grievance System Reporting (G***YYQQ.txt)
See Section XII.C. Table 2
Fixed record length text file
Quarterly - Combines both medical and behavioral health care requirements to
cover all grievances and appeals related to services across the plan. Due 45
days after the end of the quarter being reported - Contains data for entire
quarter.
Secure File Transfer Protocol (SFTP) or CD/DVD submission

 
 
 
Behavioral Health Specific Reporting
 Report
 Specific Data Elements
 Format
 Frequency Requirements
 Submit to:
Critical Incidents Individual
See section XII.S. Table 11-A
Electronic template provided by the Agency
Immediately upon occurrence
AHCA Contract Manager & designee
Critical Incident Summary (S***YYMM.xls) 
See section XII.S. Table 11
Electronic template provided by the Agency
Quarterly - Due on the 15th of the month- Contains previous calendar month’s
data
AHCA Contract Manager & designee via the AHCA Secure FTP site
Behavioral Health Encounter Data (E***YYQ*.txt) 
See section XII.V. Table 14
Fixed record length text file
Quarterly - Due 45 days after the end of the quarter being reported - Contains
data for the entire quarter.
AHCA Contract Manager & designee via the AHCA Secure FTP site
Behavioral Health Pharmacy Encounter Data
(B***YYQ*.txt)
See section XII.W. Tables 16 and 16-A
Fixed record length text file
Quarterly - Due 45 days after the end of the quarter being reported - Contains
data for the entire quarter.
AHCA Contract Manager & designee via the AHCA Secure FTP site
Required Staff/Providers (P***YYQQ.xls)
See section XII.T. Table 12
Electronic template provided by the Agency
Quarterly - Due 45 days after the end of the quarter being reported - Contains
data for the entire quarter.
AHCA Contract Manager & designee via the AHCA Secure FTP site
Behavioral Health Services Grievance and Appeals
See Section XII.R. (see Section XII.C. and Table 2 for reporting instructions)
Fixed record length text file
Quarterly - Due 30 days after the end of the quarter being reported - Contains
data for the entire quarter. Requires certification letter.
CD/DVD to Contract Manager, or his/her designee, at HSD

 
 
Report
Specific Data Elements
Format
Frequency Requirements
Submit to:
FARS / CFARS (O***YY06.txt or O***YY12.txt)
See section XII.U. Table 13
Fixed record length text file
Semi-annually - The reporting periods cover January thru June and July thru
December. It is due 45 days after the end of the reporting period ( August 15
and February 15).
AHCA Contract Manager & designee via the AHCA Secure FTP site
Enrollee Satisfaction Survey Summary
See section XII.P. Table 9
Hardcopy
Semi-annually - due 60 days after the end of the six months being reported. Also
requires submission of copy of survey tool, the methodology used, and the
results.
AHCA Contract Manager & designee
Stakeholders Satisfaction Survey Summary
See section XII.Q. Table 10
Hardcopy
Annually - due 60 days after the end of the six months being reported. Also
requires submission of copy of survey tool, the methodology used, and the
results.
AHCA Contract Manager & designee
Behavioral Health: Annual 80/20 Expenditure Report
TBD
Electronic template provided by the Agency
Annually - due no later than April 1. Reporting is done for each calendar year.
A new template is provided by AHCA for each reporting cycle
Electronic mail to mmcfin@ahca.myflorida.com or CD ROM submission

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

B.
Enrollment/Disenrollment Reports:

1. Downloaded Enrollment/Disenrollment Reports

 
a.
The Agency or its Agent will report Enrollment/Disenrollment information to the
Health Plan.

 
b.
The Health Plan shall review the Enrollment/Disenrollment reports for accuracy
and will notify the Agency within three (3) Business Days of any discrepancies.
Failure to notify the Agency of any discrepancies within three (3) Business Days
shall lead to fines and other sanctions as detailed in Section XIV, Sanctions.

 
c.
The Enrollment/Disenrollment Reports will use HIPAA-compliant standard
transactions. The Agency or its Agent will use the X12N 834 transaction for all
Enrollee maintenance and reporting. The Health Plan must be capable of receiving
and processing X12N 834 transactions.

 
d.
During the transition period from proprietary to standard formats, the Health
Plan shall cooperatively participate with the Agency in the transition process.

2. Uploaded Disenrollment Reports

Involuntary disenrollments that meet the criteria established by the Agency
shall be submitted by the Health Plan using the X12N 834 transaction. This
monthly file must meet the specifications outlined in the AHCA/ACS ANSI ASC X12N
834 Benefit Enrollment and Maintenance Florida Medicaid Companion Guide, and
must be uploaded to the Medicaid fiscal agent’s secure Internet site. Upon
60-day notification from the Agency, the report format and submission
requirements may change.

C.
Grievance System

 

 
1.
The Health Plan shall submit the Grievance System report to the Agency via the
Agency’s secure FTP server or CD/DVD.

 
2.
The report is due forty-five (45) Calendar Days following the end of the
reported quarter.

3.  
The Health Plan must submit the Grievance System report each quarter. If no new
Grievances or Appeals have been filed with the Health Plan, or if the status of
an unresolved Appeal has not changed to 'Resolved,' please submit one (1) record
only. This record must contain the PLAN_ID field only, with the first 7-digits
of the 9-digit Medicaid provider number.

 
4.
The report shall contain information about Grievances and Appeals concerning
both medical and behavioral health issues.

 

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Table 2
Structure for Grievance/Appeal Reporting File

Field Name
Length
Start Column
End Column
Description
PLAN_ID
9
1
9
The nine digit Medicaid provider number.
RECIP_ID
9
10
18
The Enrollee’s 9 digit Medicaid ID number
LAST_NAME
20
19
38
The Enrollee’s last name
FIRST_NAME
10
39
48
The Enrollee’s first name
MID_INIT
1
49
49
The Enrollee’s middle initial
GRV_DATE
10
50
59
The date of the grievance (MM/DD/CCYY)
GRV_TYPE
2
60
61
1. Quality of Care
2. Access to Care
3. Emergency Services
4. Not Medically Necessary
5. Pre-Existing Condition
6. Excluded Benefit
7. Billing Dispute
8. Contract Interpretation
9. Enrollment/Disenrollment
10. Termination of Contract
11. Services after termination
12. Unauthorized out of plan svcs
13. Unauthorized in-plan svcs
14. Benefits available in plan
15. Experimental/ Investigational
99. Other
APP_DATE
10
62
71
The date of the appeal (MM/DD/CCYY)
APP_ACTION
1
72
72
The type of action (42 CFR 438.400):
 
 
 
 
1. The denial or limited authorization of a requested service, including the
type or level of service.
2. The reduction, suspension, or termination of a previously authorized service.
3. The denial, in whole or in part, of payment for a service.
4. The failure to provide services in a timely manner, as defined by the state.
5. The failure of the plan to act within the time frames provided in Sec.
438.408(b).
6. For an Enrollee of a Rural area with only one managed care entity, the denial
of a Medicaid Enrollee’s request to exercise his or her right, under Sec.
438.52(b)(2)(ii), to obtain services outside the network.
DISP_DATE
10
73
82
The date of the Disposition (MM/DD/CCYY)
DISP_TYPE
2
83
84
The Disposition of the Appeal / Grievance:
 
 
 
 
1. Referral made to specialist
2. PCP Appointment made
3. Bill Paid
4. Procedure scheduled
5. Reassigned PCP
6. Reassigned Center
7. Disenrolled Self
8. Disenrolled by plan
9. In HMO QA Review
10. In HMO Grievance System
11. Referred to Area Office
12. Member sent OLC form
13. Lost contact with member
14. Hospitalized / Institutionalized
15. Confirmed original decision
16. Reinstated in HMO
99. Other
DISP_STAT
1
85
85
R = Resolved
U = Unresolved
   
 
 
Note: Any grievance or appeal first reported as unresolved must be reported
again when resolved. Grievances and appeals that are resolved in the quarter
prior to reporting should be reported for the first time as resolved.
EXPED_REQ
1
86
86
Indicate whether the appeal was an expedited request
Y =Yes N = No Note: This field is required for all reported appeals.
FILE_TYPE
2
87
88
Indicate whether the report is related to Grievance or Appeal and a behavioral
health service respectively
G = Grievance Report GB = Grievance Behavioral Report
A = Appeal Report AB = Appeal Behavioral Report
ORIGINATOR
1
89
89
1 = An Enrollee
2 = A provider, acting on behalf of the Enrollee and with the Enrollee’s written
consent

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D.
Provider Reporting

 
1.
The Health Plan shall submit its provider directory as described in Section
IV.A.5, Provider Directory, of this Contract, to the Agency or its Choice
Counselor/Enrollment Broker at least on a monthly basis via FTP. The required
file will be due the first Thursday of each month.

 
2.
The Health Plan shall ensure that the Provider Network Report as described in
Table 3 of this Section is an electronic representation of the Health Plan’s
complete network of Providers, not a listing of entities for whom the Health
Plan has paid claims.

 
3.
The Provider Network Report shall be in an ASCII flat file and must be a
complete refresh of the Health Plan’s Provider information. The file name will
be XXX_PROVYYYYMMDD.dat (replacing X’s with the Health Plan’s three character
approved abbreviation and the date the file is submitted). This file name may
change in implementation. Plans will receive final instructions regarding file
naming, Plan Code (see layout below), file transfers, file submission frequency
and schedule and other issues prior to implementation.

 
4.
The Health Plan may choose to submit the Provider Network Report each Thursday
of the month as needed. The files will be compiled during the following weekend
and available for Agency and Choice Counselor/Enrollment Broker staff use on the
following Monday (or workday if the Monday is a Holiday.) If a new file is not
submitted, the last, good file will be used. This reporting schedule is subject
to change upon notice from the Agency.

NOTE: The following reporting material is proprietary information of ACS Inc.
and may not be used, duplicated, or altered without the written permission of
Corporate Management.

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Table 3
File Layout for Provider Networks

Field Name
Field Length
Required Field
Field Format
Justification
Comments
Plan Code
9
X
alpha
Left with leading zeros
This is the 9 digit Medicaid Provider ID number specific to the county of HMO/
operation.
Provider Type
1
X
alpha
Left
Identifies the provider’s general area of service with an alpha character, as
follows:
P = Primary Care Provider (PCP)
I = Individual Practitioner other than a PCP
B = Birthing Center
T = Therapy
G = Group Practice (includes FQHCs and RHCs)
H = Hospital
C = Crisis Stabilization Unit
D = Dentist
R = Pharmacy
A = Ancillary Provider (DME providers, Home Health Care
Agencies, etc.)
Plan Provider Number
15
X
alpha
Left with leading zeros
Unique number assigned to the provider by the plan.
Group Affiliation
15
Required for all groups and providers who are members of a group
alpha
Left with leading zeros
The unique provider number assigned by the HMO/ to the group practice. This
field is required for all providers who are members of a group, such as PCPs and
specialists. The group affiliation number must be the same for all providers who
are members of that group. A record is also required for each group practice
being reported. For groups, this identification number must be the same as the
plan provider number.
SSN or FEIN
9
X
alpha
Left with leading zeros
Social Security Number of Federal Identification Number for the individual
provider or the group practice.
Provider last name
30
X
alpha
Left
The last name of the provider, or the first 30 characters of the name of the
group. (Please do not include courtesy titles such as Dr., Mr., Ms., since this
titles can interfere with electronic searches of the data.) This field should
also be used to note hospital name. UPPER CASE ONLY PLEASE.
Provider first name
30
X
alpha
Left
The first name of the provider, or the continuation of the name of the group.
Please do not include provider middle name in this field. Middle name field has
been added at the end of the file for this purpose. UPPER CASE ONLY PLEASE.
Address line 1
30
X
alpha
Left
Physical location of the provider or practice. Do not use P.O. Box or mailing
address is different from practice location. UPPER CASE ONLY PLEASE.
Address line 2
30
 
alpha
Left
 
City
30
X
alpha
Left
Left
Physical city location of the provider or practice. UPPER CASE ONLY PLEASE
Zip Code
9
X
numeric
Left with trailing zeros
Physical zip code location of the provider or practice. Accuracy is important,
since address information is one of the standard items used to search for
providers that are located in close proximity to the member.
Phone area code
3
 
numeric
Left
 
Phone number
7
 
numeric
Left
Please note that the format does not allow for use of a hyphen.
Phone extension
4
 
numeric
Left
 
Sex
1
 
alpha
Left
The gender of the provider. Valid values: M = male; F = Female; U = Unknown
PCP Indicator
1
X
alpha
Left
Used to indicate if an individual provider is a primary care physician, or for
the , a medical home. Valid values: P = Yes, the provider is a PCP/medical home;
N = No, the provider is not a PCP/medical home. This field should not be used to
note group providers as PCPs, since members must be assigned to specific
providers, not group practices.
Provider Limitation
1
Required if PCP Indicator = P
alpha
Left
X = Accepting new patients
N = Not accepting new patients but remaining a contracted network provider
L = Not accepting new patients; leaving the network (Please note the “L”
designation at the earliest opportunity)
P = Only accepting current patients
C = Accepting children only
A = Accepting adults only
R = Refer member to HMO/ member services
F = Only accepting female patients
S = Only serving children through CMS (MediPass/PSN only)
HMO//MediPass Indicator
1
X
alpha
Left
H = HMO/
This field must be completed with this designation for each record submitted by
the HMO/.
Evening hours
1
 
alpha
Left
Y = Yes; N = No
Saturday hours
1
 
alpha
Left
Y = Yes; N = No
Age restrictions
20
 
alpha
Left
Populate this field with free-form text, to identify any age restriction the
provider may have on their practice.
Primary Specialty
3
Required if Provider Type = P or I
numeric
Left with leading zeros
Insert the 3 digit code that most closely describes
001 Adolescent Medicine 002 Allergy
003 Anesthesiology 004 Cardiovascular Medicine
005 Dermatology 006 Diabetes
007 Emergency Medicine 008 Endocrinology
009 Family Practice 010 Gastroenterology
011 General Practice 012 Preventative Medicine
013 Geriatrics 014 Gynecology
015 Hematology 016 Immunology
017 Infectious Diseases 018 Internal Medicine
019 Neonatal/Perinatal 020 Neoplastic Diseases
021 Nephrology 022 Neurology
023 Neurology/Children 024 Neuropathology
025 Nutrition 026 Obstetrics
027 OB-GYN 028 Occupational Medicine
029 Oncology 030 Ophthalmology
031 Otolaryngology 032 Pathology
033 Pathology, Clinical 034 Pathology, Forensic
035 Pediatrics 036 Pediatric Allergy
037 Pediatric Cardiology 038 Pediatric Oncology &Hematology
039 Pediatric Nephrology 040 Pharmacology
041 Physical Medicine and Rehab 042 Psychiatry 
043 Psychiatry, Child 044 Psychoanalysis
045 Public Health 046 Pulmonary Diseases
047 Radiology 048 Radiology, Diagnostic
049 Radiology, Pediatric 050 Radiology, Therapeutic
051 Rheumatology 052 Surgery, Abdominal
053 Surgery, Cardiovascular 054 Surgery, Colon / Rectal
055 Surgery, General 056 Surgery, Hand
057 Surgery, Neurological 058 Surgery, Orthopedic
059 Surgery, Pediatric 060 Surgery, Plastic
061 Surgery, Thoracic 062 Surgery, Traumatic
063 Surgery, Urological 064 Other Physician Specialty
065 Maternal/Fetal 066 Assessment Practitioner
067 Therapeutic Practitioner 068 Consumer Directed Care
069 Medical Oxygen Retailer  070 Adult Dentures Only
071 General Dentistry 072 Oral Surgeon (Dentist)
073 Pedodontist 074 Other Dentist
075 Adult Primary Care Nurse Practitioner 076 Clinical Nurse Spec
077 College Health Nurse Practitioner 078 Diabetic Nurse Practitioner
079 Brain & Spinal Injury Medicine  080 Family/Emergency Nurse Practitioner
081 Family Planning Nurse Practitioner 082 Geriatric Nurse Practitioner
083 Maternal/Child Family Planning Nurse Practitioner 084 Reg. Nurse Anesthetist
085 Certified Registered Nurse Midwife 086 OB/GYN Nurse Practitioner
087 Pediatric Neonatal  088 Orthodontist
089 Assisted Living for the Elderly 090 Occupational Therapist
091 Physical Therapist 092 Speech Therapist
093 Respiratory Therapist 
 
100 Chiropractor
101 Optometrist 102 Podiatrist
103 Urologist 104 Hospitalist
 
BH1 Psychology, Adult BH2 Psychology, Child
BH3 Mental Health Counselor BH4 Community Mental Health Center
BH5 Clubhouse (TBD) 
Specialty 2
3
 
numeric
Left with leading
Use codes listed above.
Specialty 3
3
 
numeric
Left with leading
Use codes listed above.
Language 1
2
 
numeric
Left with leading
01 = English
02 = Spanish
03 = Haitian Creole
04 = Vietnamese
05 = Cambodian
06 = Russian
07 = Laotian
08 = Polish
09 = French
10 = Other
Language 2
2
 
numeric
 
Use codes listed above.
Language 3
2
 
numeric
 
Use codes listed above.
Hospital Affiliation 1
9
 
numeric
Left with leading zeros
Hospital with which the provider is affiliated. Use the AHCA ID for accurate
identification,
Hospital Affiliation 2
9
 
numeric
Left with leading zeros
as above
Hospital Affiliation 3
9
 
numeric
Left with leading zeros
as above
Hospital Affiliation 4
9
 
numeric
Left with leading zeros
as above
Hospital Affiliation 5
9
 
numeric
Left with leading zeros
as above
Wheel Chair Access
1
 
alpha
 
Indicates if the provider’s office is wheelchair accessible. Use Y = Yes or N =
No.
# of HMO/ Members
4
X
numeric
Left with leading zeros
Information must be provided for PCPs only. Indicates the total number of
patients who are enrolled in submitting plan. For providers who practice at
multiple locations, the number of HMO/ members specific to each physical
location must be specified.
Active Patient Load
4
X
numeric
Left with leading zeros
Total Active Patient Load, as defined in contract
Professional License Number
10
X
alpha/ numeric
 
Must be included for all health care professionals. License number is formatted
with up to 3 alpha characters followed by up to 7 numeric digits.
AHCA Hospital ID1   
8
Required if Provider Type = “H”
numeric
Left with leading zeros
The number assigned by the Agency to uniquely identify each specific hospital by
physical location. Any out of state hospital for which an AHCA ID is not
included should be designated with the pseudo-number 99999999.
County Health Department (CHD) Indicator
1
X
alpha
 
Used to designate whether the individual or group provider is associated only
with a county health department. Y = Yes; N = No. This field must be completed
for all PCP and specialty providers.
Filler
47
X
     

Trailer Record
The trailer record is used to balance the number of records received with the
number loaded on BESST. The data
from the Trailer Record is not loaded on BESST.

