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Back to Form 10-Q [form10-q.htm]
Exhibit 10.7

STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES

Amendment Number:
1
Contract #:
093-HUS-WCC-2
Contract Period:
07/01/2005 - 06/30/2007
Contractor Name:
WELLCARE OF CONNECTICUT, INC.
Contractor Address:
127 Washington Avenue, North Haven, CT 06473

Contract number 093-HUS-WCC-2 by and between the Department of Social Services
(the "Department") and WELLCARE of CONNECTICUT, Inc. (the "Contractor") for the
provision of services under the HUSKY A program is hereby amended as follows:

 
1.
Part II "GENERAL CONTRACT TERMS FOR MCOs" dated December 12, 2003 are deleted in
their entirety and replaced with Part II "GENERAL CONTRACT TERMS FOR MCOs" pages
1 through 108 dated 05/01/07 attached hereto.

 
2.
Appendices A through J are deleted in their entirety and replaced with the
following appendices attached hereto;

 
A. HUSKY B Covered Services
B. DELETED
C. HUSKY Plus
D. Provider Credentialing and Enrollment Requirements
E.  American Academy of Pediatrics - Recommendations for Preventative Pediatric
Health Care
F.  DSS Marketing Guidelines
G.  Standards for Internal Quality Assurance Programs for Health Plans
H.  Claims Inventory, Aging and Unaudited Quarterly Financial Reports
I.   Capitation Payment Amount
J.   Inpatient/Eligibility Recategorization Chart
K. Abortion Reporting
L.  BLANK - RESERVED FOR POSSIBLE FUTURE USE
M.BLANK - RESERVED FOR POSSIBLE FUTURE USE
N.  HUSKY Behavioral Health Carve-Out Coverage and Coordination of Medical and
Behavioral Services
O.  CTBHP Master Covered Services Table

 
3.
Appendices A through H and J through O shall become effective upon the proper
execution of this amendment by the Department and the Contractor.

 
Page 1 of 2

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4.
Appendix I Capitation Payment Amount HUSKY B Capitation Rate shall be effective
for the 07/01/06 - 06/30/07.

 
5.
Pursuant to Public Act 07-1, An Act Concerning the State Contractor Contribution
Ban and Gifts to State and Quasi-Public Agencies the Department must provide and
each Contractor must acknowledge receipt of the State Elections Enforcement
Commission's notice advising state contractors of state campaign contribution
and solicitation prohibitions. Through the execution of this amendment the
Department certifies that SEEC FORM 11 - NOTICE TO EXECUTIVE BRANCH STATE
CONTRACTORS AND PROSPECTIVE STATE CONTRACTORS OF CAMPAIGN CONTRIBUTION AND
SOLICITATION BAN has been provided to the Contractor and the Contractor
acknowledges receipt of the same.

 
ACCEPTANCES AND APPROVALS
 
This document constitutes an amendment to the above numbered contract. All
provisions of that contract, except those explicitly changed or described above
by this amendment, shall remain in full force and effect.

WELLCARE of CONNECTICUT, Inc.
 
Department of Social Services
/s/  Todd Farha
5/30/2007
/s/  Michael P. Starkowski
5/31/2007
Signature (Authorized Official)
Date
Signature (Authorized Official)
Date
 
Todd Farha
President & CEO
Michael P. Starkowski
Commissioner
Typed Name (Authorized Official)
Title
Typed Name (Authorized Official)
Title

Attorney General (as to
form)                                                                                                                        Date

 
(   ) This contract does not require the signature of the Attorney General
pursuant to an agreement between the Department and the Office of the Attorney
General dated: __________
 
 
Page 2 of 2

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05 01 07 HUSKY B Final

PART I:   STANDARD CONNECTICUT CONTRACT TERMS
PART  II: GENERAL CONTRACT TERMS FOR MCOS

 
1.      DEFINITIONS
 
2.      DELEGATIONS OF AUTHORITY
 
3.      FUNCTIONS AND DUTIES OF THE MCO

3.01  Provision of Services
3.02  Non-Discrimination
3.03  Gag Rules/Integrity of Professional Advice to Members
3.04  Coordination and Continuation of Care
3.05  Emergency Services
3.06  Geographic Coverage
3.07  Choice of Health Professional
3.08  Provider Network
3.09  Network Adequacy and Maximum Enrollment Levels
3.10  Provider Contracts
3.11  Provider Credentialing and Enrollment
3.12  Specialist Providers and the Referral Process
3.13  PCP and Specialist Selection, Scheduling and Capacity
3.14  Family Planning Access and Confidentiality
3.15  Pharmacy Access
3.16  Mental Health and Substance Abuse Access
3.17  Children's Issues and Preventive Care and Services
3.18  Well-Care Services for Adolescents
3.19  HUSKY Plus Physical
3.20  Prenatal Care
3.21  Dental Care
3.22  Pre-Existing Conditions
3.23  Prior Authorization
3.24  Newborn Enrollment and Minimum Hospital Stays
3.25  Acute Care Hospitalization at Time of Enrollment or Disenrollment
3.26  Open Enrollment
3.27  Special Disenrollment
3.28  Linguistic Access
3.29  Services to Members
3.30  Information to Potential Members
3.31  DSS Marketing Guidelines
3.32  Health Education
3.33  Quality Assessment and Performance Improvement
3.34  Inspection of Facilities
3.35  Examination of Records
3.36  Medical Records
3.37  Audit Liabilities
3.38  Clinical Data Reporting

 
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05 01 07 HUSKY B Final

 
3.39   Utilization Management
3.40   Financial Records
3.41   Insurance
3.42   Subcontracting for Services
3.43   Timely Payment of Claims
3.44   Insolvency Protection
3.45   Fraud and Abuse

 
4.  MCO Responsibility Concerning Payments Made On Behalf Of The Member
 
4.1     Deductibles, Coinsurance, Annual Benefit Maximums, and Lifetime Benefit
Maximums
4.2     Payments for Noncovered Services
4.3     Cost-Sharing Exemption for American Indian/Native American Children
4.4     Copayments
4.5     Copayments Prohibited
4.6     Maximum Annual Limits for Copayments
4.7     Tracking Copayments
4.8     Amount of Premium Paid
4.9     Billing and Collecting the Premium Payments
4.10   Notification of Premium Payments Due
4.11   Notification of Non-payment of the Premium Payments
4.12   Past Due Premium Payments Paid
4.13   Resumption of Services if the Child is Re-enrolled
4.14   Overpayment of Premium
4.15   Member Premium Share Paid by Another Entity
4.16   Tracking Premium Payments
4.17   Behavioral Health Payment Adjustment