RECORD LENGTH: 76

Filed Name
Field Length
Field Format
Values
Trailer Record Text
36
Alpha
‘TRAILER RECORD DATA’
Record Count
7
Numeric
Total number of records on file excluding the trailer record (right justified,
zero filled)
System Process date
8
Alpha
Mmddyyyy
Filler
25
   

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1 The Agency provided the list of AHCA IDs for Hospitals to Health Plans on
8-26-05. 

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

Provider Error File Layout

File Name
Provider Error File
XXX_PROV_ERRyyyymmdd.dat
The date is the day the file is made available.

XXX = 3 character plan identifier

File Layout
Row #
Type
Description
1
Text
Message identifying purpose of file
2
Date
Date file was processed
3
Title and count
Count of records skipped by load process
4
Title and count
Count of records read by load process
5
Title and count
Count of records rejected by load process
6
Title and count
Count of records discarded by load process
7
Count
Number of rows loaded - should match the number of rows in the trailer record
minus any skipped, rejected or discarded
8
Blank
 
9
Title
BAD:
10
Blank
List of records skipped
11
Title
DISCARDED
12
Blank
List of records read and discarded
13
Title
Trailer record
14
Trailer record
Trailer record from provider file

Notes:

If trailer record of the submitted provider file is not 76 characters it will be
counted as Discarded and under Trailer Record section of the error file.
If trailer record starts with ‘TRAILER RECORD DATA’ but does not otherwise match
the trailer record format for the provider file it will be listed as Discarded
and under Trailer Record section of the error file.

Blank rows in the provider file will show in the error file under BAD. This
section of the file generally only has one blank row between it and the
DISCARDED section. If more rows exist then the program is reporting blank rows
in the provider file.

If there is no trailer record listed in the Trailer Record of the file then
there was no trailer record in the provider file. A trailer record must match
the file layout to be considered by the program as a trailer record.

File Example

THE FOLLOWING ERRORS WERE FOUND IN YOUR PROVIDER FILE
15-Feb-2006
Total logical records skipped: 0
Total logical records read: 5983
Total logical records rejected: 0
Total logical records discarded: 0
5983 Rows successfully loaded.
 
BAD:

DISCARDED:

Trailer Record:
TRAILER RECORD DATA 000598302132006

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E.
Marketing Representative Report

 
1.
The Health Plan shall register each marketing representative with the Agency as
outlined in Section IV, Enrollee Services and Marketing. The file will be
submitted to the Agency prior to initial marketing activity to the following
e-mail address: MMCDATA@ahca.myflorida.com. The Agency-supplied spreadsheet
template must be used - Agent Registration Template.xls. Changes to the initial
registration will be submitted immediately upon occurrence to the Agency at the
following e-mail address: MMCDATA@ahca.myflorida.com. The Agency-supplied
spreadsheet template must be used - Change in Agent Registration Template.xls.
Do not change or alter the templates. These templates contain the following
required data elements:

Table 4

Required Information for Marketing Representative Report Template

Plan Information
Marketing Representative Information
Plan Name
Last Name
Address
First Name
Contact Person
License Number issued by DFS
Phone
DFS License Issue Date
Fax
DFS License Termination Date
 
Address
 
City
 
State
 
Zip Code
 
Office Telephone
 
Cellular Telephone
 
Home Telephone
 
Last HMO Employer

 
2.
Agent Registration Template.xls Template is an Excel workbook consisting of
three (3) worksheets:

§  
Instructions for the completion of the Template

§  
Jurat - health plan information

§  
Active Agents - marketing representative information

 
3.
Complete the Jurat worksheet by entering the correct information for (Plan
Name), (Plan Address), (Contact Name), (Phone Number), (Fax Number) and the
correct date for the month being reported.

4.  
Complete the Active Agents worksheet by entering the required information for
all Marketing Representatives for the Health Plan.

5.  
Submit to the Agency. The file will be submitted to the Agency prior to initial
marketing activity via electronic mail to mmcdata@ahca.myflorida.com. Name the
file in the convention of R***YYMM.xls where *** is the 3-character plan
identifier, YY is the year and MM is the month being reported.

6.  
The Agent Registration Template.xls Template is an Excel workbook consisting of
three (3) worksheets:

§  
Instructions for the completion of the Template

§  
Jurat - health plan information

§  
New Activity - changes, additions and deletions to marketing representative
information

7.  
Complete the Jurat worksheet by entering the correct information for (Plan
Name), (Plan Address), (Contact Name), (Phone Number), (Fax Number) and the
correct date for the month being reported.

8.  
Submit to the Agency immediately upon occurrence via electronic mail to
mmcdata@ahca.myflorida.com. Name the file in the convention of R***YYMM.xls
where *** is the 3-character plan identifier, YY is the year and MM is the month
being reported.

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F.
Critical Incidents

 
a.
The Health Plan shall report all serious Enrollee injuries occurring through
health care services within 15 days of the Health Plan receiving information
about the injury. The Health Plan will use the Florida Agency for Health Care
Administration, Division of Health Quality Assurance’s Code 15 Report for
Florida Ambulatory Surgical Centers, Hospitals and HMOs to document the
incident. The Health Plan shall send the Code 15 Report to the Health Plan’s
analyst in the Bureau of Managed Health Care. The Health Plan can find the Code
15 Report at:

www.ahca.myflorida/MCHQ/Health_Facility_Regulation/Risk/reporting

G.
Hernandez Settlement Agreement (HSA) Report

 
1.
If the Health Plan has authorization requirements for prescribed drug services,
the Health Plan shall file reports biannually to the Bureau of Managed Health
Care, to include the following:

 
a.
The results of the HSA survey with:

 
(1)
The total number of pharmacy locations surveyed;

 
(2)
The HSA areas surveyed;

 
(3)
Those HSA areas in which the pharmacy locations were delinquent; and

 
(4)
The process by which the Health Plan selected the pharmacy locations.

 
b.
A copy of the Health Plan’s completed Hernandez Ombudsman Log.

H.
Performance Measure Report

 
1.
The Health Plan shall report the performance measures described in Section
VIII.A.3.c.

 
2.
The Health Plan shall calculate the performance measures based on the calendar
year (January 1 through December 31), unless otherwise specified.

 
3.
The performance measure report is due by October 1 after the measurement year.

I.
Financial Reporting

 
1.
The Health Plan shall complete the spreadsheet supplied by the Agency.

 
2.
Audited financial reports — The Health Plan shall submit to the Agency annual
audited financial statements and four (4) quarterly unaudited financial
statements.

 
a.
The audited financial statements are due no later than three (3) calendar months
after the end of the Health Plan’s fiscal year.

 
b.
The Health Plan shall submit the quarterly unaudited financial statements no
later than forty-five (45) days after each calendar quarter and shall use
generally accepted accounting principles in preparing the unaudited quarterly
financial statements, which shall include, but not be limited to, the following:

(1) A Balance Sheet;

(2) A Statement of Revenues and Expenses;

(3) A Statement of Cash Flows; and

(4) Footnotes.

 
c.
The Health Plan shall submit the annual and quarterly financial statements
using, an Agency-supplied template, by electronic transmission to the following
e-mail address:

MMCFIN@AHCA.MYFLORIDA.COM

 
d.
The Health Plan should mail in hard copy form (or submit to the above email
address in a .PDF format) the audited financial statement along with a copy of
the audited CPA report and CPA letter of opinion to:

Agency for Health Care Administration
Bureau of Managed Health Care
Data Analysis Unit
2727 Mahan Drive, MS # 26
Tallahassee, Florida 32308

 
e.
The Health Plan shall submit annual and quarterly financial statements that are
specific to the operations of the Health Plan rather than to a parent or
umbrella organization.

J.
Suspected Fraud Reporting

 
1.
Provider Fraud and Abuse

 
a.
Upon detection of a potential or suspected fraudulent claim submitted by a
provider, the Health Plan shall file a report with the Agency’s Bureau of
Managed Health Care, MPI and MFCU. The report shall contain at a minimum:

 
(1)
The name of the provider;

 
(2)
The assigned Medicaid provider number and the tax identification number;

 
(3)
A description of the suspected fraudulent act; and

2. Enrollee Fraud

 
a.
Upon detection of all instances of fraudulent claims or acts by an Enrollee, the
Health Plan shall file a report with the Agency and MPI.

 
b.
The report shall contain, at a minimum:

(1) The name of the Enrollee,

(2) The Enrollee’s Health Plan identification number,

(3) The Enrollee’s Medicaid identification number,

(4) A description of the suspected fraudulent act, and

 
3.
Failure to report instances of suspected Fraud and Abuse is a violation of law
and subject to the penalties provided by law.

K.
Information Systems Availability and Performance Report

 
1.
The Information Systems Availability and Performance Report shall be submitted
using the template provided by the Agency; the template’s layout is illustrated
in Table 6, below.  This Report shall be submitted to the Agency by the Health
Plan only if it extends access to “critical systems functions” to Providers and
Enrollees as described in Section XI.D.1 of this Contract.  The Report shall
only include “critical systems functions” as indicated per Section XI.D.1 of
this Contract.  The Report shall provide total uptime, total downtime and total
unscheduled downtime by system function for the report month.

Table 5

Information Systems Availability and Performance Report

Sample Information Systems Availability and Performance Report Format and
Content
System
 
Total Up Time
Total Down Time
Total UNSCHEDULED Down Time ("Outage Time")
 
Measurement Period
Up Time During Period
Up Time During Period
During Period
Notes/Comments
 
For All Measured Systems:
98.66%
1.34%
 
 
system1
28 days
02/01-02/28
94.79%
5.21%
 
 
system2
28 days
02/01-02/28
99.29%
0.71%
 
 
system3
28 days
02/01-02/28
99.42%
0.58%
 
 
system4
28 days
02/01-02/28
100.00%
0.00%
 
 
system5
28 days
02/01-02/28
96.76%
3.24%
 
 
system6
28 days
02/01-02/28
99.33%
0.67%
 
 
system7
28 days
02/01-02/28
99.39%
0.61%
 
 
system8
28 days
02/01-02/28
99.45%
0.55%
 
 
system9
28 days
02/01-02/28
98.76%
1.24%
 
 
system10
28 days
02/01-02/28
99.40%
0.60%
 
 
Note: color scheme indicates systems which total down time that exceeded a
threshold
(e.g. exceeded 0.5% = light yellow; exceeded 3% = yellow; exceeded 5% = red).

L.
Claims Inventory Summary Report

 
1.
The Health Plan shall file an Aging Claims Summary Report quarterly, noting
paid, denied and unpaid claims by provider type. The Health Plan will submit
this report using the CLAIMS AGING TEMPLATE.xls file supplied by the Agency and
presented in Tables 6, 6-A, 6-B, 6-C and 6-D. This file is an Excel spreadsheet
and may be submitted to the following email address: mmcclms@ahca.myflorida.com.

Table 6

Total Claims Aging By Provider Type

00/00/00
 
 
NOTE: List ALL claims including those contained in the beginning inventory on
this page.
 
 
 
days
 
days
 
days
 
days
 
days
 
TOTAL
PROVIDER
1-30
%
31-60
%
61-90
%
91-120
%
120+
%
CLAIMS
PRIMARY CARE
 
0%
 
0%
 
0%
 
0%
 
0%
0
SPECIALTY
 
0%
 
0%
 
0%
 
0%
 
0%
0
OTHER
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
 
 
 
 
 
 
 
 
 
 
HOSPITALS:
 
 
 
 
 
 
 
 
 
 
 
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0

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Table 6-A

Paid Claims Aging by Provider Type Report

00/00/00
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
days
 
days
 
days
 
days
 
days
 
TOTAL
PROVIDER
1-30
%
31-60
%
61-90
%
91-120
%
120+
%
CLAIMS
PRIMARY CARE
 
0%
 
0%
 
0%
 
0%
 
0%
0
SPECIALTY
 
0%
 
0%
 
0%
 
0%
 
0%
0
OTHER
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
 
 
 
 
 
 
 
 
 
 
HOSPITALS:
 
 
 
 
 
 
 
 
 
 
 
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0

Table 6-B

Denied Claims Aging By Provider Type

00/00/00
   
 
 
 
 
 
 
 
 
 
days
 
days
 
days
 
days
 
days
 
TOTAL
PROVIDER
1-30
%
31-60
%
61-90
%
91-120
%
120+
%
CLAIMS
PRIMARY CARE
 
0%
 
0%
 
0%
 
0%
 
0%
0
SPECIALTY
 
0%
 
0%
 
0%
 
0%
 
0%
0
OTHER
 
0%
 
0%
 
0%
 
0%
 
0%
0
                       
HOSPITALS:
                     
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0
 
 
0%
 
0%
 
0%
 
0%
 
0%
0

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Table 6-C

Unpaid Claims Aging by Provider Type Report

 
00/00/00
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
days
 
days
 
days
 
days
 
days
 
TOTAL
PROVIDER
1-30
%
31-60
%
61-90
%
91-120
%
120+
%
CLAIMS
PRIMARY CARE
0
0%
0
0%
0
0%
0
0%
0
0%
0
SPECIALTY
0
0%
0
0%
0
0%
0
0%
0
0%
0
OTHER
0
0%
0
0%
0
0%
0
0%
0
0%
0
 
 
 
 
 
 
 
 
 
 
 
 
HOSPITALS:
 
 
 
 
 
 
 
 
 
 
 
 
0
0%
0
0%
0
0%
0
0%
0
0%
0
 
0
0%
0
0%
0
0%
0
0%
0
0%
0
 
0
0%
0
0%
0
0%
0
0%
0
0%
0

Table 6-D

Claims Inventory by Provider Type

00/00/00
 
Inventory
 
 
 
 
(Ending Inventory from Previous quarter)
 
 
 
 
 
Beginning
Claims
 
 
Ending
PROVIDER
Inventory
Received
Claims Paid
Claims Denied
Inventory
PRIMARY CARE
 
0
0
0
0
SPECIALTY
 
0
0
0
0
OTHER
 
0
0
0
0
 
 
 
 
 
 
HOSPITALS:
 
 
 
 
 
 
 
0
0
0
0
 
 
0
0
0
0
 
 
0
0
0
0

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M.
Child Health Check-Up Reports

 
1.
The Health Plan shall submit the Child Health Check Up, CMS 416. The Health Plan
shall submit the report annually in the format set forth in Table 7, below. The
reporting period is the federal fiscal year, October 1 - September 30. The
report is due on January 15, following the reporting period. The Health Plan
shall submit to the Agency a certification by an Agency-approved independent
auditor that the information and data contained in the Child Health Check-Up
report is fairly and accurately presented before October 1 following each
reporting period. This filing requires a copy of the audited reports and a copy
of the auditors' letter of opinion.

 
2.
For each of the following line items, report total counts by the age groups
indicated. In cases where calculations are necessary, perform separate
calculations for the total column and each age group. Report age based upon the
child's age as of September 30 of the federal fiscal year.

Medicaid Provider ID Number: Enter the plan's seven digit Medicaid Provider ID
number, i.e., 015----

Plan Name: Enter the name of the Health Plan.

Fiscal Year: Enter the federal fiscal year being reported.

Line 1 - Total Individuals Eligible for Child Health Check-Up (CHCUP):  Enter
the total unduplicated number of all Enrollees under the age of 21, distributed
by age and by basis of Medicaid Eligibility category. Unduplicated means that an
Enrollee is reported only once, although he or she may have had more than one
period of Eligibility during the year. All Enrollees under age 21 are considered
eligible for CHCUP services, regardless of whether they have been informed about
the availability of CHCUP services or whether they accept CHCUP services at the
time of informing. Do not count Enrollees in the MediKids populations.

Line 2a - State Periodicity Schedules - Given.

Line 2b - Number of Years in Age Group - Given.

Line 2c - Annualized State Periodicity Schedule - Given.

Line 3a - Total Months Eligibility - Enter the total months of Eligibility for
the Enrollees in each age group in Line 1 during the reporting year.

Line 3b - Average Period of Eligibility - Pre-calculated by dividing the total
months of Eligibility by Line 1, then by dividing that number by 12. This number
represents the portion of the year that Enrollees remain Medicaid Eligible
during the reporting year, regardless of whether Eligibility was maintained
continuously.

Line 4 - Expected Number of Screenings per Eligible Multiply - Pre-calculated by
multiplying Line 2c by Line 3b. This number reflects the expected number of
initial or periodic screenings per Child/Adolescent per year based on the number
required by the State-specific periodicity schedule and the average period of
Eligibility.

Line 5 - Expected Number of Screenings - Pre-calculated by multiplying Line 4 by
Line 1. This reflects the total number of initial or periodic screenings
expected to be provided to the Enrollees in Line 1.

Line 6 - Total Screenings Received - Enter the total number of initial or
periodic screens furnished to Enrollees. Use the CPT codes listed below or any
Health Plan-specific CHCUP codes developed for these screens. Use of these proxy
codes is for reporting purposes only.

 
3.
The Health Plan must continue to ensure that all five (5) age-appropriate
elements of an CHCUP screen, as defined by law, are provided to CHCUP eligible
Enrollees

 
4.
This number should not reflect sick visits or episodic visits provided to
Children/Adolescents unless an initial or periodic screen was also performed
during the visit. However, it may reflect a screen outside of the normal state
periodicity schedule that the Plan uses as a "catch-up" CHCUP screening. The
Agency defines a catch-up CHCUP screening as a complete screening that is
provided to bring a child up-to-date with the State's screening periodicity
schedule. The Health Plan shall use data reflecting date of service within the
fiscal year for such screening services or other documentation of such services.
The Health Plan shall not count MediKids Enrollees, who have had a check-up. The
Health Plan shall use the following CPT-4 codes to document the receipt of an
initial or periodic screen:

Codes for Preventive Medicine Services

99381 New Patient Under One Year
99382 New Patient Ages 1 - 4 Years
99383 New Patient Ages 5 - 11 Years
99384 New Patient Ages 12 - 17 Years
99385EP New Patient Ages 18 - 39 Years
99391 Established Patient Under One Year
99392 Established Patient Ages 1 - 4 Years
99393 Established Patient Ages 5 - 11 Years
99394 Established Patient Ages 12 - 17 Years
99395EP Established Patient Ages 18 - 39 Years
99431 Newborn Care - History and Examination
99432 Normal Newborn Care
99435 Newborn Care (history and examination)

Codes For Evaluation and Management Services (must be used in conjunction with V
codes V20-V20.2 and/or V70.0 and/or V70.3-V70.9)

99201-99205 New Patient
99211-99215 Established Patient

Line 7 - Screening Ratio - Pre-calculated by dividing the actual number of
initial and periodic screening services received (Line 6) by the expected number
of initial and periodic screening services (Line 5). This ratio indicates the
extent to which CHCUP eligible Enrollees receive the number of initial and
periodic screening services required by the State's periodicity schedule,
adjusted by the proportion of the year for which they are Medicaid Eligible.
This ratio should not be over 100%. Any data submitted which exceeds 100% will
be reflected as 100% on the final report.

Line 8 - Total Eligibles Who Should Receive at Least One (1) Initial or Periodic
Screen- The number of Enrollees who should receive at least one (1) initial or
periodic screen is dependent on the State's periodicity schedule. The State uses
the following calculations to determine the number of Enrollees:

 
a.
If the number entered in Line 4 is greater than 1, the number 1 is used. If the
number in Line 4 is less than or equal to 1, the number in Line 4 is used. This
eliminates situations where more than one visit is expected in any age group in
a year.

 
b.
The number from calculation 1 is multiplied by the number in Line 1 and entered
on Line 8.

Line 9 - Total Eligibles Receiving at Least One (1) Initial or Periodic Screen -
Enter the unduplicated count of Enrollees who received at least one (1)
documented initial or periodic screen during the year. Refer to codes in Line 6
and count Enrollees where the Health Plan have received a claim. The Health Plan
shall not count MediKids Enrollees who have had a check-up.

Line 10 - Participant Ratio - Pre-Calculated by dividing Line 9 by Line 8. This
ratio indicates the extent to which Enrollees are receiving any initial and
periodic screening services during the year. NOTE: The Health Plan shall adopt
annual participation goals to achieve at least an eighty percent (80%) CHCUP
participation rate pursuant to Section 5360, Annual Participation Goals, of the
State Medicaid Manual.

Line 11 - Total Eligibles Referred for Corrective Treatment - Enter the
unduplicated number of Enrollees who, as a result of at least one (1) health
problem identified during an initial or periodic screening service, including
vision and hearing screenings, were scheduled for another appointment with the
screening provider or referred to another provider for further needed diagnostic
or treatment services. This element does not include correction of health
problems during the course of a screening examination. This element is required.
The Health Plan should include the new federally required referral codes in Line
11.

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For reporting on the CMS-416 only count the referral codes "T" and "V". 
U
Complete Normal
Used when there are no referrals made.
2
Abnormal, Treatment Initiated
Used when a child is currently under treatment for referred diagnostic or
corrective health problem.
T
Abnormal, Recipient Referred
Used for referrals to another provider for diagnostic or corrective treatments
or scheduled for another appointment with check-up provider for diagnostic or
corrective treatment
for at least one (1) health problem identified during an initial check-up
V
Patient Refused Referral
Used when the patient refused a referral.

 
5.
For purposes of reporting information on dental services, unduplicated means
that the Health Plan counts each child once for each line of data requested.
Example: The Health Plan would count a child once on Line 12a for receiving any
dental service and count the child again for Line 12b and/or 12c if the child
received a preventive and/or treatment dental service. These numbers should
reflect services received in managed care. Lines 12b and 12c do not equal total
services reflected on Line 12a.

Line 12a - Total Eligibles Receiving Any Dental Services - Enter the
unduplicated number of Children/Adolescents receiving any dental services as
defined by CDT Codes D0100 - D9999.

Line 12b - Total Eligibles Receiving Preventive Dental Services - Enter the
unduplicated number of Children/Adolescents receiving a preventive dental
service as defined by CDT Codes D1000 - D1999.

Line 12c - Total Eligibles Receiving Dental Treatment Services - Enter the
unduplicated number of Children/Adolescents receiving treatment services as
defined by CDT Codes D2000 - D9999.

Line 13 - Total Eligibles Enrolled in Managed Care - This number is for
informational purposes only. This number represents all Enrollees eligible for
CHCUP services, who were Enrolled at any time during the reporting year. The
Health Plan should include these Enrollees in the total number of unduplicated
eligibles on Line 1 and the Health Plan should include the number of initial or
periodic screenings provided to these Enrollees in Lines 6 and 8 for purposes of
determining the State's screening and participation rates. The Health Plan
should include the number of Enrollees referred for corrective treatment and
receiving dental services in Lines 11 and 12, respectively. Do not count
MediKids Enrollees.

 
6.
To report the number of screening blood lead tests the Health Plan shall do the
following: Count the number of times CPT code 83655 ("lead") or any
State-specific (local) codes used for a blood lead test reported with any
ICD-9-CM except with diagnosis codes 984 (.0 - .9) ("Toxic Effects of Lead and
Its Compounds"), E861.5 ("Accidental Poisoning by Petroleum Products, Other
Solvents and Their Vapors NEC: Lead Paints"), and E866.0 (Accidental Poisoning
by Other Unspecified Solid and Liquid Substances: Lead and Its Compounds and
Fumes"). The Agency uses these specific ICD-9-CM diagnosis codes to identify
people who are lead poisoned. The Health Plan should not count blood lead tests
done on these individuals as a screening blood lead test. This is a federally
mandated test for Enrollees ages 12 months, 24 months and between the ages of 36
- 72 months whom the Health Plan has not previously screened for lead poisoning.

Line 14 - Total Number of Screening Blood Lead Tests - Enter the total number of
screening blood lead tests furnished to eligible Enrollees. Blood lead tests
done on Enrollees who have been diagnosed or treated for lead poisoning should
not be counted. Do not make entries in the shaded columns.

Line 15 - Total Number of POSITIVE Screening Blood Lead Tests - Enter the total
number of positive blood lead tests.

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Table 7

Child Health Check Up Report

 
Enter Data in Blue Colored Out-Lined Cells Only
CHILD HEALTH CHECK-UP REPORT (CHCUP) [CMS-416]
 
Seven Digit Medicaid Provider Number :
 
This report is due to the Agency no later than January 15.
 
Plan Name :
 
 
 
 
Federal Fiscal Year :
 
 
 
The Audited Report is due October 1.
 
Age Groups
 
 
 
 
 
 
 
Less than 1 Year
1-2 Years *
3-5 Years
6-9 Years
10-14 Years
15-18 Years
19-20 Years
Total All Years
1.
Total Individuals Eligible for CHCUP (Unduplicated)
 
 
 
 
 
 
 
 
2a.
State Periodicity Schedule
6
4
3
2
5
4
2
 
2b.
Number of Years in Age Group
1
2
3
4
5
4
2
 
2c.
Annualized State Periodicity Schedule
6.00
2.00
1.00
0.50
1.00
1.00
1.00
 
3a.
Total Months of Eligibility
 
 
 
 
 
 
 
 
3b.
Average Period of Eligibility
 
 
 
 
 
 
 
 
4.
Expected Number of screenings per Eligible
 
 
 
 
 
 
 
 
5.
Expected Number of screenings
 
 
 
 
 
 
 
 
6.
Total Screens Received
 
 
 
 
 
 
 
 
7.
Screening Ratio
 
 
 
 
 
 
 
 
8.
Total Eligible who should receive at least one Initial or periodic screening
 
 
 
 
 
 
 
 
9.
Total Eligibles receiving at least one Initial or periodic screen (Unduplicated)
 
 
 
 
 
 
 
 
10.
Participation Ratio
 
 
 
 
 
 
 
 
11.
Total eligibles referred for corrective treatment (Unduplicated)
 
 
 
 
 
 
 
 
12a.
Total Eligibles receiving any dental services (Unduplicated)
 
 
 
 
 
 
 
 
12b.
Total Eligibles receiving preventative dental services (Unduplicated)
 
 
 
 
 
 
 
 
12c.
Total Eligibles receiving dental treatment services (Unduplicated)
 
 
 
 
 
 
 
 
13.
Total Eligibles Enrolled in Plan
 
 
 
 
 
 
 
 
14.
Total number of Screening Blood Lead Tests
 
 
 
 
 
 
 
 
15
Total number of POSITIVE Screening Blood Lead Tests
 
 
 
 
 
 
 
 

 

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

 
7.
Florida Sixty Percent (60%) Ratio

 
1.
The Health Plan shall submit the Child Health Check Up, CMS 416 Report annually
and in the formats as presented in Table 7-A. The reporting period is the
federal fiscal year. The report is due on January 1, following the reporting
period. The Health Plan shall submit to the Agency a certification by an
Agency-approved independent auditor that the information and data contained in
the Child Health Check-Up 60% Ratio report is fairly and accurately reported
before October 1 following each reporting period. This filing requires a copy of
the audited reports and a copy of the auditors' letter of opinion.

 
2.
For each of the following line items, the Health Plan shall report total counts
by the age groups indicated. In cases where calculations are necessary, the
Agency has inserted formulas to pre-calculate the field. Report age based upon
the child's age as of September 30 of the Federal fiscal year.

Medicaid Provider ID Number: Enter the Health Plan's basic seven digit Medicaid
Provider ID number, i.e., 015----

Plan Name: Enter the name of the Health Plan.

Fiscal Year: The federal fiscal year being reported.

Line 1 - Total Individuals Eligible for Child Health Check-Up (CHCUP): Enter the
total unduplicated number of all Enrollees under the age of 21 Enrolled
continuously for 8 months, distributed by age and by basis of Medicaid
Eligibility. Unduplicated means that an Enrollee is reported only once although
he or she may have had more than one period of Eligibility during the year. All
Enrollees under age 21 (except MediKids Enrollees) are considered eligible for
CHCUP services, regardless of whether they have been informed about the
availability of CHCUP services or whether they accept CHCUP services at the time
of informing.

Line 2a - State Periodicity Schedules - Given.

Line 2b - Number of Years in Age Group - Given.

Line 2c - Annualized State Periodicity Schedule - Given.

Line 3a - Total Months Eligibility - Enter the total months of eligibility for
the Enrollees in each age group in Line 1 during the reporting year.

Line 3b - Average Period Eligibility - Calculated by dividing the total months
of eligibility by Line 1, then by dividing that number by 12. This number
represents the portion of the year that Enrollees remain Medicaid Eligible
during the reporting year, regardless of whether Eligibility was maintained
continuously.

Line 4 - Expected Number of Screenings per Eligible Multiply - Calculated by
multiplying Line 2c by Line 3b. This number reflects the expected number of
initial or periodic screenings per Child/Adolescent per year based on the number
required by the State-specific periodicity schedule and the average period of
Eligibility.

Line 5 - Expected Number of Screenings - Calculated by multiplying Line 4 by
Line 1. This reflects the total number of initial or periodic screenings
expected to be provided to the Enrollees in Line 1.

Line 6 - Total Screenings Received - Enter the total number of initial or
periodic screens furnished to Enrollees. Use the CPT codes listed below or any
Health Plan-specific CHCUP codes developed for these screens. Use of these proxy
codes is for reporting purposes only.

 
3.
Health Plans must continue to ensure that all five (5) age-appropriate elements
of an CHCUP screen, as defined by law, are provided to CHCUP eligible Enrollees.

 
4.
The Health Plan shall not include sick visits or episodic visits provided to
Children/Adolescents in this number, unless an initial or periodic screen was
also performed during the visit. However, it may reflect a screen outside of the
normal State periodicity schedule that the Health Plan uses as a "catch-up"
CHCUP screening. The Agency defines a catch-up CHCUP screening as a complete
screening that is provided to bring a Child/Adolescent up-to-date with the
State's screening periodicity schedule. Use data reflecting date of service
within the fiscal year for such screening services or other documentation of
such services. Do not count MediKids Enrollees, who have had a check-up. The
Health Plan shall use the following CPT-4 codes to document the receipt of an
initial or periodic screen:

Codes for Preventive Medicine Services

99381 New Patient Under One Year
99382 New Patient Ages 1 - 4 Years
99383 New Patient Ages 5 - 11 Years
99384 New Patient Ages 12 - 17 Years
99385EP New Patient Ages 18 - 39 Years
99391 Established Patient Under One Year
99392 Established Patient Ages 1 - 4 Years
99393 Established Patient Ages 5 - 11 Years
99394 Established Patient Ages 12 - 17 Years
99395EP Established Patient Ages 18 - 39 Years
99431 Newborn Care - History and Examination
99432 Normal Newborn Care
99435 Newborn Care (history and examination)

Codes for Evaluation and Management (must be used in conjunction with V codes
V20-V20.2 and/or V70.0 and/or V70.3-V70.9)

99201-99205 New Patient
99211-99215 Established Patient

Line 7 - Screening Ratio - Calculated by dividing the actual number of initial
and periodic screening services received (Line 6) by the expected number of
initial and periodic screening services (Line 5). This ratio indicates the
extent to which CHCUP eligible Enrollees receive the number of initial and
periodic screening services required by the State's periodicity schedule,
adjusted by the proportion of the year for which they are Medicaid eligible.
This ratio should not be over 100%. Any data submitted which exceeds 100% will
be reflected as 100% on the final report. The goal ratio is sixty percent (60%)
or higher under State requirements.

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Table 7-A
Child Health Check Up Report

 
COMPLETE THIS 60% TEMPLATE TO MEET THE 60% SCREENING RATIO PURSUANT TO SECTION
409.912, FLORIDA STATUTES AND SECTIONS V.E.3 AND XIII, 2006-2009 MEDICAID HMO
CONTRACT
 
Enter Data in Blue Colored Out-Lined Cells ONLY - This report reflects only
those eligibles that have at least 8 months of continuous enrollment - State
Required
 
 
FL 60% SCREENING RATIO - CHILD HEALTH CHECK-UP REPORT (CHCUP) - 8 MONTHS
CONTINUOUS ENROLLMENT

 
Seven Digit Medicaid Provider ID Number :
 
The unaudited report is due to the Agency no later than January 15. The audited
report is due October 1.
 
Plan Name :
 
F.S. 409.912 & Section V.E.3., Medicaid HMO Contract
 
Federal Fiscal Year :
October 1, 2006 - September 30, 2007
REQUIRED FILING
 
Age Groups
 
 
 
 
 
 
 
 
 
Less than 1 Year
1-2 Years *
3-5 Years
6-9 Years
10-14 Years
15-18 Years
19-20 Years
Total All Years
1.
Total Individuals Eligible for CHCUP with 8 months continuous enrollment
(Unduplicated)
 
 
 
 
 
 
 
 
2a.
State Periodicity Schedule
6
4
3
2
5
4
2
26
2b.
Number of Years in Age Group
1
2
3
4
5
4
2
21
2c.
Annualized State Periodicity Schedule
6.00
2.00
1.00
0.50
1.00
1.00
1.00
1.24
3a.
Total Months of Eligibility
 
 
 
 
 
 
 
 
3b.
Average Period of Eligibility
 
 
 
 
 
 
 
 
4.
Expected Number of screenings per Eligible
 
 
 
 
 
 
 
 
5.
Expected Number of screenings                
 6.
 Total Screens Received                  
7.
 Screening Ratio - F.S. 409.912 & Section V.E.3., Medicaid HMO Contract        
       

 

 

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

N.
Pharmacy Encounter Data

 
1.
Health Plans shall submit pharmacy encounter data on an ongoing quarterly
payment schedule. For example, all claims paid between 04/01/06 and 06/30/06 is
due to the Agency by 07/31/06. The Health Plan should submit the data using the
following:

 
a.
The Health Plan must submit any claims paid during the payment period within
thirty (30) days after the end of the quarter.

b. The Health Plan should submit only the final adjudication of claims.

 
c.
The File Naming Convention is: [health plan abbreviation]_[current date]_[file
type]_[Production]_[file#]_[total # of files].format. For example:
ABC_07312006_Rx_Production_1_7.txt

 
d.
The Health Plan must include and accompany the files with a field layout and the
records must have carriage-returns and line-feeds for record/file separation.

 
e.
The Health Plan must submit all Medicaid pharmacy data via CD to the Bureau of
Health Systems Development. The Health Plan shall ensure that it submits the
data to the Agency timely, accurately and completely. The Health Plan must
include a certification letter as to the accuracy and completeness of the
information contained on the CD.

 
f.
At a minimum, the Health Plan must include the following data requirements - the
Plan ID, Transaction Reference number (claim identifier), NDC code, Date of
Service (CCYYMMDD), Medicaid ID as assigned by the State, and process/payment
date (CCYYMMDD).

 
g.
The Agency anticipates changing the format to reflect the NCPDP and is in the
process of developing the companion guide. The Health Plan shall conform to this
change upon notification.