 
5. LIMITED COVERAGE OF SOME GOODS AND SERVICES AND ALLOWANCES
5.01    Limited Coverage of Some Goods and Services

 
6.      FUNCTIONS AND DUTIES OF THE DEPARTMENT
6.1    Eligibility Determinations
6.2    Ineligibility Determinations
6.3    Enrollment / Disenrollment
6.4    Lock-In / Open Enrollment
6.5    Capitation Payments to the MCO
6.6    Newborn Retroactive Adjustments
6.7    Information
 
7.      DECLARATIONS AND MISCELLANEOUS PROVISIONS
7.01  Competition not Restricted
7.02  Nonsegregated Facilities

 
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05 01 07 HUSKY B Final

7.03   Offer of Gratuities
7.04   Employment/Affirmative Action Clause
7.05   Confidentiality
7.06   Independent Capacity
7.07   Liaison
7.08   Freedom of Information
7.09   Waivers
7.10   Force Majeure
7.11   Financial Responsibilities of the MCO
7.12   Captilization and Reserves
7.13   Members Held Harmless
7.14   Compliance with Applicable Laws, Rules and Policies
7.15   Federal Requirements and Assurances
7.16   Civil Rights
7.17   Statutory Requirements
7.18   Disclosure of Interlocking Relationships
7.19   DEPARTMENT'S Data Files
7.20   Hold Harmless
7.21   Executive Order Number 16

 
8.      MCO RESPONSIBILITIES CONCERNING INTERNAL AND EXTERNAL APPEALS
8.1    MCO Responsibilities Concerning Internal and External
Appeals and   Notices of Denial
8.2    Internal Appeal Process Required
8.3    Denial Notice
8.4    Internal Appeal Process
8.5    Written Appeal Decision
8.6    Expedited Review
8.7    External Appeal Process through the DOI
8.8    Provider Appeal Process

 
9.      CORRECTION ACTION AND CONTRACT TERMINATION
9.1     Performance Review
9.2     Settlement of Disputes
9.3     Administrative Errors
9.4     Suspension of New Enrollment
9.5     Sanctions
9.6     Payment Withhold, Class C Sanctions
9.7     Emergency Services Denials
9.8     Termination for Default
9.9     Termination for Mutual Convenience
9.10   Termination for Financial Instability of the MCO
9.11   Termination for Unavailability of Funds
9.12   Termination for Collusion in Price Determination
9.13    Termination Obligations of Contracting Parties
9.14    Waiver of Default

 
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05 01 07 HUSKY B Final

10.     OTHER PROVISIONS
10.1    Severability
10.2    Effective Date
10.3    Order of Precedence
10.4    Correction of Deficiencies
10.5    This is not a Public Works Contract

 
11.        APPENDICES
Appendix A  HUSKY B Covered Services
 

Appendix B   HUSKY Plus-Behavioral Deleted
 

Appendix C  HUSKY Plus
 

Appendix D  Provider Credentialing and Enrollment Requirements; (same as HUSKY
A)
 

Appendix E  American Academy of Pediatrics - Recommendations for Preventive
Pediatric Health Care
 

Appendix F  DSS Marketing Guidelines; (same as HUSKY A)
 

Appendix G Standards for Internal Quality Assurance Programs for Health Plans;
(same as HUSKY A)
 

Appendix H Claims Inventory, Aging and Unaudited Quarterly Financial Reports;
(same as HUSKY A)
 

Appendix I  Capitation Payment Amount
 

Appendix J  Inpatient/Eligibility Recategorization Chart, (same as HUSKY A)
 

Appendix K Abortion Reporting.
 

Appendix N HUSKY (Behavioral Health Carve-Out Coverage and Coordination of
Medical and Behavioral Services) (same as HUSKY A)
 

Appendix O CTBHP Master Covered Services Table (same as HUSKY A)
 

12.        SIGNATURES

 

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05 01 07 HUSKY B Final

PART II: GENERAL CONTRACT TERMS  FOR MCOs

1.        DEFINITIONS

As used throughout this contract, the following terms shall have the meanings
set forth below.

Abuse:

MCO and/or provider practices that are inconsistent with sound fiscal, business,
or medical practices, and result in an unnecessary cost to the HUSKY program, or
the reimbursement for services that are not medically necessary or that fail to
meet professionally recognized standards for health care, or a pattern of
failing to provide medically necessary services required by this contract.
Member practices that result in unnecessary cost to the HUSKY program, also
constitute abuse.

Administrative Services Organization (ASO):

An organization providing utilization management, benefit information and
intensive care management services within a centralized information system
framework

Allowance:

The amount that a managed care organization (MCO) is responsible to pay a
provider towards the cost of a limited covered benefit.

American Indian/Alaska Native (Al):
 

1)
A member of a Federally recognized Indian tribe, band, or group;
 

2)
An Eskimo or Aleut other Alaska Native enrolled by the Secretary of the Interior
pursuant to the Alaska Native Claims Settlement Act, 43 U.S.C. 1601 et seq.; or

3)
A person who is considered by the Secretary of HHS to be an Indian for any
purpose.

Applicant:

Any of the following individuals who are applying for coverage under HUSKY B on
behalf of a child, pursuant to Section 17b-290 of the Connecticut General
Statutes:

1)
A natural parent, adoptive parent, legal guardian, caretaker relative, foster
parent, or a stepparent who is over eighteen years of age and who lives with the
child for whom he or she is applying;

2)
A non-custodial parent who is under order of a court or family support
magistrate to provide health insurance for his or her child;

3)
A child who is eighteen (18) years of age who is applying on his or her own
behalf or on behalf of a minor dependent with whom he or she lives; and

4)
A child who is emancipated in accordance with the provisions of Sections 46b-150
to 46b-150e, inclusive, of the Connecticut General Statutes, who is applying on
his or her own behalf or on behalf of a minor dependent with whom he or she
lives.
 
A child is an applicant until the child receives coverage under HUSKY B.

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05 01 07 HUSKY B Final
 
Behavioral Health Partnership ("Partnership" or "BHP"):

An integrated behavioral health service system for HUSKY Part A and HUSKY Part B
members, children enrolled in the Voluntary Services Program operated by the
Department of Children and Families and may, at the discretion of the
Commissioners of Children and Families and Social Services, include other
children, adolescents, and families served by the Department of Children and
Families

Behavioral Health Services:

Services that are necessary to diagnose, correct or diminish the adverse effects
of a psychiatric or substance use disorder.

Capitation Rate:

The amount paid per Member by the DEPARTMENT to each managed care organization
(MCO) on a monthly basis.

Capitation Payment:

The individualized monthly payment made by the DEPARTMENT to the MCO on behalf
of Members.