O.
Transportation Services

 
1.
The Health Plan shall report the Transportation Services encounter data on a
quarterly basis as set forth below and in Tables 8 through 8-I.

a. A call log broken down by month that includes the following information:

 
(1)
Number of calls received;

 
(2)
Average time required to answer a call;

 
(3)
Number of abandoned calls;

 
(4)
Percentage of calls that are abandoned;

 
(5)
Average abandonment time; and

 
(6)
Average call time.

 
b.
A listing of the total number of reservations of Transportation Services by
month, level of service and percentage of level of service utilized, to include,
but not be limited to, the following:

(1) Ambulatory transportation;

(2) Long haul ambulatory transportation;

(3) Wheelchair transportation;

(4) Stretcher transportation;

(5) Ambulatory multiload transportation;

(6) Wheelchair multiload transportation;

(7) Mass transit pending transportation;

(8) Mass transit transportation;

(9) Mass transit transportation (Enrollee has pass); and

(10) Mass transit transportation (sent pass to Enrollee).

 
c.
A listing of the total number of authorized uses of Transportation Services, by
month, level of service and percentage of level of service utilized, to include,
but not be limited to, the following:

 
(1)
Ambulatory transportation;

 
(2)
Long haul ambulatory transportation;

 
(3)
Wheelchair transportation;

 
(4)
Stretcher transportation;

 
(5)
Ambulatory multiload transportation;

 
(6)
Wheelchair multiload transportation;

 
(7)
Mass transit pending transportation;

 
(8)
Mass transit transportation;

 
(9)
Mass transit transportation (Enrollee has pass); and

 
(10)
Mass transit transportation (sent pass to Enrollee).

 
d.
A listing of the total number of canceled trips, by month, level of service and
percentage of level of service utilized, to include, but not be limited to, the
following:

 
(1)
Ambulatory transportation;

 
(2)
Long haul ambulatory transportation;

 
(3)
Wheelchair transportation;

 
(4)
Stretcher transportation;

 
(5)
Ambulatory multiload transportation;

 
(6)
Wheelchair multiload transportation;

 
(7)
Mass transit pending transportation;

 
(8)
Mass transit transportation;

 
(9)
Mass transit transportation (Enrollee has pass); and

 
(10)
Mass transit transportation (sent pass to Enrollee).

 
e.
A listing of the total number of denied Transportation Services, by month, and a
detailed description of why the Plan denied the Transportation Service request.

 
f.
A listing of the total number of authorized trips, by facility type, for each
month and level of service.

 
g.
A listing of the total number of Transportation Service claims and payments, by
facility type, for each month and level of service.

 
2.
Establish a performance measure to evaluate the safety of the Transportation
Services provided by Participating Transportation Providers. The Health Plan
shall report the results of the evaluation to the Agency on August 15th of each
year;

 
3.
Establish a performance measure to evaluate the reliability of the vehicles
utilized by Participating Transportation Providers. The Health Plan shall report
the results of the evaluation to the Agency on August 15th of each year; and

 
4.
Establish a performance measure to evaluate the quality of service provided by a
Participating Transportation Provider. The Health Plan shall report the results
of the evaluation to the Agency on August 15th of each year.

 
5.
Certification - Each Health Plan/Transportation Provider shall submit an annual
safety and security certification in accordance with 14-90.10, F.A.C. and shall
submit to any and all Safety and Security Inspections and Reviews in accordance
with 14-90.12, F.A.C..

 
6.
The Plan shall report the following by August 15th of each year:

 
a.
The estimated number of one-way passenger trips the Health Plan expects to
provide in the following categories:

(1) Ambulatory transportation;

(2) Long haul ambulatory transportation;

(3) Wheelchair transportation;

(4) Stretcher transportation;

(5) Ambulatory multiload transportation;

(6) Wheelchair multiload transportation;

(7) Mass transit pending transportation;

(8) Mass transit transportation;

(9) Mass transit transportation (Enrollee has pass); and

(10) Mass transit transportation (sent pass to Enrollee).

 
7.
The actual amount of funds expended and the total number of trips provided
during the previous fiscal year; and

 

 
8.
The operating financial statistics for the previous fiscal year.

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

Table 8

Transportation Telephone Log Report

CY [yyyy]
 
AVERAGE
NUMBER
ABANDON-
AVERAGE
AVERAGE
 
CALLS
SPEED TO
ABANDONED
MENT
ABANDONMENT
TALK
MONTH
OFFERED
ANSWER
CALLS
PERCENT
TIME
TIME
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
[mm]
 
x:xx
#
pp.p%
x:xx
x:xx
Total
 
x:xx
#
pp.p%
x:xx
x:xx

- “yyyy” refers to the calendar year (e.g., “2007”)
- “mm” refers to the month (e.g., “01” for January, etc.)
- “x:xx” refers to a measurement of time (e.g., “2:45” for two minutes and
forty-five seconds or “0:59” for fifty-nine seconds
- “#” refers to a number
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

 
Table 8-A

Non-Emergency Transportation Staffing Report

CY yyyy
Non-Emergency Transportation Operations Staffing
 
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Administration
 
 
               
 
 
 
Billing Verification
 
 
               
 
 
 
Customer Service Representatives
 
 
               
 
 
 
Driver Training & Field Investigations
 
 
               
 
 
 
Fraud and Abuse
 
 
               
 
 
 
Information Technology
 
 
               
 
 
 
Ombudsman
 
 
               
 
 
 
Quality Assurance
 
 
               
 
 
 
Regional Offices
 
 
               
 
 
 
Social Services/Standing Order Dept.
 
 
               
 
 
 
Transportation Coordinators
 
 
               
 
 
 
Utilization Review
 
 
               
 
 
 
Vehicle Inspectors
                   
 
   
Public Transit Specialist
                   
 
   
Total
 
 
               
 
 
 

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)

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

Table 8-B
 

   
GROSS RESERVATIONS by Month by Level of Service
 
CY yyyy
Month:
Jan
Feb
Mar
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec
Totals
[County]
Ambulatory
                           
Commercial Air
                           
Long Haul Ambulatory
                           
Wheelchair
                           
Stretcher
                           
Ambulatory Multiload
                           
Wheelchair Multiload
                           
Mass Transit Pending
                           
Mass Transit
                           
Mass Transit Has Pass
                           
Mass Transit Sent Pass
                         
[County] Total
                         
 
 
 
                       
Percent
Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Commercial Air
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Long Haul Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Stretcher
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Ambulatory Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Pending
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Has Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Sent Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

Total Gross Transportations Reservations Report
- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

 

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

Table 8-C Net Authorized Transportation Report
 

   
NET AUTHORIZED TRIPS (Gross reservations less cancellations) for each Month by
Level of Service
 
CY yyyy
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
[County]
Ambulatory
                           
Commercial Air
                           
Long Haul Ambulatory
                           
Wheelchair
                           
Stretcher
                           
Ambulatory Multiload
                           
Wheelchair Multiload
                           
Mass Transit Pending
                           
Mass Transit
                           
Mass Transit Has Pass
                           
Mass Transit Sent Pass
                         
[County] Total
                         
 
 
 
                       
Percent
Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Commercial Air
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Long Haul Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Stretcher
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Ambulatory Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Pending
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Has Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Sent Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

Table 8-D Canceled Trip Transportation Report
 

   
CANCELLED TRIPS for each Month by Level of Service. Please note that the numbers
for a given month will likely increase over the ensuing month or two as
additional cancellations are entered.
 
CY yyyy
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
[County]
Ambulatory
                           
Commercial Air
                           
Long Haul Ambulatory
                           
Wheelchair
                           
Stretcher
                           
Ambulatory Multiload
                           
Wheelchair Multiload
                           
Mass Transit Pending
                           
Mass Transit
                           
Mass Transit Has Pass
                           
Mass Transit Sent Pass
                         
[County] Total
                         
 
 
 
                       
Percent
Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Commercial Air
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Long Haul Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Stretcher
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Ambulatory Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Pending
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Has Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Sent Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

Table 8-E

Transportation Complaint Report

   
COMPLAINTS for each Month by Complaint Type
CY yyyy
 
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
Region:
Complaint Type:
                         
[County]
Issue w/Health Plan
                         
 
Provider Late
                         
 
Issue with Driver
                         
 
Provider No Show
                         
 
Issue with tran. provider
                         
 
Rider No Show
                         
 
Injury*
                         
Broward County Total
                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
% reservations complaint free
 
 
                     
Percent
Issue w/Health Plan
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Provider Late
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Issue with Driver
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Provider No Show
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Issue with tran. provider
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Rider No Show
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Injury
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100% 
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

 
Table 8-F

Transportation Mileage Report

   
MILEAGE (based on Net Authorized Trips) for each MONTH and LEVEL of SERVICE:
CY yyyy
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[County[
Ambulatory
                           
Wheelchair
                           
Stretcher
                           
Ambulatory Multiload
                           
Wheelchair Multiload
                           
Mass Transit Has Pass
                           
Mass Transit Sent Pass
                         
[County] Total
                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Percent
Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Stretcher
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Ambulatory Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Wheelchair Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Has Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mass Transit Sent Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100%
100% 
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
AVERAGE MILES PER TRIP (based on Net Authorized Trips)
CY yyyy
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[County]
Ambulatory
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
 
Wheelchair
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
 
Stretcher
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
 
Ambulatory Multiload
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
 
Wheelchair Multiload
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
 
Mass Transit Has Pass
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
 
Mass Transit Sent Pass
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
[County] Total
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x
x.x

-
“x.x” refers to a measurement of distance (e.g., “2.5” for two and a half miles
or “0.9” for 9/10 of a mile)

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

Table 8-G

Denied Transportation Request Report

   
DENIED TRIP REQUESTS by Month and Region
CY yyyy
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
                             
[County]
Abuses NET services
                           
Has access to vehicle
                           
Non-covered service
                           
Lacks 3 days' notice
                           
Needs 9-1-1
                           
Ineligible for Medicaid
                           
Ineligible for M'caid NET (e.g., QMB)
                           
Refuses closest facil.
                           
Requires Ambulance
                           
Refused public transit
                           
Relative can transport
                           
Resides outside LCI service areas
                           
Uncooperative/abusive
                           
Dental Care 21 and Over
                         
[County] Total
                                                       
Percent
Abuses NET services
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
for
Has access to vehicle
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Month
Non-covered service
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Lacks 3 days' notice
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Needs 9-1-1
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Ineligible for Medicaid
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Ineligible for M'caid NET (e.g., QMB)
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Refuses closest facil.
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Requires Ambulance
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Refused public transit
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Relative can transport
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Resides outside LCI service areas
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Uncooperative/abusive
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Dental Care 21 and Over
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

 
Table 8-H

Net Authorized Trip Transportation Report

   
NET AUTHORIZED TRIPS by Facility Type for each Month and Level of Service
CY yyyy
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
[County]
Adult Daycare
                           
Assisted Living
                           
Clinic - Health
                           
Clinic - Specialty
                           
Dental
                           
Dialysis
                           
Doctors Office
                           
Facility
                           
Health Department
                           
Hospital
                           
Lab and x-ray
                           
Mental Health
                           
Mental Retardation
                           
Nursing Home
                           
Other
                           
Pharmacy
                           
Rehabilitation
                           
Residence
                           
School
                           
Specialist
                         
[County] Total
                         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Percent
Adult Daycare
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Assisted Living
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Clinic - Health
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Clinic - Specialty
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Dental
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Dialysis
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Doctors Office
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Facility
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Health Department
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Hospital
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Lab and x-ray
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mental Health
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Mental Retardation
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Nursing Home
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Other
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Pharmacy
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Rehabilitation
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Residence
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
School
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
 
Specialist
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
[County] Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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

Table 8-I

Unduplicated Riders Transportation Report

[County]
UNDUPLICATED RIDERS for each Month by Level of Service
CY - yyyy
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Totals
 
                         
Ambulatory
                         
Stretcher
                         
Wheelchair
                         
Ambulatory Multiload
                         
Wheelchair Multiload
                         
Mass Transit - Has Pass
                         
Mass Transit - Sent Pass
                         
Total
                         
 
                         
Ambulatory
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Stretcher
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Wheelchair
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Ambulatory Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Wheelchair Multiload
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Mass Transit - Has Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Mass Transit - Sent Pass
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
pp.p%
Percentage Total
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%

- “CY” stands for the Calendar Year
- “yyyy” refers to the calendar year (e.g., “2007”)
- [County] refers to the County Name (e.g., Broward County, Dade County, etc.)
- “pp.p” refers to a number expressed as a percentage (e.g., “23.8%” or “08.4%”)

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P.
Enrollee Satisfaction Survey Summary

 
1.
In all Service Areas in which the Health Plan provides Behavioral Health
Services, the Health Plan shall conduct a Behavioral Health Services Enrollee
Satisfaction Survey in both English and Spanish.

 
2.
The Health Plan shall report the Enrollee Satisfaction Survey Summary to the
Agency in accordance with the requirements set forth in Table 9, Enrollee
Satisfaction Survey Summary, below.

Table 9

Enrollee Satisfaction Survey Summary

Number of surveys distributed
 
Number of surveys completed
 
Method used
 
Number of Responses for each item on the survey
 

Item Numbers
Agree
Disagree
No Response
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
6
 
 
 
7
 
 
 
8
 
 
 
9
 
 
 
10
             
Significant findings or results that will be addressed: 
         

 

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

Q.
Stakeholders’ Satisfaction Survey Summary

 
1.
The Health Plan shall submit to the Agency the results of a Stakeholders’
Satisfaction Survey Summary in all Service Areas in which the Health Plan
provides Behavioral Health Services.

 
2.
The Health Plan shall report the results from the survey in accordance with
Table 10, Stakeholders’ Satisfaction Survey Summary, below.

Table 10

Stakeholders Satisfaction Survey Summary

Types of Stakeholders Surveyed
DCF
Counselors
Community Based Care Providers
Foster Parents
Consumer Advocacy Groups
Parents of SED Children
Out-of-Plan Providers (specify)
Others
 
Number of Surveys Distributed
 
             
 
Number of surveys completed in each type
 
             
 
Method used for distribution
 
             

Summary of Responses:
 
Significant findings or results that will be addressed:
 

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R.
Behavioral Health Services Grievance and Appeals Reporting Requirements

See Section XII.C. and Table 2, above, for reporting instructions.

S.
Critical Incident Reporting

 
a.
For Providers and providers under contract with DCF, the State’s operating
procedures for incident reporting and client risk protection establishes
departmental procedures and guidelines for reporting information related to the
incidents specified in this Section. See CF Operating Procedure No. 215-6,
November 1, 1998.

 
b.
The critical incident reporting requirements set forth in this section do not
replace the abuse, neglect and exploitation reporting system established by the
State. Additionally, the Health Plan must report to the Agency in accordance
with the format in Table 11, Critical Incidents Summary, and Table 11-A,
Critical Incident Individual, below.

 
c.
The definitions of reportable critical incidents apply to the Health Plan,
Providers (participating and non-participating) and any Subcontractors/delegates
providing services to Enrollees.

 
d.
The Health Plan shall report the following events immediately to the Agency, in
accordance with the format set forth in Table 11-A, Critical Incident
Individual, below:

(1) Death of an Enrollee due to one (1) of the following:

(a) Suicide;

(b) Homicide;

(c) Abuse;

(d) Neglect; or

 
(e)
An accident or other incident that occurs while the Enrollee is in a facility
operated or contracted by the Health Plan or in an acute care facility.

 
(2)
Enrollee Injury or Illness - A medical condition that requires medical treatment
by a licensed health care professional and which is sustained, or allegedly is
sustained, due to an accident, act of abuse, neglect or other incident occurring
while an Enrollee is in a Facility operated or contracted by the Health Plan or
while the Enrollee is in an acute care facility.

 
(3)
Sexual Battery - An allegation of sexual battery, as determined by medical
evidence or law enforcement involvement, by:

(a) An Enrollee on another Enrollee;

 
(b)
An employee of the Health Plan, a provider or a Subcontractor, an Enrollee;
and/or

 
(c)
An Enrollee on an employee of the Health Plan, a provider or a Subcontractor.

 
e.
The Health Plan shall immediately report to the Agency, in accordance with the
format in Table 11-A, Critical Incident Individual, below, if one (1) or more of
the following events occur:

(1) Medication errors in an acute care setting; and/or

 
(2)
Medication errors involving Children/Adolescents in the care or custody of DCF.

 
f.
The Health Plan shall report quarterly to the Agency, in accordance with the
format in Table 11 Critical Incidents Summary, below, a summary of all critical
incidents.

 
g.
In addition to supplying a quarterly Critical Incidents Summary, the Health Plan
shall also report Critical Incidents in the manner prescribed by the appropriate
district’s DCF Alcohol, Drug Abuse Mental Health office, using the appropriate
DCF reporting forms and procedures.