Child:

For the purposes of the HUSKY B program, an individual under nineteen (19) years
of age, as defined in Section 17b-290 of the Connecticut General Statutes.

Child Health Assistance:

Payment for part or all of the cost of health benefits coverage provided to
targeted low-income children for the services listed at 42 CFR 457.402.

Child Preventive Care:

Preventive care and services that include periodic and well-child visits,
routine immunizations, health screenings and routine laboratory tests.

Children with Special Health Care Needs:

Children at elevated risk for (biologic or acquired) chronic physical,
developmental, behavioral, or emotional conditions and who also require health
and related (not educational or recreational) services of a type and amount not
usually required by children of the same age.

Clean Claim:

A bill for service(s) or goods, a line item of services or all services and/or
goods for a recipient contained on one bill which can be processed without
obtaining additional information from the provider of service(s) or a third
party. A clean claim does not include a claim from a provider who is under
investigation for fraud or abuse or a claim under review for medical necessity.

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05 01 07 HUSKY B Final

CMS:

Centers for Medicare and Medicaid Services (CMS), formerly known as the Health
Care Financing Administration (HCFA), a division within the United States
Department of Health and Human Services.

Coinsurance:

The sharing of health care expenses by the insured and an insurer in a specified
ratio, as defined in Section 17b-290 of the Connecticut General Statutes.

Commissioner:

The Commissioner of the Department of Social Services, as defined in Section
17b-290 of the Connecticut General Statutes.

Complaint:

A written or oral communication from a Member expressing dissatisfaction with
some aspect of the MCO's services.

Consultant:

A corporation, company, organization or person or their affiliates retained by
the DEPARTMENT to provide assistance in administering the HUSKY B program, not
the MCO or subcontractor.

Contract Administrator:

The DEPARTMENT employee responsible for fulfilling the administrative
responsibilities associated with this managed care project.

Contract Services:

Those goods and services including limited benefits, which the MCO is required
to provide Members under this contract.

Co-payment:

A payment made by or on behalf of a Member for a specified covered benefit under
HUSKY B, as defined in Section 17b-290 of the Connecticut General Statutes.

Cost-sharing:

An arrangement made by or on behalf of a Member to pay a portion of the cost of
health services and share costs with the DEPARTMENT and the MCO, which includes
co-payments, premiums, deductibles and coinsurance, as defined in Section
17b-290 of the Connecticut General Statutes.

CPT Codes or Current Procedure Terminology:

A listing of descriptive terms and identifying codes for reporting medical
services and procedures for a variety of uses, including billing of public and
private health insurance programs. The codes are developed and published by the
American Medical Association.

Date of Application:

The date on which an application for the HUSKY B program is received by the
DEPARTMENT or its agent, containing the applicant's signature.

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05 01 07 HUSKY B Final

Day:

Except where the term business day is expressly used, all references in this
contract will be construed as calendar days.

Deductible:

The amount of out-of-pocket expenses that would be paid for health services by
or on behalf of a Member before becoming payable by the insurer, as defined in
Section 17b-290 of the Connecticut General Statutes.

DEPARTMENT:

The Department of Social Services (DSS), State of Connecticut.

DSM IV or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition:

The current listing of descriptive terms and identifying codes for reporting a
classification of mental and substance abuse disorders.

Durable Medical Equipment (DME):
Equipment furnished by a supplier or a home health agency that:
1)    Can withstand repeated use;
2)    Is primarily and customarily used to serve a medical purpose;
3)    Generally is not useful to an individual in the absence of an illness
or injury; and
4)    Is appropriate for use in the home.

Emergency or Emergency Medical Condition:

A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in placing the health of the individual
(or with respect to a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy, serious impairment to body functions or serious
dysfunction of any body organ or part.

Emergency Services:

Covered inpatient and outpatient services that are:
1)      Furnished by a qualified provider and
2)      Needed to evaluate or stabilize an emergency medical condition.

Such services shall include, but not be limited to, behavioral health and
detoxification needed to evaluate or stabilize an emergency medical condition
that is found to exist using the prudent layperson standard.

External Quality Review Organization (EQRO):

An entity responsible for conducting reviews of the quality outcomes, timeliness
of the delivery of care, and access to items and services for which the MCO is
responsible under this contract.

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05 01 07 HUSKY B Final
 
Family:

For the purposes of this contract, the family is defined as the household that
includes the child and the following individuals who live with the child:
1)  All of the child's siblings who are under nineteen (19) years of
age, including full and half, and siblings who are HUSKY A Members;
2)  Natural and adoptive parents of the child;
3)  The spouse of the child; and
4)  Stepparent and stepsiblings of the child, except when the inclusion of
the stepparent and stepsiblings in the filing unit make the child ineligible
for HUSKY B.
 
Federal Poverty Level (FPL):

The poverty guidelines updated annually in the Federal Register by the U.S.
Department of Health & Human Services under authority of 42 U.S.C. Section 9902.

Formulary:

 
A list of selected Pharmaceuticals felt to be the most useful and cost effective
for patient care, developed by a pharmacy and therapeutics committee at the MCO.

FQHC-Sponsored MCO:

An MCO that is more than fifty (50) percent owned by Connecticut Federally
Qualified Health Centers (FQHC), certified by the Department of Social Services
to enroll HUSKY B Members.

Fraud:

 
Intentional deception or misrepresentation, or reckless disregard or willful
blindness, by a person or entity with the knowledge that the deception,
misrepresentation, disregard or blindness could result in some unauthorized
benefit to himself or some other person, including any act that constitutes
fraud under applicable federal or state law.

Free-look Period:

The ninety (90) day period of time, occurring from the date of onset of a
lock-in period of the Member with the earliest date of enrollment in the MCO,
during which time a family of which the Member is a part, shall have the
opportunity to choose another MCO. Such period is contingent upon no Members of
the family having previously been enrolled in the MCO chosen by the family.

Global Plan of Care:

The treatment plan that integrates the needed services from the benefit packages
of the HUSKY B and the HUSKY Plus Physical programs when a medically eligible
Member is concurrently receiving services from HUSKY B and the HUSKY Plus
Physical programs.

Health Plan Employer Data and Information Set (HEDIS):

A standardized performance measurement tool that enables users to evaluate the
quality of different MCOs based on the following categories: effectiveness of
care; MCO stability; use of services; cost of care; informed health care
choices; and MCO descriptive information.

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05 01 07 HUSKY B Final

HHS:

The United States Department of Health and Human Services.

HUSKY, Part A, or HUSKY A:

For purposes of this contract, HUSKY PART A includes all those coverage groups
previously covered in Connecticut Access, subject to expansion of eligibility
groups pursuant to Section 17b-266 of the Connecticut General Statutes.