Table 11

Critical Incidents Summary

Incident Type
# of Events
Enrollee Death - Suicide
 
Enrollee Death - Homicide
 
Enrollee Death - Abuse/Neglect
 
Enrollee Death - other
 
Enrollee Injury or Illness
 
Sexual Battery
 
Medication Errors - acute care
 
Medication Errors - children
 
Enrollee Suicide Attempt
 
Altercations requiring Medical Interventions
 
Enrollee Escape
 
Enrollee Elopement
 
Other reportable incidents
 
 
Total
 

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Table 11-A

Critical Incident Individual

 
Enrollee Medicaid ID#:
 
 
Date of Incident:
 
 
Location of Incident:
 
 
Critical Incident Type:
 
 
Details of Incident: (Include enrollee’s age, gender, diagnosis, current
medication, source of information, all reported details about the event, action
taken by Health Plan or provider, and any other pertinent information)
 
 
Follow up planned or required: (Include information related to any Health Plan
or provider protocol that applies to event.)
 
 
Assigned provider:
 
 
Report submitted by:
 
 
Date of submission:
 

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T.
Required Staff/Providers

The Health Plan shall submit contracted and subcontracted staffing information
by position, name and FTE for all direct service positions on a quarterly basis
in accordance with Table 12, Required Staff/Providers, below.

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Table 12
Required Staff/Providers

Plan Name:
               
Plan 7-Digit Medicaid ID#:
               
As of Date (3rd Month of the Qtr/Year):
               
AHCA Area:
                                                   
Positions
Total
Non-Clinical Specialties
Therapeutic Specialty Areas With 2 Years Clinical Experience
Bi-Lingual
Expert Witness
Court Ordered Evals
Adoption/ Attachment Issues
Post Traumatic Stress Syndrome
Dual Diagnosis (Mental Disorder / Substance Abuse)
Gender / Sexual Issues
Geriatrics / Aging Issues
Separation, Grief & Loss
Eating Disorders
Adolescent/ Children's Issues
Sexual/ Physical Abuse-Child
Sexual/ Physical Abuse-Adult
Domestic Violence-Child
Domestic Violence-Adult
Adult Psychiatrists
                               
Child Psychiatrists
                               
Other Physicians
                               
Psychiatric ARNPs
                               
Psychologists
                               
Master Level Clinicians (LCSW, LMFT, LMHC, MFCC)
                               
Bachelor Level
                               
RN
                               
Unduplicated Totals
                                 
This report provides a snapshot of the required staff/providers on a day in the
3rd month of the quarter: March, June, September, and December.
       
The report is due within 45 days at the end of the quarter: May 15th, August
15th, November 15th, and February 15th.
         

U.
FARS/CFARS

 
1.
The Health Plan shall submit FARS and CFARS reports in accordance with Table 13
below. In addition, the Health Plan shall submit summary trend data by
individual recipient based on the data reported in Table 13 in a format to be
specified by the Agency within the notice requirements indicated in Section
XII.A.3., above.

Table 13
FARS/CFARS Reporting
O***YY06.txt (January through June, due August 15) OR
O***YY12.txt (July through December, due February 15)
Data Element Name
Length
Start Column
End Column
Description
Recipient ID
9
1
9
9-Digit Medicaid ID Number of plan member
Recipient DOB
10
10
19
Plan member’s date of birth (MM/DD/CCYY)
Provider ID
9
20
28
9-Digit Medicaid HMO ID Number
Assessment Type
1
29
29
Designate the type of functional assessment that was done using “F: for FARS or
“C” for CFARS
Initial Date
10
30
39
Date of initial assessment (MM/DD/CCYY)
Initial Score
2
40
41
Initial overall assessment score
6 Month Date
10
42
51
Date of 6 month assessment, if applicable** (MM/DD/CCYY)
6 Month Score
2
52
53
6 month overall assessment score, if applicable**
Discharge Date
10
54
63
Date of Discharge (MM/DD/CCYY)
Discharge Score
2
64
65
Overall assessment score at discharge
         
** Note: Discharge date may occur prior to the 6 month assessment.

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V.
Behavioral Health Encounter Report

 
1.
The Health Plan shall report Behavioral Health encounter data in the format
given in Table 14, below. The Health Plan should use the following when
completing the report.

 
a.
Diagnostic Criteria

 
(1)
All provider claims are restricted to claims for Enrollees with an ICD-9CM
diagnosis code of 290 through 290.43; 293 through 298.9; 300 through 301.9;
302.7, 306.51 through 312.4; 312.81 through 314.9; 315.3, 315.31, 315.5, 315.8,
and 315.9.

 
b.
Provider and Coding Criteria

 
(1)
General Hospital Services, Provider Type 01, Claim Input Indicator “I” - Use
Revenue Codes 0114, 0124, 0134, 0144, 0154, or 0204 on the UB-92 or 837-I.

 
(2)
Hospital Outpatient Services - Provider Type 01, Claim Input Indicator “O” - Use
Revenue Center Codes 0450, 0513, 0901, 0914, or 0918 on the UB-92 or 837-I.

 
c.
Community Mental Health Services

 
(1)
Provider Type - 05, Community Alcohol, Drug and Mental Health, or Provider Type
- 07, Mental Health Practitioner - Both are Claim Input Indicator “J.”

 
(2)
Use Procedure code H0001; H000lHN; H0001H0; H0001TS; H0031; H0031 HO; H003lHN;
H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO;
H2010HE; H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
H2019HO; H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
Tl023HE; or T1023HF.

 
d. Physician Services

 
(1)
Provider Type 25 (MD) or 26 (DO) with a specialty code of "42" Psychiatrist,
"43” Child Psychiatrist, or "44" Psychoanalysis -All claims submitted by these
specialists apply.

 
e.
Advanced Nurse Practitioner Provider Type 30 (ARNP) with a specialty code of
“76” - Clinical Nurse Specialist - All claims submitted by these specialists
apply.

 
f.
Case Management Agency - Provider Type 91

 
(1)
Procedure code T1017 (Targeted Case Management for Adults); T1017HA (Targeted
Case Management for Children (birth through 17); and T1017HK (Intensive Team
Targeted Case Management, Adults 18 an over).

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

Table 14
Behavioral Health Encounter Data

Field Name
Field Length
Comments
Medicaid ID
9
First 9 digits of the Enrollee ID number
Plan ID
9
9 digit Medicaid ID of the Health Plan in which Enrollee was Enrolled on the
first date of service
Service Type
1
I Hospital Inpatient
C CSU
O Hospital Outpatient
P Physician (MD or DO)
A Advanced Nurse Practitioner, ARNP
H Comm. Mental Health, Mental Health Practitioner
T Targeted Case Management
L Locally Defined or Optional Service
First Date of Service
8
For Inpatient and CSU encounters, this equals the admit date. Use YYYYMMDD
format.
Revenue Code
4
Use only for Hospital Inpatient and Hospital Outpatient Encounters
Procedure Code
5
5 digit CPT or HCPCS Procedure Code (For Inpatient Claims only, use the ICD9-CM
Procedure Code.)
Procedure Modifier 1
2
 
Procedure Modifier 2
2
 
Units of Service
3
For Inpatient and CSU encounters, report the number of covered days. For all
other encounters, use the units of service referenced in the appropriate
Medicaid Coverage and Limitations Handbook.
Diagnosis
6
Primary Diagnosis Code
Provider Type
1
1 M.D.
2 D.O.
3 A.R.N.P.
4 P.A.
5 Community Mental Health Center
6 Licensed Psychologist, LCSW, LMFT, LMHC
7 Other
Provider ID Type
1
Type of unique identifier for the direct service provider:
A = AHCA ID
M = Medicaid Provider ID
L = Professional License Number
Provider ID
9
Unique identifier for the direct service provider
Amount Paid
10
Costs associated with the claim. Format with an explicit decimal point and 2
decimal places but no explicit commas. Optional.
Run Date
8
The date the file was prepared. Use YYYYMMDD format
Claim Reference Number
25
The Health Plan’s internal unique claim record identifier

W.
Behavioral Health Pharmacy Encounter Data Report

 
1.
The Health Plan shall report Behavioral Health encounter data as set forth in
the format given in Table 16, below. The Health Plan shall use the Behavioral
Health Related Therapeutic Class Codes listed in Table 16-A for the Behavioral
Health Pharmacy Encounter Data report.

Table 16
Behavioral Health Pharmacy Encounter Data (B***YYQ*.txt)
 
Data Element Name
Length
Data Type
Start Column
End Column
Description
RECIP_ID
9
Character
1
9
Enrollee Medicaid Identification Number (first 9 digits; no check digit
necessary)
NDC
11
Character
10
20
National Drug Code Identification Number of the Dispensed Medication
CLASS
3
Character
21
23
Therapeutic Class Code (see Behavioral Health Related Therapeutic Class Code
Listing, below)
QUANT
8
Numeric
24
31
Quantity of Drug Dispensed
DOS
10
Character
32
41
Date of Service (mm/dd/ccyy Please include the “/”)
HMO_ID
9
Character
42
50
9 digit Medicaid Provider Number of the HMO
RX_NUM
7
Character
51
57
Prescription Identification Number
DEA
9
Character
58
66
9 digit DEA Number of Prescriber
LICENSE
10
Character
67
76
Professional License Number of Prescriber
PHARM_ID
7
Character
77
83
Dispensing Pharmacy’s seven character National Association of Boards of Pharmacy
Number (NABP)

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Table 16-A
BEHAVIORAL HEALTH RELATED THERAPEUTIC CLASS CODES

Class Code
Description
J5B
ADRENERGICS, AROMATIC, NON-CATECHOLAMINE
H7B
ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS
C0D
ANTI-ALCOHOLIC PREPARATIONS
H2F
ANTI-ANXIETY DRUGS
H4B
ANTICONVULSANTS
H2J
ANTIDEPRESSANTS O.U.
Z2A
ANTIHISTAMINES
H2M
ANTI-MANIA DRUGS
H6B
ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC
H6A
ANTIPARKINSONISM DRUGS, OTHER
L3P
ANTIPRURITICS, TOPICAL
H7R
ANTIPSYCH, DOPAMINE ANTAG., DIPHENYLBUTYLPIPERIDINES
H7X
ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED
H7U
ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS
H7T
ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG
H7P
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES
H7O
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES
H7S
ANTIPSYCHOTICS,DOPAMINE ANTAGONST,DIHYDROINDOLONES
H2L
ANTI-PSYCHOTICS,NON-PHENOTHIAZINES
H2G
ANTI-PSYCHOTICS,PHENOTHIAZINES
H2D
BARBITURATES
U6W
BULK CHEMICALS
H2A
CENTRAL NERVOUS SYSTEM STIMULANTS
C6M
FOLIC ACID PREPARATIONS
H2C
GENERAL ANESTHETICS,INJECTABLE
H7J
MAOIS - NON-SELECTIVE & IRREVERSIBLE
H2H
MONOAMINE OXIDASE(MAO) INHIBITORS
H3T
NARCOTIC ANTAGONISTS
H7D
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)
S2B
NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE
H2E
SEDATIVE-HYPNOTICS,NON-BARBITURATE
H2S
SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)
H7E
SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)
H7C
SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)
H7N
SMOKING DETERRENTS, OTHER
H2X
TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS
H2W
TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS
H2U
TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB
H2V
TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY

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

X.
Minority Participation Report

 
1.
The Agency encourages the Health Plan to use Minority and Certified Minority
businesses as Subcontractors when procuring commodities or services to meet the
requirements of this Contract.

 
2.
The Agency requires information regarding the Vendor’s use of minority-owned
businesses as Subcontractors under this Contract. The Agency will use this
information for assessment and evaluation of the Agency’s Minority Business
Utilization Plan. During the term of the Contract, the Health Plan shall provide
this information monthly by the fifteenth (15th) day after the reporting month.
A minority-owned business is defined as any business enterprise owned and
operated by the following ethnic groups:

 
a.
African American (Certified Minority Code H or Non-Certified Minority Code N);

 
b.
Hispanic American (Certified Minority Code I or Non-Certified Minority O);

 
c.
Asian American (Certified Minority Code J or Non-Certified Minority Code P);

 
d.
Native American (Certified Minority Code K or Non-Certified Minority Code Q); or

 
e.
American Woman (Certified Minority Code M or Non-Certified Minority Code R).

 
3.
The Agency may waive this requirement, in writing, if the Health Plan
demonstrates that it is either at least fifty-one percent (51%) minority-owned,
at least fifty-one percent (51%) of its board of directors are a minority, at
least fifty-one (51%) of its officers are a minority, or if the Health Plan is a
not-for-profit corporation and at least fifty-one percent (51%) of the
population it serves belong to a minority.

 
4.
The Health Plan shall provide the following information on company letterhead:

a. Minority Subcontractor's company name and Minority Code (see above); 

 
b.
Subcontracted services related to this Contract;

 
c.
Dates of service (beginning and ending);

 
d.
Total dollar amount paid to Subcontractor for services related to this Contract;
or

 
e.
A statement that the Health Plan did not use the services of any minority
Subcontractors during this period.

 
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Section XIII
 
Method of Payment
 
A.
Fixed Price Unit Contract

This is a fixed price unit cost contract. The Agency or its appointed Fiscal
Agent shall make payment to the Health Plan on a monthly basis for the Health
Plan’s satisfactory performance of its duties and responsibilities as set forth
in this Contract. To accommodate payments, the Health Plan is a capitated health
plan with the Fiscal Agent. Section XII, Reporting Requirements, details the
enrollment reports, the monthly payment request processing and service
utilization procedures.

B.
Child Health Check-Up Incentive Program

Health Plans will be eligible to participate in the Child Health Check-Up
(CHCUP) incentive program when the Health Plan has exceeded both the sixty
percent (60%) State screening rate and the federal eighty percent (80%)
participation and screening ratio goals as outlined in Section V, Covered
Services, E.2. The Agency will determine which Health Plans will participate
based upon the audited CHCUP reports submitted each October as set forth in
Section XII.M., above.

1.  
The amount of the incentive payment shall be calculated as follows: the ratio of
a qualified Health Plan’s screenings to the total of all Health Plans’
screenings will be multiplied by the total amount in the fund for the incentive
payment. The ratios will be based on the Health Plans’ audited CHCUP reports.
The total amount in the fund will be determined at the discretion of the Agency.
In no event shall the total monies allotted to the incentive program be in
excess of the incentive payment fund.

 
2.
Pursuant to 42 CFR 438.6, I(1)(iv) and (5)(iii), the payment to any one (1)
Health Plan shall not be in excess of five percent (5%) of the capitation amount
paid to all Health Plans for CHCUP services provided pursuant to this Contract.

C.
Capitation Rate

The Agency shall pay the applicable Capitation Rate for each Enrollee whose name
appears on the ONGOING REPORT (FLMR 8200-R004) and the REINSTATEMENT REPORT
(FLMR 8200-R009) for each month, except that the Agency shall not pay for, and
shall recoup, any part of the total Enrollment that exceeds the maximum
authorized Enrollment level(s) expressed in Attachment I. The total payment
amount to the Health Plan shall depend upon the number of Enrollees in each
eligibility category and each rate group, as provided for by this Contract, or
as adjusted pursuant to the Contract when necessary. The Health Plan is
obligated to provide services pursuant to the terms of this Contract for all
Enrollees for whom the Health Plan has received capitation payment and for whom
the Agency has assured the Health Plan that capitation payment is forthcoming.

 
1.
The Agency’s Capitation Rates are developed using historical rates paid by
Medicaid fee-for-service for similar services in the same Service Area, adjusted
for inflation, where applicable, in accordance with 42 CFR 438.6(c).

 
2.
The Capitation Rates to be paid specific to the Health Plan shall be as
indicated in Attachment I, which indicates the initial and maximum authorized
Enrollment levels and Capitation Rates applicable to each authorized eligibility
category.

 
3.
At such time as the Agency receives legislative direction to assess Health Plans
for Enrollment and Disenrollment Services costs, the Agency shall apply
assessments, in quarterly installments each Contract Year, against the Health
Plan’s next capitation payment to pay for the Enrollment and Disenrollment
Services Contractor as follows:

 
a.
July 1, for costs estimated for the Agency’s Enrollment and Disenrollment
Services Contractor system and contract for July and the following two (2)
months.

 
b.
October 1, for costs related to the third party Enrollment and Disenrollment
Services contract for October and the following two (2) months.

 
c.
January 1, for costs related to maintaining the third party Enrollment and
Services contract for January and the following two (2) months.

 
d.
April 1, for costs related to maintaining the third party Enrollment and
Disenrollment Services contract for April and the following two (2) months.

 
4.
Unless otherwise specified in this Contract, the Health Plan shall accept the
capitation payment received each month as payment in full by the Agency for all
services provided to Enrollees covered under this Contract and the
administrative costs incurred by the Health Plan in providing or arranging for
such services. Any and all costs incurred by the Health Plan in excess of the
capitation payment shall be borne in total by the Health Plan.

 
5.
The Agency shall pay a retroactive Capitation Rate for each Newborn enrolled in
the Health Plan for up to the first (1st) three (3) months of life, provided the
Newborn was enrolled through the Unborn Activation Process.

 
a.
The Health Plan shall use the Unborn Activation Process to enroll all babies
born to pregnant Enrollees as specified in Section III.B.3, Newborn Enrollment.

 
b.
The Health Plan is responsible for payment of all Covered Services provided to
Newborns enrolled through the Unborn Activation Process.

 
6.
Because the HomeSafeNet program covers the cost of Behavioral Health Services
provided to members of the HomeSafeNet program, the Agency shall not pay the
Health Plan the behavioral health component of the Capitation Rate for Enrollees
that are part of the HomeSafeNet program, even if the Health Plan provides
Behavioral Health Services in the county in which the Enrollee resides.

D.
Errors

 
1.
The Agency expects the Health Plan to prepare all reports and monthly payment
requests for submission to the Agency. If after preparation and electronic
submission, the Health Plan discovers an error, including, but not limited to,
errors resulting in capitated payments above the Health Plan’s authorized
levels, either by the Health Plan or the Agency, the Health Plan has thirty (30)
Business Days from its discovery of the error, or thirty (30) Business Days
after receipt of notice by the Agency, to correct the error and re-submit
accurate reports and/or invoices. Failure to respond within the thirty (30)
Business Day period shall result in a loss of any money due to the Health Plan
for such errors and/or sanctions against the Health Plan pursuant to Section XIV
of this Contract.

E.
Member Payment Liability Protection

 
1.
Pursuant to Section 1932 (b)(6), Social Security Act (as enacted by section 4704
of the Balanced Budget Act of 1997), the Health Plan shall not hold members
liable for the following:

 
a.
For debts of the Health Plan, in the event of the Health Plan’s insolvency;

 
b.
For payment of Covered Services provided by the Health Plan if the Health Plan
has not received payment from the Agency for the Covered Services, or if the
provider, under contract or other arrangement with the Health Plan, fails to
receive payment from the Agency or the Health Plan; and/or

 
c.
For payments to a provider, including referral providers, that furnished Covered
Services under a contract, or other arrangement with the Health Plan, that are
in excess of the amount that normally would be paid by the Enrollee if the
Covered Services had been received directly from the Health Plan.

F.
Co-payments

 
1.
The Health Plan shall not require any co-payment or cost sharing for Covered
Services, expanded services and/or optional services listed in Section V,
Covered Services or Section VI, Behavioral Health Care, nor may the Health Plan
charge Enrollees for missed appointments.

G.
Enrollment Levels

 
1.
The Health Plan is assigned an authorized maximum Enrollment level for each
operational county. The authorized maximum Enrollment level is in effect on
September 1, 2006, or upon Contract execution, whichever is later.

 
2.
The Agency must approve in writing any increase in the Health Plan’s maximum
Enrollment level for each operational county and subpopulation to be served, as
applicable. Such approval shall not be unreasonably withheld, and shall be based
on the Health Plan’s satisfactory performance of terms of the Contract and
approval of the Health Plan’s administrative and service resources, as specified
in this Contract, in support of each Enrollment level.

 
3.
Authorized Enrollment Levels in Attachment I indicate the Health Plan’s maximum
authorized Enrollment levels for each Medicaid Reform county and each applicable
authorized eligibility category.

 
4.
Attachment I sets forth the total Contract amount.

 
5.
Attachment I, Exhibit I sets forth the Health Plan’s authorized Service Areas
and maximum enrollment levels.

 
6.
Attachment I, Exhibit II sets forth the Health Plan’s Capitation Rates for each
County in which it is authorized to provide services.

 
7.
Attachment I, Exhibit III lists the Capitation Rates for the Health Plan’s
authorized Service Areas.

H.
Transition to Medicaid Reform

 
1.
The Health Plan understands that the State is commencing Medicaid Reform that
shall start in Broward County and Duval County on September 1, 2006, with other
counties added as authorized by the State. As a result, in all areas in which
the State implements Medicaid Reform, the Health Plan’s Enrollment will
transition from coverage under this Contract to the Medicaid Reform Contract in
accordance with the Agency’s implementation schedule. By April 1, 2007, the
Health Plan’s total maximum Enrollment in Broward County and Duval County, if
any, will be zero (0).

 
2.
When the State authorizes expansion of Medicaid Reform into a new county in
which the Health Plan is currently providing, or will provide, Medicaid
services, the Health Plan acknowledges that it must request an amendment for an
expansion of service under the Medicaid Reform Contract in order to continue to
provide Benefits in the new Medicaid Reform county. Upon implementation of
Medicaid Reform, the Health Plan shall not:

 
a.
Engage in Marketing activities with regard to the services and/or Benefits
provided under this Contract;

 
b.
Receive voluntary or mandatory Enrollees for the Medicaid Reform county under
this Contract; and must

I.
Cost Effectiveness

 
1.
The Agency shall ensure that the Health Plan is cost-effective (see Section
409.912(44), F.S.). The Agency may not renew this Contract if it is not
cost-effective.

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Section XIV
 
Sanctions
 
A.
General Provisions

 
1.
The Health Plan shall comply with all requirements and performance standards set
forth in this Contract. In the event the Agency identifies a violation of this
Contract, or other non-compliance with this Contract, the Health Plan shall
submit a corrective action plan (CAP) within three (3) Calendar Days of the date
of receiving notification of the violation or non-compliance from the Agency.

 
2.
Within five (5) Business Days of receiving the CAP the Agency will either
approve or disapprove the CAP. If disapproved, the Health Plan shall resubmit,
within ten (10) Business Days, a new CAP that addresses the concerns identified
by the Agency.

 
3.
Upon approval of the CAP, whether the initial CAP or the revised CAP, the Health
Plan shall implement the CAP within the time frames specified by the Agency.

 
4.
Except where specified below, the Agency shall impose a monetary sanction of
$100 per day on the Health Plan for each Calendar Day that the approved CAP is
not implemented to the satisfaction of the Agency.

B.
Specific Sanctions

 
1.
As described in 42 CFR 438.700, the Agency may impose any of the following
sanctions against a Health Plan if it determines that a Health Plan has violated
any provision of this Contract, or any applicable statutes:

 
a.
Suspension of the Health Plan’s Voluntary Enrollments and participation in the
Mandatory Assignment process for Enrollment

 
b.
Suspension or revocation of payments to the Health Plan for Enrollees during the
sanction period;

 
c.
For any nonwillful violation of the Contract, the Agency shall impose a fine,
not to exceed $2,500 per Violation. In no event shall such fine exceed an
aggregate amount of $10,000 for all nonwillful Violations arising out of the
same action;

 
d.
With respect to any knowing and willful violation of the Contract the Agency
shall impose a fine upon the Health Plan in an amount not to exceed $20,000 for
each such violation. In no event shall such fine exceed an aggregate amount of
$100,000 for all knowing and willful violations arising out of the same action;

 
e.
If the Health Plan fails to carry out substantive terms of the Contract or fails
to meet all applicable requirements in 42 CFR 438.700, the Agency shall
terminate the Contract. After the Agency notifies the Health Plan that it
intends to terminate the Contract, the Agency shall give the Health Plan’s
Enrollees written notice of the State’s intent to terminate the Contract and
allow the Enrollees to disenroll immediately without Cause.

 
f.
The Agency may impose intermediate sanctions in accordance with 42 CFR 438.702,
including, but not limited to:

 
(1)
Civil monetary penalties in the amounts specified in this Contract.

 
(2)
Appointment of temporary management for the Health Plan. Rules for temporary
management pursuant to 42 CFR 438.706 are as follows:

 
(a)
The State may impose temporary management only if it finds (through on-site
survey, Enrollee Grievances, financial audits, or any other means) that:

 
(i)
There is continued egregious behavior by the Health Plan, including but not
limited to behavior that is described in 42 CFR 438.700;

 
(ii)
There is substantial risk to Enrollees' health;

 
(iii)
The sanction is necessary to ensure the health of the Health Plan’s Enrollees;

 
(iv)
While improvements are made to remedy the Health Plan’s violation(s) under 42
CFR 438.700; and/or

 
(v)
Until there is an orderly termination or reorganization of the Health Plan.

 
(3)
The State must impose temporary management (regardless of any other sanction
that may be imposed) if it finds that the Health Plan has repeatedly failed to
meet substantive requirements in 42 CFR 438.706. The State must also grant
Enrollees the right to terminate Enrollment without Cause, as described in 42
CFR 438.702(a)(3), and must notify the affected Enrollees of their right to
terminate Enrollment.

 
(4)
The State shall not delay imposition of temporary management to provide a
hearing before imposing this sanction.

 
(5)
The State shall not terminate temporary management until it determines that the
Health Plan can ensure that the sanctioned behavior will not recur.

 
g.
Granting Enrollees the right to terminate Enrollment without Cause and notifying
affected Enrollees of their right to disenroll;

 
h.
Suspension or limitation of all new Enrollment, including Mandatory Enrollment,
after the effective date of the sanction;

 
i.
Suspension of payment for Enrollees after the effective date of the sanction and
until CMS or the Agency is satisfied that the reason for imposition of the
sanction no longer exists and is not likely to recur; and/or

 
j.
Before imposing any intermediate sanctions, the State must give the Health Plan
timely notice according to 42 CFR 438.710.

 
7.
If the Health Plan’s CHCUP Screening compliance rate is below sixty percent
(60%), it must submit to the Agency, and implement, an Agency accepted CAP. If
the Health Plan does not meet the standard established in the CAP during the
time period indicated in the plan, the Agency has the authority to impose
sanctions in accordance with this Section;

 
8.
Unless the duration of a sanction is specified, a sanction shall remain in
effect until the Agency is satisfied that the basis for imposing the sanction
has been corrected and is not likely to recur; and/or

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Section XV
 
Financial Requirements
 

 
A.
Insolvency Protection 

 
1.
The Health Plan shall establish a restricted Insolvency protection account with
a federally guaranteed financial institution licensed to do business in Florida
(See Section 1903(m)(1) of the Social Security Act as amended by Section 4706 of
the Balanced Budget Act of 1997, and Section 409.912, F.S.). The Health Plan
shall deposit into that account five percent (5%) of the capitation payments
made by the Agency each month until a maximum total of two percent (2%) of the
total current Contract amount is reached. No interest may be withdrawn from this
account until the maximum Contract amount is reached. This provision shall
remain in effect as long as the Health Plan continues to contract with the
Agency. The restricted Insolvency protection account may be drawn upon with the
authorized signatures of two (2) persons designated by the Health Plan and two
(2) representatives of the Agency. The signature card shall be resubmitted when
a change in authorized personnel occurs. If the authorized persons remain the
same, the Health Plan shall submit an attestation to this effect annually. The
Health Plan may obtain a sample Multiple Signature Verification Agreement form
from the Agency or its Agent.  All such agreements or other signature cards must
be approved in advance by the Agency.

 
2.
In the event that a determination is made by the Agency that the Health Plan is
insolvent, as defined in Section I Definitions, of this Contract, the Agency may
draw upon the amount solely with the two (2) authorized signatures of
representatives of the Agency and funds may be disbursed to meet financial
obligations incurred by the Health Plan under this Contract. A statement of
account balance shall be provided by the Health Plan within fifteen (15)
Calendar Days of request of the Agency.

 

 
3.
If the Contract is terminated, expired, or not continued, the account balance
shall be released by the Agency to the Health Plan upon receipt of proof of
satisfaction of all outstanding obligations incurred under this Contract.

 
4.
In the event the Contract is terminated or not renewed and the Health Plan is
Insolvent, the Agency may draw upon the Insolvency protection account to pay any
outstanding debts the Health Plan owes the Agency including, but not limited to,
overpayments made to the Health Plan and fines imposed under the Contract or
Section 641.52, F.S., for which a final order has been issued. In addition, if
the Contract is terminated or not renewed and the Health Plan is unable to pay
all of its outstanding debts to health care providers, the Agency and the Health
Plan agree to the court appointment of an impartial receiver for the purpose of
administering and distributing the funds contained in the Insolvency protection
account. Should a receiver be appointed, he or she shall give outstanding debts
owed to the Agency priority over other claims.

B.
Insolvency Protection Account Waiver

Pursuant to Section 409.912, the Agency may waive the Insolvency protection
account requirement, in writing, when evidence of adequate Insolvency insurance
and reinsurance are on file with the Agency which shall protect Enrollees in the
event the Health Plan is unable to meet its obligations.

C.
Surplus Start Up Account 

All new Health Plans, after initial Contract execution, but prior to initial
Enrollee Enrollment, shall submit to the Agency, if a private entity, proof of
working capital in the form of cash or liquid assets, excluding revenues from
Medicaid premium payments, equal to at least the first three (3) months of
operating expenses or $200,000, whichever is greater. This provision shall not
apply to Health Plans that have been providing services to Enrollees for a
period exceeding three (3) continuous months.

D.
Surplus Requirement 

 
1.
In accordance with Section 409.912, F.S., the Health Plan shall maintain at all
times in the form of cash, investments that mature in less than 180 Calendar
Days and allowable as admitted assets by the Department of Financial Services,
and restricted funds of deposits controlled by the Agency (including the Health
Plan’s Insolvency protection account) or the Department of Financial Services, a
Surplus amount equal to one and one half (1½) times the Health Plan’s monthly
Medicaid prepaid revenues. In the event that the Health Plan’s Surplus falls
below an amount equal to one and one half (1½) times the Health Plan’s monthly
Medicaid prepaid revenues, the Agency shall:

 
a.
Prohibit the Health Plan from engaging in Marketing and Request for Benefit
Information activities;

 
b.
Shall cease to process new Enrollments until the required balance is achieved;
and/or

c. May terminate the Health Plan’s Contract.

E.
Interest

 
1.
Interest generated through investments made by the Health Plan under this
Contract shall be the property of the Health Plan and shall be used at the
Health Plan’s discretion.

F.
Inspection and Audit of Financial Records

 
1.
The State and DHHS may inspect and audit any financial records of the Health
Plan or its Subcontractors. Pursuant to section 1903(m)(4)(A) of the Social
Security Act and State Medicaid Manual 2087.6(A-B), non-federally qualified
health plans must report to the State, upon request, and to the Secretary and
the Inspector General of DHHS, a description of certain transactions with
parties of interest as defined in Section 1318(b) of the Social Security Act.

G.
Physician Incentive Plans

 
1.
Physician incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h), 42
CFR 422.208 and 42 CFR 422.210. The Health Plan shall make no specific payment,
directly or indirectly, under a physician incentive plan to a physician or
physician group as an inducement to reduce or limit Medically Necessary services
furnished to an individual Enrollee. Physician incentive plans must not contain
provisions which provide incentives, monetary or otherwise, for the withholding
of Medically Necessary care.

 
2.
The Health Plan shall disclose information on physician incentive plans listed
in 42 CFR 417.479(h)(1) and 42 CFR 417.479(i) at the times indicated in 42 CFR
417.479(d)-(g). All such arrangements must be submitted to the Agency for
approval, in writing, prior to use. If any other type of withhold arrangement
currently exists, it must be omitted from all Provider contracts.

H.
Third Party Resources 

 
1.
The Health Plan must specify whether it will assume full responsibility for
third party collections in accordance with this Section.

 
2.
The Health Plan shall be responsible for making every reasonable effort to
determine the legal liability of third parties to pay for services rendered to
Enrollees under this Contract. The Health Plan has the same rights to recovery
of the full value of services as the Agency (see Section 409.910, F.S.). The
following standards govern recovery:

 
a.
If the Health Plan has determined that third party liability exists for part or
all of the services provided directly by the Health Plan to an Enrollee, the
Health Plan shall make all reasonable efforts to recover from third party liable
sources the value of services rendered.

 
b.
If the Health Plan determines that third party liability exists for part or all
of the services provided to an Enrollee by a Subcontractor or referral Provider,
and the third party is reasonably expected to make payment within 120 Calendar
Days, the Health Plan may pay the Subcontractor or referral Provider only the
amount, if any, by which the Subcontractor’s or referral Provider’s allowable
claim exceeds the amount of the anticipated third party payment; or, the Health
Plan may assume full responsibility for third party collections for services
provided through the Subcontractor or referral Provider.

 
c.
The Health Plan may not withhold payment for services provided to an Enrollee if
third party liability or the amount of liability cannot be determined, or if
payment shall not be available within a reasonable time, beyond 120 Calendar
Days from the date of receipt.

 
d.
When both the Agency and the Health Plan have liens against the proceeds of a
third party resource, the Agency shall prorate the amount due to Medicaid to
satisfy such liens between the Agency and the Health Plan (see Section 409.910,
F.S.). This prorated amount shall satisfy both liens in full.

 
e.
The Agency may, at its sole discretion, offer to provide third party recovery
services to the Health Plan. If the Health Plan elects to authorize the Agency
to recover on its behalf, the Health Plan shall be required to provide the
necessary data for recovery in the format prescribed by the Agency. All
recoveries, less the Agency’s cost to recover shall be income to the Health
Plan. The Health Plan shall express the cost to recover as a percentage of
recoveries and shall be fixed at the time the Health Plan elects to authorize
the Agency to recover on its behalf.

 
f.
All funds recovered from third parties shall be treated as income for the Health
Plan.

I.
Fidelity Bonds

 
1.
The Health Plan shall secure and maintain during the life of this Contract a
blanket fidelity bond from a company doing business in the State of Florida on
all personnel in its employment. The bond shall be issued in the amount of at
least $250,000 per occurrence. Said bond shall protect the Agency from any
losses sustained through any fraudulent or dishonest act or acts committed by
any employees of the Health Plan and Subcontractors, if any. Proof of coverage
must be submitted to the Agency’s contract manager within sixty (60) Calendar
Days after execution of the Contract and prior to the delivery of health care.
To be acceptable to the Agency for fidelity bonds, a surety company shall comply
with the provisions of Chapter 624, F.S.

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Section XVI
 
Terms and Conditions
 

A.
Agency Contract Management

 
1.
The Division of Medicaid within the Agency shall be responsible for management
of the Contract. The Division of Medicaid shall make all statewide policy
decision-making or Contract interpretation. In addition, the Division of
Medicaid shall be responsible for the interpretation of all federal and State
laws, rules and regulations governing, or in any way affecting, this Contract.
Management shall be conducted in good faith, with the best interest of the State
and the Medicaid Recipients it serves being the prime consideration. The Agency
shall provide final interpretation of general Medicaid policy. When
interpretations are required, the Health Plan shall submit written requests to
the Agency’s contract manager.

 
2.
The terms of this Contract do not limit or waive the ability, authority or
obligation of the Office of Inspector General, the Bureau of Medicaid Program
Integrity, its contractors, or other duly constituted government units (State or
federal) to audit or investigate matters related to, or arising out of this
Contract.