HUSKY Plan, Part B or HUSKY B:

The health insurance plan for children established pursuant to Title XXI of the
Social Security Act, the provisions of Sections 17b-289 to 17b-303, inclusive,
of the Connecticut General Statutes, and Section 16 of Public Act 97-1 of the
October special session.

HUSKY Plus Physical Programs:

A supplemental physical health programs pursuant to Section 17b-294 of the
Connecticut General Statutes, for medically eligible Members of the HUSKY B
program in Income Bands 1 and 2, whose intensive physical health needs cannot be
accommodated within the HUSKY Plan, Part B.

ICD9-CM:

The International Classification of Disease, 9th Revision, Clinical
Modification. A widely recognized system of disease classification developed and
published by the National Center for Health Statistics.

Immigrant:

A non-citizen or North American Indian born in Canada who is lawfully admitted
into the United States for the express purpose of maintaining permanent
residence.

Income:

As defined in Section 17b-290 of the Connecticut General Statutes. Income as
calculated in the same manner as under the Medicaid program pursuant to Section
17b-261 of the Connecticut General Statutes.

Income Band 1:

Families with household incomes over 185% and up to and including 235% of the
federal poverty level.

Income Band 2:

Families with household incomes over 235% and up to and including 300% of the

 
federal poverty level.

Income Band 3:

Families with household incomes over 300% of the federal poverty level.

In-network providers or network providers:

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05 01 07 HUSKY B Final

Providers who have contracted with the MCO to provide services to Members.

Institution:

An establishment that furnishes food, shelter and some treatment or services to
four (4) or more persons unrelated to the proprietor.

Limited Benefits:

Goods and services that are covered only up to a specified dollar limit.

Lock-in:

Limitations on Member changes of managed care organizations for a period of
time, not to exceed twelve (12) months.

Lock-out:

The period of time HUSKY B Members are not permitted to participate in an MCO
due to nonpayment of a premium owed to the MCO in which they were enrolled.

Managed Care Organization (MCO):

The organization signing this agreement with the Department of Social Services.

Marketing:

Any communication from an MCO to a HUSKY B recipient who is not enrolled in that
MCO, that can be reasonably interpreted as intended to influence the recipient
to enroll or reenroll in that particular MCO or either to not enroll in, or
disenroll from, another MCO.

Maximum Annual Aggregate Cost-sharing:

The maximum amount which the family is required to pay (out-of-pocket) for
services under HUSKY B. These payments include co-payments and premiums.

Medicaid:

The Connecticut Medical Assistance Program operated by the Connecticut
Department of Social Services under Title XIX of the Federal Social Security
Act, and related State and Federal rules and regulations.

Medical Appropriateness or Medically Appropriate:

Health care that is provided in a timely manner and meets professionally
recognized standards of acceptable medical care; is delivered in the appropriate
medical setting; and is the least costly of multiple, equally-effective
alternative treatments or diagnostic modalities.

Medically Necessary or Medical Necessity:

Health care provided to correct or diminish the adverse effects of a medical
condition or mental illness; to assist an individual in attaining or maintaining
an optimal level of health; to diagnose a condition; or prevent a medical
condition from occurring.

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05 01 07 HUSKY B Final

Member:

For the purposes of HUSKY B, a child who has been deemed eligible for the HUSKY
B program pursuant to Section 17b-290 of the Connecticut General Statutes. For
the purposes of this contract, Members of the HUSKY B program are enrollees as
defined by Section 17b-290(11) of the Connecticut General Statutes.

National Committee on Quality Assurance (NCQA):

A not-for-profit organization that develops and defines quality and performance
measures for managed care, thereby providing an external standard of
accountability.

Non-citizen:

A person who is not a citizen of the United States.

Open Enrollment Period:

A sixty (60) day period, which ends on the fifteenth (15th) of the last month of
the lock-in period, during which time the applicant will be given the
opportunity to change plans for any reason.

Out-of-network Provider:

A provider that has not contracted with the MCO.

Passive Billing:

Automatic capitation payments generated by the DEPARTMENT or its agent based on
enrollment.

Post-Stabilization Services:

Covered services related to an emergency medical condition that are provided
after a Member is stabilized in order to maintain the stabilized condition, or
under the circumstances described in 42 CFR 422.114(3), to improve or resolve
the Member's condition.

Premium:

Any required payment made by an individual to offset or pay in full the
capitation rate under HUSKY B, as defined in Section 17b-290 of the Connecticut
General Statutes.

Preventive Care and Services:

1)
Child preventive care, including periodic and interperiodic well-child visits,
routine immunizations, health screenings and routine laboratory tests;

2)  Prenatal care, including care of all complications of pregnancy;

3)
Dare of newborn infants, including attendance at high-risk deliveries and normal
newborn care;

4)  WIC evaluations as applicable

5)
Child abuse assessment required under Sections 17a-106a and 46-b-129a of the
Connecticut General Statutes;

6)  Preventive dental care for children; and

7)
Periodicity schedules and reporting based on the standards specified by the
American Academy of Pediatrics.

 
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05 01 07 HUSKY B Final
 
Primary and Preventive Health Care Services:

The services of licensed health care professionals which are provided on an
outpatient basis, including routine well-child visits; diagnosis and treatment
of illness and injury; laboratory tests; diagnostic x-rays; prescription drugs;
radiation therapy; chemotherapy; hemodialysis; emergency room services; and
outpatient alcohol and substance abuse services.

Primary Care Provider (PCP):

A licensed health professional responsible for performing or directly
supervising the primary care services of Members.

Prior Authorization:

The process of obtaining prior approval as to the medical necessity or
appropriateness of a service or plan of treatment.

Redetermination:

The periodic determination of eligibility of the eligible beneficiary for HUSKY
B performed by the DEPARTMENT or its agent.

Risk:

The possibility of monetary loss or gain by the MCO resulting from service costs
exceeding or being less than the capitation rates negotiated by the DEPARTMENT.

Routine Cases:

A symptomatic situation (such as a chronic back condition) for which the Member
is seeking care, but for which treatment is neither of an emergency nor an
urgent nature.

State Children's Health Insurance Program (SCHIP):

Services provided in accordance with Title XXI of the Social Security Act.

State-Funded HUSKY Plan, Part B or State-Funded HUSKY B:

A program which is funded solely by the State of Connecticut and which provides
the same benefits as HUSKY B.

Subcontract:

Any written agreement between the MCO and another party to fulfill any
requirements of this contract.

Subcontractor:

A party contracting with the MCO to manage or arrange for one or more of the
health care services provided by the MCO pursuant to this contract, but
excluding services provided by a vendor.

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05 01 07 HUSKY B Final

Title V:

For purposes of this contract, a state and federally funded program based at the
Centers for Children with Special Health Care Needs at Connecticut Children's
Medical Center and Yale Center for Children with Special Health Care.