 
3.
The Contract shall only be amended as follows:

 
a.
The parties cannot amend or alter the terms of this Contract without a written
amendment.

 
b.
The Agency and the Health Plan understand that any such written amendment to
amend or alter the terms of this Contract shall be executed by an officer of
both parties, who is duly authorized to bind the Agency and the Health Plan.

 
c.
Only a person authorized by the Agency and a person authorized by the Health
Plan may amend or alter the terms of this Contract.

 
B.
Applicable Laws and Regulations

 
1.
The Health Plan agrees to comply with all applicable federal and State laws,
rules and regulations including but not limited to: Title 42 CFR Chapter IV,
Subchapter C; Title 45 CFR Part 74, General Grants Administration Requirements;
Chapters 409 and 641, F.S.; all applicable standards, orders, or regulations
issued pursuant to the Clean Air Act of 1970 as amended (42 USC 1857, et seq.);
Title VI of the Civil Rights Act of 1964 (42 USC 2000d) in regard to persons
served; Title IX of the education amendments of 1972 (regarding education
programs and activities); 42 CFR 431, Subpart F; Section 409.907(3)(d), F.S.,
and Rule 59G-8.100 (24)(b), F.A.C. in regard to the contractor safeguarding
information about Enrollees; Title VII of the Civil Rights Act of 1964 (42 USC
2000e) in regard to employees or applicants for employment; Rule 59G-8.100,
F.A.C.; Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794
(which prohibits discrimination on the basis of handicap in programs and
activities receiving or benefiting from federal financial assistance); the Age
Discrimination Act of 1975, as amended, 42 USC 6101 et. seq. (which prohibits
discrimination on the basis of age in programs or activities receiving or
benefiting from federal financial assistance); the Omnibus Budget Reconciliation
Act of 1981, P.L. 97-35, which prohibits discrimination on the basis of sex and
religion in programs and activities receiving or benefiting from federal
financial assistance; Medicare - Medicaid Fraud and Abuse Act of 1978; the
federal Omnibus Budget Reconciliation Acts; Americans with Disabilities Act (42
USC 12101, et seq.); the Newborns’ and Mothers’ Health Protection Act of 1996,
the Balanced Budget Act of 1997, and the Health Insurance Portability and
Accountability Act of 1996. The Health Plan is subject to any changes in federal
and state law, rules, or regulations.

C.
Assignment

 
1.
Except as provided below, or with the prior written approval of the Agency,
which approval shall not be unreasonably withheld, this Contract and the monies
which may become due are not to be assigned, transferred, pledged or
hypothecated in any way by the Health Plan, including by way of an asset or
stock purchase of the Health Plan, and shall not be subject to execution,
attachment or similar process by the Health Plan.

 
a.
When a merger or acquisition of a health plan has been approved by the
Department of Financial Services (see Section 628.4615, F.S.), the Agency shall
approve the assignment or transfer of the appropriate Medicaid health plan
contract upon the request of the surviving entity of the merger or acquisition
if the health plan and the surviving entity have been in good standing with the
Agency for the most recent twelve (12) month period, unless the Agency
determines that the assignment or transfer would be detrimental to Medicaid
Recipients or the Medicaid program (see Section 409.912, F.S.). The entity
requesting the assignment or transfer shall notify the Agency of the request
ninety (90) days prior to the anticipated effective date.

 
b.
To be in good standing, a Health Plan must not have failed accreditation or
committed any material violation of the requirements of Section 641.52, F.S.,
and must meet the Medicaid contract requirements.

 
c.
For the purposes of this section, a merger or acquisition means a change in
controlling interest of a health plan, including an asset or stock purchase.

D.
Attorney's Fees

 
1.
In the event of a dispute, each party to the Contract shall be responsible for
its own attorneys’ fees, except as otherwise provided by law.

E.
Conflict of Interest

 
1.
This Contract is subject to the provisions of Chapter 112, F.S. The Health Plan
shall disclose the name of any officer, director, or agent who is an employee of
the State of Florida, or any of its agencies. Further, the Health Plan shall
disclose the name of any State employee who owns, directly or indirectly, an
interest of five percent (5%) or more in the offerer's firm or any of its
branches. The Health Plan covenants that it presently has no interest and shall
not acquire any interest, direct or indirect, which would conflict in any manner
or degree with the performance of the services hereunder. The Health Plan
further covenants that in the performance of the Contract no person having any
such known interest shall be employed. No official or employee of the Agency and
no other public official of the State of Florida or the federal government who
exercises any functions or responsibilities in the review or approval of the
undertaking of carrying out the Contract shall, prior to completion of this
Contract, voluntarily acquire any personal interest, direct or indirect, in this
Contract or proposed Contract.

F.
Contract Variation

 
1.
If any provision of the Contract (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both the Agency
and the Health Plan shall be relieved of all obligations arising under such
provisions. If the remainder of the Contract is capable of performance, it shall
not be affected by such declaration or finding and shall be fully performed. In
addition, if the laws or regulations governing this Contract should be amended
or judicially interpreted as to render the fulfillment of the Contract
impossible or economically infeasible, both the Agency and the Health Plan shall
be discharged from further obligations created under the terms of the Contract.
However, such declaration or finding shall not affect any rights or obligations
of either party to the extent that such rights or obligations arise from acts
performed or events occurring prior to the effective date of such declaration or
finding.

G.
Court of Jurisdiction or Venue

 
1.
For purposes of any legal action occurring as a result of, or under, this
Contract, between the Health Plan and the Agency, the place of proper venue
shall be Leon County.

H.
Damages for Failure to Meet Contract Requirements

 

 
1.
In addition to any remedies available through this Contract, in law or equity,
the Health Plan shall reimburse the Agency for any federal disallowances or
sanctions imposed on the Agency as a result of the Health Plan’s failure to
abide by the terms of this Contract.

I.
Disputes  

1. The Health Plan may request in writing an interpretation of the Contract from
the contract manager. In the event the Health Plan disputes this interpretation,
the Health Plan may request that the dispute be decided by the Division of
Medicaid. The ability to dispute an interpretation does not apply to issues that
are a matter of law or fact. Any disputes shall be decided by the Agency’s
Division of Medicaid which shall reduce the decision to writing and serve a copy
on the Health Plan. The written decision of the Agency’s Division of Medicaid
shall be final and conclusive. The division will render its final decision based
upon the written submission of the Health Plan and the Agency, unless, at the
sole discretion of the Division director, the division allows an oral
presentation by the Health Plan and the Agency. If such a presentation is
allowed, the information presented will be considered in rendering the
division’s decision. Should the Health Plan challenge an Agency decision through
arbitration as provided below, the Agency action shall not be stayed except by
order of an arbitrator. Thereafter, a Health Plan shall resolve any controversy
or claim arising out of, or relating to, the Contract, or the breach thereof, by
arbitration. Said arbitration shall be held in the City of Tallahassee, Florida,
and administered by the American Arbitration Association in accordance with its
applicable rules and the Florida Arbitration Code (chapter 682, F.S.). Judgment
upon any award rendered by the arbitrator may be entered by the Circuit Court in
and for the Second Judicial Circuit, Leon County, Florida. The chosen arbitrator
must be a member of the Florida Bar actively engaged in the practice of law with
expertise in the process of deciding disputes and interpreting contracts in the
health care field. Any arbitration award shall be in writing and shall specify
the factual and legal bases for the award. Either party may appeal a judgment
entered pursuant to an arbitration award to the First District Court of Appeal.
The parties shall bear their own costs and expenses relating to the preparation
and presentation of a case in arbitration. The arbitrator shall award to the
prevailing party all administrative fees and expenses of the arbitration,
including the arbitrator’s fee. This Contract with numbered attachments
represents the entire agreement between the Health Plan and the Agency with
respect to the subject matter in it and supersedes all other contracts between
the parties when it is duly signed and authorized by the Health Plan and the
Agency. Correspondence and memoranda of understanding do not constitute part of
this Contract. In the event of a conflict of language between the Contract and
the attachments, the provisions of the Contract shall govern. However, the
Agency reserves the right to clarify any contractual relationship in writing
with the concurrence of the Health Plan and such clarification shall govern.
Pending final determination of any dispute over an Agency decision, the Health
Plan shall proceed diligently with the performance of the Contract and in
accordance with the Agency’s Division of Medicaid direction.

J.
Force Majeure

 
1.
The Agency shall not be liable for any excess cost to the Health Plan if the
Agency's failure to perform the Contract arises out of causes beyond the control
and without the result of fault or negligence on the part of the Agency. In all
cases, the failure to perform must be beyond the control without the fault or
negligence of the Agency. The Health Plan shall not be liable for performance of
the duties and responsibilities of the Contract when its ability to perform is
prevented by causes beyond its control. These acts must occur without the fault
or negligence of the Health Plan. These include destruction to the facilities
due to hurricanes, fires, war, riots, and other similar acts. Annually by May
31, the Health Plan shall submit to the Agency for approval an emergency
management plan specifying what actions the Health Plan shall conduct to ensure
the ongoing provisions of health services in a disaster or man-made emergency.

K.
Legal Action Notification

 
1.
The Health Plan shall give the Agency, by certified mail, immediate written
notification (no later than thirty (30) Calendar Days after service of process)
of any action or suit filed or of any claim made against the Health Plan by any
Subcontractor, vendor, or other party which results in litigation related to
this Contract for disputes or damages exceeding the amount of $50,000. In
addition, the Health Plan shall immediately advise the Agency of the Insolvency
of a Subcontractor or of the filing of a petition in bankruptcy by or against a
principal Subcontractor.

L.
Licensing

 

 
1.
In accordance with Section 409.912, F.S., all entities that provide Medicaid
prepaid health care services must be commercially licensed in accordance with
the provisions of Part I and Part III of Chapter 641, F.S.

 
M.
Misuse of Symbols, Emblems, or Names in Reference to Medicaid

 
1.
No person or Health Plan may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other communication, or
a broadcast, telecast, or other production, alone or with other words, letters,
symbols or emblems the words “Medicaid,” or “Agency for Health Care
Administration,” except as required in the Agency’s Standard Contract, page two
(2), unless prior written approval is obtained from the Agency. Specific written
authorization from the Agency is required to reproduce, reprint, or distribute
any Agency form, application, or publication for a fee. State and local
governments are exempt from this prohibition. A disclaimer that accompanies the
inappropriate use of program or Agency terms does not provide a defense. Each
piece of mail or information constitutes a violation.

N.
Offer of Gratuities

 
1.
By signing this agreement, the Health Plan signifies that no member of, or a
delegate of, Congress, nor any elected or appointed official or employee of the
State of Florida, the General Accounting Office, Department of Health and Human
Services, CMS, or any other federal agency has or shall benefit financially or
materially from this procurement. The Agency may terminate this Contract may be
terminated by the Agency if it is determined that gratuities of any kind were
offered to, or received by, any officials or employees from the State, its
agents, or employees.

 
O.
Subcontracts

 
1.
The Health Plan is responsible for all work performed under this Contract, but
may, with the prior written approval of the Agency, enter into Subcontracts for
the performance of work required under this Contract. All Subcontracts must
comply with 42 CFR 438.230. All Subcontracts and amendments executed by the
Health Plan shall meet the following requirements. All Subcontractors must be
eligible for participation in the Medicaid program; however, the Subcontractor
is not required to participate in the Medicaid program as a provider. The Agency
encourages use of minority business enterprise Subcontractors. See Section X.C.,
Provider Contract Requirements, above of this Contract, for provisions and
requirements specific to Provider contracts.

 
2.
No Subcontract that the Health Plan enter into with respect to performance under
the Contract shall, in any way, relieve the Health Plan of any responsibility
for the performance of duties under this Contract. The Health Plan shall assure
that all tasks related to the Subcontract are performed in accordance with the
terms of this Contract. The Health Plan shall identify in its Subcontracts any
aspect of service that may be further subcontracted by the Subcontractor.

 
3.
All model and executed Subcontracts and amendments used by the Health Plan under
this Contract must be in writing, signed, and dated by the Health Plan and the
Subcontractor and meet the following requirements:

 
a.
Identification of conditions and method of payment:

 
(1)
The Health Plan agrees to make payment to all Subcontractors pursuant to all
State and federal laws, rules and regulations, specifically, Section 641.3155,
F.S., 42 CFR 447.46, and 42 CFR 447.45(d)(2), (3), (d)(5) and (d)(6);

 
(2)
Provide for prompt submission of information needed to make payment;

 
(3)
Make full disclosure of the method and amount of compensation or other
consideration to be received from the Health Plan;

 
(4)
Require an adequate record system be maintained for recording services, charges,
dates and all other commonly accepted information elements for services rendered
to the Health Plan; and

 
(5)
Specify that the Health Plan shall assume responsibility for cost avoidance
measures for third party collections in accordance with Section XV., Financial
Requirements.

 
b.
Provisions for monitoring and inspections:

 
(1)
Provide that the Agency and DHHS may evaluate through inspection or other means
the quality, appropriateness and timeliness of services performed;

 
(2)
Provide for inspections of any records pertinent to the Contract by the Agency
and DHHS;

 
(3)
Require that records be maintained for a period not less than five (5) years
from the close of the Contract and retained further if the records are under
review or audit until the review or audit is complete. (Prior approval for the
disposition of records must be requested and approved by the Health Plan if the
Subcontract is continuous.)

 
(4)
Provide for monitoring and oversight by the Health Plan and the Subcontractor to
provide assurance that all licensed medical professionals are Credentialed in
accordance with the Health Plan’s and the Agency’s Credentialing requirements as
found in Section VIII.A.3.h Credentialing and Recredentialing, above, if the
Health Plan has delegated the Credentialing to a Subcontractor; and

 
(5)
Provide for monitoring of services rendered to Enrollees sponsored by the
Provider.

 
c.
Specification of functions of the Subcontractor:

 
(1)
Identify the population covered by the Subcontract;

 
(2)
Provide for submission of all reports and clinical information required by the
Health Plan, including Child Health Check-Up reporting (if applicable); and

 
(3)
Provide for the participation in any internal and external quality improvement,
utilization review, peer review, and grievance procedures established by the
Health Plan.

 
d.
Protective clauses:

 
(1)
Require safeguarding of information about Enrollees according to 42 CFR, Part
438.224;

 
(2)
Require compliance with HIPAA privacy and security provisions;

 
(3)
Require an exculpatory clause, which survives Subcontract termination, including
breach of Subcontract due to insolvency, which assures that Medicaid Recipients
or the Agency will not be held liable for any debts of the Subcontractor; and

 
(4)
If there is a Health Plan physician incentive plan, include a statement that the
Health Plan shall make no specific payment directly or indirectly under a
physician incentive plan to a Subcontractor as an inducement to reduce or limit
Medically Necessary services to an Enrollee, and affirmatively state that all
incentive plans do not provide incentives, monetary or otherwise, for the
withholding of Medically Necessary care.

 
4.
Contain a clause indemnifying, defending and holding the Agency and the Health
Plan’s Enrollees harmless from and against all claims, damages, causes of
action, costs or expenses, including court costs and reasonable attorney fees,
to the extent proximately caused by any negligent act or other wrongful conduct
arising from the Subcontract agreement. This clause must survive the termination
of the Subcontract, including breach due to Insolvency. The Agency may waive
this requirement for itself, but not Health Plan Enrollees, for damages in
excess of the statutory cap on damages for public entities, if the Subcontractor
is a public health entity with statutory immunity. All such waivers must be
approved in writing by the Agency.

 
5.
Require that the Subcontractor secure and maintain, during the life of the
Subcontract, worker's compensation insurance for all of its employees connected
with the work under this Contract unless such employees are covered by the
protection afforded by the Health Plan. Such insurance shall comply with
Florida's Worker's Compensation Law.

 
6.
Specify that if the Subcontractor delegates or Subcontracts any functions of the
Health Plan, that the Subcontract or delegation includes all the requirements of
this Contract.

 
7.
Make provisions for a waiver of those terms of the Subcontract, which, as they
pertain to Medicaid Recipients, are in conflict with the specifications of this
Contract.

 
8.
Provide for revoking delegation, or imposing other sanctions, if the
Subcontractor’s performance is inadequate.

P.
Hospital Provider Contracts

All Hospital Provider Contracts must meet the requirements outlined in Section
X.C., Provider Contract Requirements, above. In addition, Hospital Provider
Contracts shall require that the Hospitals notify the Health Plan of births
where the mother is a Health Plan Enrollee. The Hospital Provider Contract must
also specify which entity (Health Plan or Hospital) is responsible for
completing form DCF-ES 2039 and submitting it to the local DCF Economic
Self-Sufficiency Services office. The Hospital Provider Contract must also
indicate that the Health Plan’s name must be indicated as the referring Agency
when the form DCF-ES 2039 is completed.

Q.
Termination Procedures

 
1.
In conjunction with Section III.B., Termination, on page eight (8) of the
Standard Contract, all Provider Contracts and Subcontracts shall contain
termination procedures. The Health Plan agrees to extend the thirty (30)
Calendar Days notice found in Section III.B.1., Termination at Will, on page
eight (8) of the Standard Contract to ninety (90) Calendar Days notice. The
party initiating the termination shall render written notice of termination to
the other party by certified mail, return receipt requested, or in person with
proof of delivery, or by facsimile letter followed by certified mail, return
receipt requested. The notice of termination shall specify the nature of
termination, the extent to which performance of work under the Contract is
terminated, and the date on which such termination shall become effective. In
accordance with 1932(e)(4), Social Security Act, the Agency shall provide the
Health Plan with an opportunity for a hearing prior to termination for Cause.
This does not preclude the Agency from terminating without Cause.