Title XXI:

The provisions of Title 42 United States Code Sections 1397aa et seg., providing
funds to enable states to initiate and expand the provision of child health
assistance to uninsured, low-income children.

Urgent Cases:

Illnesses or injuries of a less serious nature than those constituting
emergencies but for which treatment is required to prevent a serious
deterioration in the Member's health and cannot be delayed without imposing
undue risk on the Member's well-being until the Member is able to secure
services from his/her regular physician(s).

Vendor:

Any party with which the MCO has subcontracted to provide administrative
services or goods.

Well-Care Visits:

Routine physical examinations, immunizations and other preventive services that
are not prompted by the presence of any adverse medical symptoms.

WIC:

The federal Special Supplemental Food Program for Women, Infants and Children
administered by the Department of Public Health, as defined in Section 17b-290
of the Connecticut General Statutes.

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05 01 07 HUSKY B Final

2.            DELEGATIONS OF AUTHORITY

Connecticut's Department of Social Services is the single state agency
responsible for administering the HUSKY B program. No delegation by either party
in administering this contract shall relieve either party of responsibility for
carrying out the terms of the contract.

3.            FUNCTIONS AND DUTIES OF THE MCO The MCO agrees to the following
duties.

3.01           Provision of Services

a.
The MCO shall provide to Members enrolled under this contract, directly or
through arrangements with others, all the covered services described in Appendix
A of this contract.

b.
The MCO shall ensure that utilization management/review and coverage decisions
concerning acute or chronic care services to each Member are made on an
individualized basis in accordance with the contractual definitions for Medical
Appropriateness or Medically Appropriate at Part II Section 1, Definitions. The
MCO shall also ensure that its contracts
with network  providers   requires  that
the  decisions  of  network  providers affecting the delivery of acute or
chronic care services to Members
are made   in   accordance   with   the   contractual   definitions   for   Medical Appropriateness
or Medically Appropriate and Medically Necessary and Medical Necessity.

c.
The MCO shall require twenty-four (24) hour accessibility to qualified medical
personnel to Members in need of urgent or emergency care. The MCO may provide
such access to medical personnel through either: 1) a hotline staffed by
physicians, physicians on-call or registered nurses; or 2) a PCP on-call system.
Whether the MCO utilizes a hotline or PCPs on- call, Members shall gain access
to medical personnel within thirty (30) minutes of their call. The MCO Member
handbook and MCO taped telephone message shall instruct Members to go directly
to an emergency room if the Member needs emergency care. If the Member needs
urgent care and has not gained access to medical personnel within thirty
(30) minutes, the Member shall be instructed to go to the emergency room. The
DEPARTMENT will randomly monitor the availability of such access.

d.
Changes to HUSKY B covered services mandated by Federal or State law, or adopted
by amendment to the State Plan for SCHIP, subsequent to the signing of this
contract will not affect the contract services for the term of this contract,
unless (1) agreed to by mutual consent of the DEPARTMENT and the MCO, or (2)
unless the change is necessary to continue federal financial participation or
due to action of a state or federal court of law. If SCHIP coverage were
expanded to include new services, such services would be paid for outside the
capitation rate through a

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05 01 07 HUSKY B Final

separate financial arrangement with the MCO, which may include reimbursement to
the MCO directly. The DEPARTMENT may opt to reimburse the MCO directly based on
claims paid by the MCO. The rate of reimbursement will be negotiated between the
DEPARTMENT and the MCO. If SCHIP covered services were changed to exclude
services, the DEPARTMENT may determine that such services will no longer be
covered under HUSKY B and the DEPARTMENT will propose a contract amendment to
reduce the capitation rate accordingly.

In the event that the DEPARTMENT and the MCO are unable to agree on a contract
amendment, the DEPARTMENT and the MCO shall negotiate a termination agreement to
facilitate the transition of the MCO's Members to another MCO within a period of
no less than ninety (90) days.

3.02           Non-Discrimination

a.
The MCO shall comply with all Federal and State laws relating to
non-discrimination and equal employment opportunity, including but not
necessarily limited to the Americans with Disabilities Act of 1990, 42 U.S.C.
Section 12101 et seq.: 47 U.S.C. Section 225; 47 U.S.C. Section 611; Title VII
of the Civil Rights Act of 1964, as amended, 42 U.S.C. Section 2000e; Title IX
of the Education Amendments of 1972; Title VI of the Civil Rights Act, 42 U.S.C.
2000d et seq.: the Civil Rights Act of 1991; Section 504 of the Rehabilitation
Act, 29 U.S.C. Section 794 et seq.: the Age Discrimination in Employment Act of
1975, 29 U.S.C. Sections 621-634; regulations issued pursuant to those Acts; and
the provisions of Executive Order 11246 dated September 26, 1965 entitled "Equal
Employment Opportunity" as amended by Federal Executive Order 11375, as
supplemented in the United States Department of Labor Regulations (41 CFR pt.
60-1 et seq., Obligations of Contractors and Subcontractors). The MCO shall also
comply with Sections 4a-60, 4a-61, 17b-520, 31-51d, 46a-64, 46a-71, 46a-75 and
46a-81 of the Connecticut General Statutes.

The MCO shall also comply with the HCFA Civil Rights Compliance Policy, which
mandates that all Members have equal access to the best health care, regardless
of race, color, national origin, age, sex, or disability.

The HCFA Civil Rights Compliance Policy further mandates that the MCO shall
ensure that its subcontractors and providers render services to Members in a
non-discriminatory manner. The MCO shall also ensure that Members are not
excluded from participation in or denied the benefits of the HUSKY programs
because of prohibited discrimination.

The MCO acknowledges that in order to achieve the civil rights goals set forth
in the HCFA Civil Rights Compliance Policy, CMS has committed itself to
incorporating civil rights concerns into the culture of its agency and its
programs and has asked all of its partners, including the DEPARTMENT and the
MCO, to do the same. The MCO further

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0501 07 HUSKY B Final

acknowledges that CMS will be including the following civil rights concerns into
its regular program review and audit activities: collecting data on access to
and participation of minority and disabled Members; furnishing information to
Members, subcontractors, and providers about civil rights compliance; reviewing
CMS publications, program regulations, and instructions to assure support for
civil rights; and initiating orientation and training programs on civil
rights.   The MCO shall provide to the DEPARTMENT or to CMS upon request, any
data or information regarding these civil rights concerns.

Within the resources available through the capitation rate, the MCO shall
allocate financial resources to ensure equal access and prevent discrimination
on the basis of race, color, national origin, age, sex, or disability.

b.
Unless otherwise specified in this contract, the MCO shall provide covered
services to HUSKY B Members under this contract in the same manner as those
services are provided to other Members of the MCO, although delivery sites,
covered services and provider payment levels may vary. The MCO shall ensure that
the locations of facilities and practitioners providing health care services to
Members are sufficient in terms of geographic convenience to low-income areas,
handicapped accessibility and proximity to public transportation routes, where
available. The MCO and its providers shall not discriminate among Members of
HUSKY B and other Members of the MCO.

3.03        Gag Rules/Integrity of Professional Advice to Members

The MCO shall comply with the provisions of Connecticut General Statutes Section
38a-478k concerning gag clauses, and with 42 CFR. 457.985, concerning the
integrity of professional advice to Members, including interference with
providers' advice to Members and information disclosure requirements related to
physician incentive plans.

3.04         Coordination and Continuation of Care

a.
The MCO shall have systems in place to provide well-managed patient care, which
satisfies the DEPARTMENT that appropriate patient care is being provided,
including at a minimum:

1.
Management and integration of health care through a PCP, gatekeeper or other
means.

2.
Systems to assure referrals for medically necessary, specialty, secondary and
tertiary care.

3.
Systems to assure provision of care in emergency situations, including an
education process to help assure that Members know where and how to obtain
medically necessary care in emergency situations.

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05 01 07 HUSKY B Final

4.
A system by which Members may obtain a covered service or services that the MCO
does not provide or for which the MCO does not arrange because it would violate
a religious or moral teaching of the religious institution or organization by
which the MCO is owned, controlled, sponsored or affiliated.

5.
Coordination and provision of well-child care services in accordance with the
schedules for immunizations and periodicity of well-child care services as
established by the DEPARTMENT and recommended by the American Academy of
Pediatrics.

6.
Coordinating with and providing a case manager to the HUSKY Pius Physical
program, as indicated in Section 3.19 of this contract.

7.
If notified, PCPs shall participate in the review and authorization
of Individual Education Plans for Members receiving School Based Child Health
services and Individual Family Service Plans for Members receiving services from
the Birth to Three program.

8.
The MCO shall coordinate Members' care with the Behavioral Health Partnership,
as outlined in this Contract, including but not limited to section 3.16, and
Appendix N.

3.05        Emergency Services

a.
The MCO shall provide all emergency services twenty-four (24) hours each day,
seven (7) days a week or arrange for the provision of said services twenty-four
(24) hours each day, seven (7) days a week through its provider network.

b.
Emergency services shall be provided without regard to prior authorization or
the emergency care provider's contractual relationship with the MCO.

c.
The MCO shall be responsible for payment for emergency department visits,
including emergent and urgent visits and all associated charges billed by the
facility, regardless of the Member's diagnosis. The Department and MCO will
jointly develop audit procedures related to emergency department services when
Members are admitted to the hospital and the primary diagnosis is behavioral.
The Partnership shall be responsible for payment for the following:

1.
Professional psychiatric services rendered in an emergency department by a
community psychiatrist, if the psychiatrist is enrolled in the Medicaid program
under either an individual provider or group provider number and bills the
emergency facility under that provider number; and

2.
 Observation stays of 23 hours or less, billed as Revenue Center Code 762, with
a primary behavioral health diagnosis.

d.           The MCO shall not limit the number of emergency visits.

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05 01 07 HUSKY B Final

e.
The MCO shall cover emergency care services furnished to a Member by a provider
whether or not the provider is a part of the Member's MCO provider network at
the time of the service.

f.
The MCO shall cover emergency care services provided while the Member is out of
the State of Connecticut, including emergency care incurred while outside the
country.

g.
The MCO shall cover all services necessary to determine whether or not an
emergency condition exists, even if it is later determined that the condition
was not an emergency.

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

i.
The determination of whether the prudent layperson standard is met must be made
on a case-by-case basis. The only exception to this general rule is that the MCO
may approve coverage on the basis of an ICD-9 code.

j.
If the screening examination leads to a clinical determination by the examining
physician that an actual emergency does not exist, then the nature and extent of
payment liability will be based on whether the Member had acute symptoms under
the prudent layperson standard at the time of presentation.

k.
Once the Member's condition is stabilized, the MCO may require authorization for
a hospital admission or follow-up care.

I.
The MCO must cover post-stabilization services attendant to the primary
presenting diagnosis that were either approved by the MCO or were delivered by
the emergency service provider when the MCO failed to respond to a request for
pre-approval of such services within one hour of the request to approve
post-stabilization care, or could not be contacted for pre-approval.

m.
If there is a disagreement between a hospital and an MCO concerning whether the
patient is stable enough for discharge or transfer from the emergency room, the
judgment of the attending physician(s) actually caring for the Member at the
treating facility prevails and is binding on the MCO. This subsection shall not
apply to a disagreement concerning discharge or transfer following an inpatient
admission. The MCO may establish arrangements with hospitals whereby the MCO may
send one of its own physicians or may contract with appropriate physicians with
appropriate emergency room privileges to assume the attending physician's
responsibilities to stabilize, treat, and transfer the patient.

n.
When a Member's PCP or other plan representative instructs the Member to seek
emergency care in-network or out-of-network, the MCO is responsible for payment
for the screening examination and for other

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05 01 07 HUSKY B Final

medically necessary emergency services, without regard to whether the patient
meets the prudent layperson standard described above.

o.
If a Member believes that a claim for emergency services has been
inappropriately denied by the MCO, the Member may seek recourse through the
MCO's internal appeal process and the Department of Insurance's (DOI) external
review process pursuant to Section 8, MCO Responsibilities Concerning Notices of
Action, Appeals and Administrative Hearings of this contract.

p.
When the MCO reimburses emergency services provided by an in-network provider,
the rate of reimbursement will be subject to the contractual relationship that
has been negotiated with said provider. When the MCO reimburses emergency
services provided by an out-of-network provider within Connecticut, the rate of
reimbursement will be the fees established by the DEPARTMENT for the Medicaid
fee-for-service program. When the MCO reimburses emergency services provided by
an out-of-network provider outside of Connecticut, the MCO may negotiate a rate
of reimbursement with said provider.

q.
The MCO shall retain responsibility for payment for emergency
medical transportation and associated charges, regardless of diagnosis. The MCO
shall also retain responsibility for hospital-to-hospital ambulance
transportation of members with a behavioral health condition.

r.
Effective January 1, 2007, when the MCO reimburses emergency services provided
by an out-of-network provider whether within or outside Connecticut, the rate of
reimbursement shall be limited to the fees established by the DEPARTMENT for the
Medicaid fee-for-service program.