 
2.
Upon receipt of final notice of termination, on the date and to the extent
specified in the notice of termination, the Health Plan shall:

 
a.
Stop work under the Contract, but not before the termination date.

 
b.
Cease enrollment of new Enrollees under the Contract.

 
c.
Terminate all Marketing activities and Subcontracts relating to Marketing.

 
d.
Assign to the State those Subcontracts as directed by the Agency's contracting
officer including all the rights, title and interest of the Health Plan for
performance of those Subcontracts.

 
e.
In the event the Agency has terminated this Contract in one or more Agency areas
of the State, complete the performance of this Contract in all other areas in
which the Health Plan’s Contract was not terminated.

 
f.
Take such action as may be necessary, or as the Agency's contracting officer may
direct, for the protection of property related to the Contract that is in the
possession of the Health Plan and in which the Agency has been granted or may
acquire an interest.

 
g.
Not accept any payment after the Contract ends, unless the payment is for the
time period covered under the Contract. Any payments due under the terms of this
Contract may be withheld until the Agency receives from the Health Plan all
written and properly executed documents as required by the written instructions
of the Agency.

 
h.
At least sixty (60) Calendar Days prior to the termination effective date,
provide written notification to all Enrollees of the following information: the
date on which the Health Plan will no longer participate in the State’s Medicaid
program and instructions on contacting the Agency’s Choice Counselor/Enrollment
Broker help line to obtain information on the Enrollee’s enrollment options and
to request a change in Health Plans.

R.
Waiver

 
1.
No covenant, condition, duty, obligation, or undertaking contained in or made a
part of the Contract shall be waived except by written agreement of the parties,
and forbearance or indulgence in any other form or manner by either party in any
regard whatsoever shall not constitute a waiver of the covenant, condition,
duty, obligation, or undertaking to be kept, performed, or discharged by the
party to which the same may apply. Until complete performance or satisfaction of
all such covenants, conditions, duties, obligations, or undertakings, the other
party shall have the right to invoke any remedy available under law or equity
not withstanding any such forbearance or indulgence.

S.
Withdrawing Services from a County

 
1.
If the Health Plan intends to withdraw services from a county, it shall provide
written notice to all Enrollees in that county at least sixty (60) Calendar Days
before the last day of service. The notice shall contain the same information as
required for a notice of termination according to Section XVI.Q., Terms and
Conditions, Termination Procedures, of this Contract. The Health Plan shall also
provide written notice of the withdrawal to all Providers and Subcontractors in
the county.

T.
MyFloridaMarketPlace Vendor Registration

 
1.
The Health Plan is exempt under Rule 60A-1.030(3)d(ii), Florida Administrative
Code, from being required to register in MyFloridaMarketPlace for this Contract.

U.
MyFloridaMarketplace Vendor Registration and Transaction Fee Exemption 

 
1.
The Health Plan is exempted from paying the 1% transaction fee per
60A-1.032(1)(g) of the Florida Administrative Code for this Contract.

V.
Ownership and Management Disclosure 

 
1.
Federal and State laws require full disclosure of ownership, management and
control of Disclosing Entities. 

 
a.
Disclosure shall be made on forms prescribed by the Agency for the areas of
ownership and control interest (42 CFR 455.104, Form CMS 1513), business
transactions (42 CFR 455.105), public entity crimes (Section 287.133(3)(a),
F.S.), and disbarment and suspension (52 Fed. Reg., pages 20360-20369, and
Section 4707 of the Balanced Budget Act of 1997). The forms are available
through the Agency and are to be submitted to the Agency with the initial
application for a Medicaid Health Plan and then submitted on an annual basis.
The Health Plan shall disclose any changes in management as soon as those occur.
In addition, the Health Plan shall submit to the Agency full disclosure of
ownership and control of the Health Plan at least sixty (60) Calendar Days
before any change in the Health Plan’s ownership or control occurs.

 
b.
The following definitions apply to ownership disclosure:

 
(1)
A person with an ownership interest or control interest means a person or
corporation that:

 
(a)
Owns, indirectly or directly, five percent (5%) or more of the Health Plan's
capital or stock, or receives five percent (5%) or more of its profits;

 
(b)
Has an interest in any mortgage, deed of trust, note, or other obligation
secured in whole or in part by the Health Plan or by its property or assets and
that interest is equal to or exceeds five percent (5%) of the total property or
assets; or

 
(c)
Is an officer or director of the Health Plan, if organized as a corporation, or
is a partner in the Health Plan, if organized as a partnership.

 
(2)
The percentage of direct ownership or control is calculated by multiplying the
percent of interest which a person owns, by the percent of the Health Plan’s
assets used to secure the obligation. Thus, if a person owns ten percent (10%)
of a note secured by sixty percent (60%) of the Health Plan’s assets, the person
owns six percent (6%) of the Health Plan.

 
(3)
The percent of indirect ownership or control is calculated by multiplying the
percentage of ownership in each organization. Thus, if a person owns ten percent
(10%) of the stock in a corporation, which owns eighty percent (80%) of the
Health Plan’s stock, the person owns eight percent (8%) of the Health Plan.

 
c.
The following definitions apply to management disclosure:

 
(1)
Changes in management are defined as any change in the management control of the
Health Plan. Examples of such changes are those listed below or equivalent
positions by another title.

 
(a)
Changes in the board of directors or officers of the Health Plan, medical
director, chief executive officer, administrator, and chief financial officer.

 
(b)
Changes in the management of the Health Plan where the Health Plan has decided
to contract out the operation of the Health Plan to a management corporation.
The Health Plan shall disclose such changes in management control and provide a
copy of the contract to the Agency for approval at least sixty (60) Calendar
Days prior to the management contract start date.

 
d.
The Health Plan shall conduct an annual background check with the Florida
Department of Law Enforcement on all persons with five percent (5%) or more
ownership interest in the Health Plan, or who have executive management
responsibility for the Health Plan, or have the ability to exercise effective
control of the Health Plan (see Section 409.912, F.S.). The Health Plan shall
submit information to the Agency for such persons who have a record of illegal
conduct according to the background check. The Health Plan shall keep a record
of all background checks to be available for Agency review upon request.

 
(1)
The Health Plan shall submit, prior to execution of a contract, complete sets of
fingerprints of principals of the Health Plan to the Agency for the purpose of
conducting a criminal history record check (see Section 409.907, F.S.).

 
(2)
Principals of the Health Plan shall be as defined in Section 409.907, F.S.

 
e.
The Health Plan shall submit to the Agency, within five (5) Business Days, any
information on any officer, director, agent, managing employee, or owner of
stock or beneficial interest in excess of five percent (5%) of the Health Plan
who has been found guilty of, regardless of adjudication, or who entered a plea
of nolo contendere or guilty to, any of the offenses listed in Section 435.03,
F.S.

 
f.
The Agency shall not contract with a Health Plan that has an officer, director,
agent, managing employee, or owner of stock or beneficial interest in excess of
five percent (5%) of the Health Plan, who has committed any of the above listed
offenses (see Section 409.912, F.S.). In order to avoid termination, the Health
Plan must submit a corrective action plan, acceptable to the Agency, which
ensures that such person is divested of all interest and/or control and has no
role in the operation and/or management of the Health Plan.

W.
Minority Recruitment and Retention Plan

 
1.
The Health Plan shall implement and maintain a minority recruitment and
retention plan in accordance with section 641.217, F.S. The Health Plan shall
have policies and procedures for the implementation and maintenance of such a
plan. The minority recruitment and retention plan may be company-wide for all
product lines.

X.
Independent Provider

 
1.
It is expressly agreed that the Health Plan and any Subcontractors, and any
agents, officers, and/or employees of the Health Plan or any Subcontractors, in
the performance of this Contract shall act in an independent capacity and not as
officers and employees of the Agency or the State of Florida. It is further
expressly agreed that this Contract shall not be construed as a partnership or
joint venture between the Health Plan or any Subcontractor and the Agency and
the State of Florida.

Y.
General Insurance Requirements

 
1.
The Health Plan shall obtain and maintain the same adequate insurance coverage
including general liability insurance, professional liability and malpractice
insurance, fire and property insurance, and directors’ omission and error
insurance. All insurance coverage must comply with the provisions set forth for
HMOs in Rule 69O-191.069, F.A.C.; excepting that the reporting, administrative,
and approval requirements shall be to the Agency rather than to the Department
of Financial Services. All insurance policies must be written by insurers
licensed to do business in the State of Florida and in good standing with the
Department of Financial Services. All policy declaration pages must be submitted
to the Agency annually. Each certificate of insurance shall provide for
notification to the Agency in the event of termination of the policy.

Z.
Worker's Compensation Insurance

 
1.
The Health Plan shall secure and maintain during the life of the Contract,
worker's compensation insurance for all of its employees connected with the work
under this Contract. Such insurance shall comply with the Florida Worker's
Compensation Law (see Chapter 440, F.S.). Policy declaration pages must be
submitted to the Agency annually.

AA.
State Ownership

 
1.
The Agency shall have the right to use, disclose, or duplicate all information
and data developed, derived, documented, or furnished by the Health Plan
resulting from this Contract. Nothing herein shall entitle the Agency to
disclose to third parties data or information which would otherwise be protected
from disclosure by State or federal law.

BB.
Disaster Plan

 
1.
The Health Plan shall submit a plan describing procedures guaranteeing the
continuation of services during an emergency, including but not limited to
localized acts of nature, accidents, and technological and/or attack-related
emergencies.

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BUSINESS ASSOCIATE AGREEMENT

The parties to this Attachment agree that the following provisions constitute a
business associate agreement for purposes of complying with the requirements of
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This
Attachment is applicable if the Vendor is a business associate within the
meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.

The Vendor certifies and agrees as to abide by the following:

1.  
Definitions. Unless specifically stated in this Attachment, the definition of
the terms contained herein shall have the same meaning and effect as defined in
45 C.F.R. 160 and 164.

1.a. Protected Health Information. For purposes of this Attachment, protected
health information shall have the same meaning and effect as defined in 45
C.F.R. 160 and 164, limited to the information created, received, maintained or
transmitted by the Vendor from, or on behalf of, the Agency.

1.b. Security Incident. For purposes of this Attachment, security incident shall
mean any event resulting in computer systems, networks, or data being viewed,
manipulated, damaged, destroyed or made inaccessible by an unauthorized
activity. See National Institute of Standards and Technology (NIST) Special
Publication 800-61, "Computer Security Incident Handling Guide,” for more
information.

2.  
Use and Disclosure of Protected Health Information. The Vendor shall not use or
disclose protected health information other than as permitted by this Contract
or by federal and state law. The Vendor will use appropriate safeguards to
prevent the use or disclosure of protected health information for any purpose
not in conformity with this Contract and federal and state law. The Vendor will
implement administrative, physical, and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity, and availability of
electronic protected health information the Vendor creates, receives, maintains,
or transmits on behalf of the Agency.

3. Use and Disclosure of Information for Management, Administration, and Legal
Responsibilities. The Vendor is permitted to use and disclose protected health
information received from the Agency for the proper management and
administration of the Vendor or to carry out the legal responsibilities of the
Vendor, in accordance with 45 C.F.R. 164.504(e)(4). Such disclosure is only
permissible where required by law, or where the Vendor obtains reasonable
assurances from the person to whom the protected health information is disclosed
that: (1) the protected health information will be held confidentially, (2) the
protected health information will be used or further disclosed only as required
by law or for the purposes for which it was disclosed to the person, and (3) the
person notifies the Vendor of any instance of which it is aware in which the
confidentiality of the protected health information has been breached.

4. Disclosure to Third Parties. The Vendor will not divulge, disclose, or
communicate protected health information to any third party for any purpose not
in conformity with this Contract without prior written approval from the Agency.
The Vendor shall ensure that any agent, including a subcontractor, to whom it
provides protected health information received from, or created or received by
the Vendor on behalf of, the Agency agrees to the same terms, conditions, and
restrictions that apply to the Vendor with respect to protected health
information.

5. Access to Information. The Vendor shall make protected health information
available in accordance with federal and state law, including providing a right
of access to persons who are the subjects of the protected health information in
accordance with 45 C.F.R. 164.524.

6. Amendment and Incorporation of Amendments. The Vendor shall make protected
health information available for amendment and to incorporate any amendments to
the protected health information in accordance with 45 C.F.R. § 164.526.

7. Accounting for Disclosures. The Vendor shall make protected health
information available as required to provide an accounting of disclosures in
accordance with 45 C.F.R. § 164.528. The Vendor shall document all disclosures
of protected health information as needed for the Agency to respond to a request
for an accounting of disclosures in accordance with 45 C.F.R. § 164.528.

8. Access to Books and Records. The Vendor shall make its internal practices,
books, and records relating to the use and disclosure of protected health
information received from, or created or received by the Vendor on behalf of the
Agency, available to the Secretary of the Department of Health and Human
Services or the Secretary’s designee for purposes of determining compliance with
the Department of Health and Human Services Privacy Regulations.

9. Reporting. The Vendor shall make a good faith effort to identify any use or
disclosure of protected health information not provided for in this Contract.
The Vendor will report to the Agency, within ten (10) business days of
discovery, any use or disclosure of protected health information not provided
for in this Contract of which the Vendor is aware. The Vendor will report to the
Agency, within twenty-four (24) hours of discovery, any security incident of
which the Vendor is aware. A violation of this paragraph shall be a material
violation of this Contract.

10. Termination. Upon the Agency’s discovery of a material breach of this
Attachment, the Agency shall have the right to terminate this Contract.

10.a. Effect of Termination. At the termination of this Contract, the Vendor
shall return all protected health information that the Vendor still maintains in
any form, including any copies or hybrid or merged databases made by the Vendor;
or with prior written approval of the Agency, the protected health information
may be destroyed by the Vendor after its use. If the protected health
information is destroyed pursuant to the Agency’s prior written approval, the
Vendor must provide a written confirmation of such destruction to the Agency. If
return or destruction of the protected health information is determined not
feasible by the Agency, the Vendor agrees to protect the protected health
information and treat it as strictly confidential.

The Vendor has caused this Attachment to be signed and delivered by its duly
authorized representative, as of the date set forth below.

Vendor Name:
 
   /s/  Paul Behrens      
Signature 
 
8/31/06  
Date
 
  Paul Behrens, SVP & Chief Financial Officer   
Name and Title of Authorized Signer

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CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1)  
No federal appropriated funds have been paid or will be paid, by or on behalf of
the undersigned, to any person for influencing or attempting to influence an
officer or employee of any agency, a member of congress, an officer or employee
of congress, or an employee of a member of congress in connection with the
awarding of any federal contract, the making of any federal grant, the making of
any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any federal
contract, grant, loan, or cooperative agreement.

 

(2)  
If any funds other than federal appropriated funds have been paid or will be
paid to any person for influencing or attempting to influence an officer or
employee of any agency, a member of congress, an officer or employee of
congress, or an employee of a member of congress in connection with this federal
contract, grant, loan, or cooperative agreement, the undersigned shall complete
and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in
accordance with its instructions.

 

(3)  
The undersigned shall require that the language of this certification be
included in the award documents for all sub-awards at all tiers (including
subcontracts, sub-grants, and contracts under grants, loans, and cooperative
agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
 

  /s/  Paul Behrens     
Signature 
 8/31/06 
Date
 
 
Paul Behrens             
Name of Authorized Individual
 
 FA 615
Application or Contract Number
 
 
WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida
8735 Henderson Rd, Ren 1 Tampa, FL 33634
Name and Address of Organization
 

 

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CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS

This certification is required by the regulations implementing Executive Order
12549, Debarment and Suspension, signed February 18, 1986. The guidelines were
published in the May 29, 1987, Federal Register (52 Fed. Reg., pages
20360-20369).

INSTRUCTIONS

1.
Each Vendor whose contract/subcontract equals or exceeds $25,000 in federal
monies must sign this certification prior to execution of each
contract/subcontract. Additionally, Vendors who audit federal programs must also
sign, regardless of the contract amount. The Agency for Health Care
Administration cannot contract with these types of Vendors if they are debarred
or suspended by the federal government.

2.
This certification is a material representation of fact upon which reliance is
placed when this contract/subcontract is entered into. If it is later determined
that the signer knowingly rendered an erroneous certification, the Federal
Government may pursue available remedies, including suspension and/or debarment.

3.
The Vendor shall provide immediate written notice to the contract manager at any
time the Vendor learns that its certification was erroneous when submitted or
has become erroneous by reason of changed circumstances.

4.
The terms "debarred," "suspended," "ineligible," "person," "principal," and
"voluntarily excluded," as used in this certification, have the meanings set out
in the Definitions and Coverage sections of rules implementing Executive Order
12549. You may contact the contract manager for assistance in obtaining a copy
of those regulations.

5.
The Vendor agrees by submitting this certification that, it shall not knowingly
enter into any subcontract with a person who is debarred, suspended, declared
ineligible, or voluntarily excluded from participation in this
contract/subcontract unless authorized by the Federal Government.

6.
The Vendor further agrees by submitting this certification that it will require
each subcontractor of this contract/subcontract, whose payment will equal or
exceed $25,000 in federal monies, to submit a signed copy of this certification.

7.
The Agency for Health Care Administration may rely upon a certification of a
Vendor that it is not debarred, suspended, ineligible, or voluntarily excluded
from contracting/subcontracting unless it knows that the certification is
erroneous.

8.
This signed certification must be kept in the contract manager's contract file.
Subcontractor's certifications must be kept at the contractor's business
location.

 
CERTIFICATION

(1)
The prospective Vendor certifies, by signing this certification, that neither he
nor his principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this
contract/subcontract by any federal department or agency.

(2)
Where the prospective Vendor is unable to certify to any of the statements in
this certification, such prospective Vendor shall attach an explanation to this
certification.

 

   /s/  Paul Behrens   
Signature
 8/31/06
Date

 
Paul Behrens, SVP & CFO
Name and Title of Authorized Signer