3.06   Geographic Coverage

a.
The MCO shall serve Members statewide. The MCO shall ensure that its provider
network includes access for each Member to PCPs, Obstetric/Gynecological
Providers and mental-health-providers at a distance of no more than fifteen (15)
miles for PCPs and Obstetric/Gynecological Providers and no more than twenty
(20) miles for general dentists and mental health providers as measured by the
Public Utility Commission. The MCO shall ensure that its provider network
has the capacity to deliver or arrange for all the goods and
services reimbursable under this contract.

b.
On a monthly basis, the MCO will provide the DEPARTMENT or its agent with a list
of all contracted network providers. The list shall be in a format and contain
such information as the DEPARTMENT may specify.

Performance Measure: Geographic Access. The DEPARTMENT will randomly monitor
geographic access by reviewing the mileage to the nearest town containing a PCP
for every town in which the MCO has Members.

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05 01 07 HUSKY B Final

3.07            Choice of Health Professional

The MCO must inform each Member about the full panel of participating providers
in their network. To the extent possible and appropriate, the MCO must offer
each Member covered under this contract the opportunity to choose among
participating providers.

3.08            Provider Network

a.
The MCO shall maintain a provider network capable of delivering or arranging for
the delivery of all covered benefits to all Members. In addition, the MCO's
provider network shall have the capacity to deliver or arrange for the delivery
of all covered benefits reimbursable under this contract regardless of whether
all the covered benefits are provided through direct provider contracts. The MCO
shall submit a file of its most current provider network listing to the
DEPARTMENT or its agent. The file shall be submitted, at a minimum, once a month
in the format specified by the DEPARTMENT.

b.
The MCO shall notify the DEPARTMENT or its agent, in a timely manner, of any
changes made in the MCO's provider network. The monthly file submitted to the
DEPARTMENT or its agent should not contain any providers who are no longer in
the MCO's network. The DEPARTMENT will randomly audit the provider network file
for accuracy and completeness and take corrective action with the MCO if the
provider network file fails to meet these requirements.

3.09            Network Adequacy and Maximum Enrollment Levels

Primary Care Providers and Dentists

a.
On a quarterly basis, except as otherwise specified the DEPARTMENT, the
DEPARTMENT shall evaluate the adequacy of the MCO's provider network. Such
evaluations shall use ratios of Members to specific types of providers based on
fee-for-service experience in order to ensure that access in the MCO is at least
equal to access experienced in the fee-for-service Medicaid program for a
similar population. For each county the maximum ratio of Members to each
provider type shall be:

1.
Adult PCPs, including general practice specialists counted at 60.8%, internal
medicine specialists counted at 88.9%, family practice specialists counted at
66.9%, nurse practitioners of the appropriate specialties, and physician
assistants, 387 Members per provider;

2.
Children's PCPs, including pediatric specialists counted at 100%, general
practice specialists counted at 39.2%, internal medicine specialists counted at
11.1%, family practice specialists counted at 33.1%, nurse practitioners of the
appropriate specialties, and physician assistants, 301 Members per provider;

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05 01 07 HUSKY B Final

3.
Women's PCPs, including obstetrics and gynecology specialists, nurse midwives,
and nurse practitioners of the appropriate specialty, 835 Members per provider;

4.
Dental providers, including general and pediatric dentists counted at 100%, and
dental hygienists counted at 50%, 486 Members per provider; and

b.
Based on the adequacy of the MCO's provider network, the DEPARTMENT may
establish a maximum HUSKY (HUSKY A and B) enrollment level for all HUSKY Members
for the MCO on a county-specific basis. The DEPARTMENT shall provide the MCO
with written notification no less than thirty (30) days prior to the effective
date of the maximum enrollment level.

c.
Subsequent to the establishment of this limit, if the MCO wishes to change its
maximum enrollment level in a specific county, the MCO must notify
the DEPARTMENT thirty (30) days prior to the desired effective date of
the change. If the change is an increase, the MCO must demonstrate an increase
in their provider network which would allow the MCO to serve additional HUSKY
(combined A and B) Members. To do so the MCO must provide the DEPARTMENT with
the signature pages from the executed provider contracts and/or signed letters
of intent. The DEPARTMENT will not accept any other proof or documentation
as evidence of a provider's participation in the MCO's provider network.
The DEPARTMENT shall review the existence of additional capacity
for confirmation no later than thirty (30) days following notice by the MCO.
An increase will be effective the first of the month after the
DEPARTMENT confirms additional capacity exists.

d.
In the event the DEPARTMENT deems that the MCO's provider network is not capable
of accepting additional enrollments, the DEPARTMENT may exercise its rights
under Section 9 of this contract, including but not limited to the rights under
Section 9.04, Suspensions of New Enrollments.

Specialists

e.
In addition to the network adequacy measures described in subsections (a)
through (d) above, the DEPARTMENT shall measure access to specialists by
examining and reviewing confirmed complaints received by the MCO, the Enrollment
Broker, the DEPARTMENT and HUSKY Infoline and taking other steps as more fully
described below:

1.
For purposes of this section, a "complaint" shall be defined as dissatisfaction
expressed by a Member, or their authorized representative, with the Member's
ability to obtain an appointment with a specialist that will accommodate the
member's medical needs within a reasonable timeframe or within a reasonable
distance.

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05 01 07 HUSKY B Final

a)
Member requests for information or referrals to specialists within the MCO's
network shall not constitute a complaint.

b)
The DEPARTMENT will count more than one complaint to different entities about a
Member's inability to access a particular specialist, within the same timeframe,
as one complaint.

c)
The DEPARTMENT will count as separate complaints when a Member complains about
being unable to make appointments with more than one specialist.

 
2.
The DEPARTMENT will refer to the MCO all complaints for resolution.

3.
The DEPARTMENT will send the MCO a "Complaint Report" when it receives a certain
number of confirmed access complaints from HUSKY A and HUSKY B members during a
quarter regarding a particular specialty.

 
a)
The number of confirmed complaints that will initiate the DEPARTMENT'S sending a
"Complaint Report" will be based on the MCOs HUSKY A membership factored by the
ratio of one complaint per 10,000 members.

b)
For purposes of this section, a "confirmed complaint" means that the DEPARTMENT
or another entity has received a complaint and the DEPARTMENT has confirmed that
the MCO has not provided a specialist or dentist within a reasonable timeframe
or within a reasonable distance from the Member's home, or both.

c)
In determining whether a complaint will be confirmed, the DEPARTMENT will
consider a number of factors, including but not limited to:

 
1)
The Member's PCP or other referring provider's medical opinion regarding how
soon the Member should be seen by the specialist;
 

2)  The severity of the Member's condition;

 
3)
Nationally recognized standards of access, if any, with respect to the
particular specialty;

4)
Whether the access problem is related to a broader access or provider
availability problem that is not within the MCO's control;

5)
The MCO's diligence in attempting to address the Member's complaint;

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05 01 07 HUSKY B Final

 
6) Whether both the Member and the MCO have reasonably attempted to obtain an
appointment that will meet his or her medical needs.

Sanctions:

1.
In the event the DEPARTMENT deems that the MCO's provider network is not capable
of accepting additional enrollments and lacks adequate access to providers as
described in (a) through (d) above, the DEPARTMENT may exercise its rights under
Section 7 of this contract, including but not limited to the rights under
Section 7.04, Suspension of New Enrollments.

2.
In the event the DEPARTMENT determines that it has received sufficient confirmed
complaints regarding specialist access problems to initiate a statewide default
enrollment freeze, The DEPARTMENT shall advise the MCO in the Complaint Report
that it has received confirmed complaints and that it will impose a default
enrollment freeze on the MCO in 30 days unless the MCO submits a satisfactory
resolution of the access issue in a corrective action plan.

 
a)
The MCO, at its request, will have an opportunity to meet with the DEPARTMENT
prior to the imposition of the default enrollment freeze;

b)
The DEPARTMENT will impose a default enrollment freeze statewide, for a minimum
of three months. The default enrollment freeze will remain in effect until
the DEPARTMENT determines that the access problem has been resolved to the
DEPARTMENT'S satisfaction.

 
3.
The MCO shall submit a corrective action plan to the DEPARTMENT when the
DEPARTMENT formally notifies the MCO that the number of confirmed specialist
complaints has passed the report threshold for that MCO during the reporting
period.

4.
If, subsequent to the DEPARTMENT'S approval of the corrective action plan, the
network deficiency is not remedied within the time specified in the corrective
action plan, or if the MCO does not develop a corrective action plan
satisfactory to the DEPARTMENT, the DEPARTMENT may impose a strike towards a
Class A sanction for each month the MCO fails to correct the deficiency,
in accordance with Section 7.05. This sanction shall be in addition to any
enrollment freeze imposed in accordance with (2) above.

3.10    Provider Contracts

All provider contracts in the MCO'S provider network shall, at a minimum,
include each of the following provisions:

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05 01 07 HUSKY B Final

a.
MCO network providers serving HUSKY Members must meet the minimum requirements
for participation in the HUSKY program stated in the Regulations of Connecticut
State Agencies, Section 17b-262-522 - 17b-262-533, as applicable.

b.
MCO Members shall be held harmless, excluding appropriate cost-sharing for the
costs of all HUSKY covered goods and services provided;

c.
Providers must provide evidence of and maintain adequate malpractice insurance.
 
For physicians, the minimum malpractice coverage requirements are $1 million per
individual episode and $3 million in the aggregate;

 
d.
Specific terms regarding provider reimbursement as specified in Timely Payment
of Claims, Section 3.43 of this contract.
 

e.  Specific terms concerning each party's rights to terminate the contract;

 
f.
That any risk shifted to individual providers does not jeopardize access to care
or appropriate service delivery;

g.
The exclusion of any provider that has been suspended from Medicare or a
Medicaid program in any state; and

h.
For PCPs, the provision of "on-call" coverage through arrangements with other
PCPs.

3.11           Provider Credentialing and Enrollment

a.
The MCO shall establish minimum credentialing criteria and shall
formally re-credential all professional participating providers in their network
at least once every two (2) years or such other time period as established
by the NCQA. The MCO shall create and maintain a credentialing file for each
participating provider that contains evidence that all
credentialing requirements have been met. The file shall include copies of all
relevant documentation including licenses, Drug Enforcement Agency
(DEA) certificates and provider statements regarding lack of
impairment. Credentialing files shall be subject to inspection by the DEPARTMENT
or its agent.

b.
The MCO's credentialing and re-credentialing criteria for professional providers
shall include at a minimum:

 

1. Appropriate license or certification as required by Connecticut law;

2.
Verification that providers have not been suspended or terminated from
participation in Medicare or the Medicaid program in any state;

3.
Verification that providers of covered services meet minimum requirements for
Medicaid participation;

4. Evidence of malpractice or liability insurance, as appropriate;

5. Board certification or eligibility, as appropriate;

 
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05 01 07 HUSKY B Final

6.           A current statement from the provider addressing:     

   

a)  Lack of impairment due to chemical dependency/drug abuse;

b) Physical and mental health status;

c)
History of past or pending professional disciplinary actions, sanctions, or
license limitations;

d) Revocation and suspension of hospital privileges; and

e) A history of malpractice claims.

 
7.
Evidence of compliance with Clinical Laboratory Improvement Amendments of 1988
(CLIA), Public Law 100-578, 42 USC Section 1395aa et seg. and 42 CFR pt. 493 (as
amended, 68 Fed. Reg. 3639-3714(2003)).

c.
The MCO may require more stringent credentialing criteria. Any other criteria
shall be in addition to the minimum criteria set forth above.

d.
Additional MCO credentialing/recredentialing criteria for PCPs shall include,
but not be limited to:

1.
Adherence to the principles of Ethics of the American Medical Association, the
American Osteopathic Association or other appropriate professional organization;

2.
Ability to perform or directly supervise the ambulatory primary care services of
Members;

3.
Membership on the medical staff with admitting privileges to at least one
accredited general hospital or an acceptable arrangement with a PCP with
admitting privileges;

 
4.
 
Continuing medical education credits;
 

5. A valid DEA certification; and

 
6.
Assurances that any Advanced Practice Registered Nurse (APRN), Nurse Midwives or
Physician Assistants are performing within the scope of their licensure.

e.
For purposes of credentialing and recredentialing, the MCO shall perform a check
on all PCPs and other participating providers by contacting the National
Practitioner Data Bank (NPDB). The DEPARTMENT will notify the MCO immediately if
a provider under contract with the MCO is subsequently terminated or suspended
from participation in the Medicare or Medicaid programs. Upon such notification
from the DEPARTMENT or any other appropriate source, the MCO shall immediately
act to terminate the provider from participation.

f.
The MCO may delegate credentialing functions to a subcontractor. The MCO is
ultimately responsible and accountable to the DEPARTMENT for compliance with the
credentialing requirements. The MCO shall demonstrate and document to the
DEPARTMENT the MCO's significant

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05 01 07 HUSKY B Final

oversight of its subcontractors performing any and all provider credentialing,
including facility or delegated credentialing. The MCO and any such entity shall
be required to cooperate in the performance of financial, quality or other
audits conducted by the DEPARTMENT or its agent(s). Any subcontracted entity
shall maintain a credentialing file for each participating provider, as set
forth above.

g.
The MCO must adhere to the additional credentialing requirements set forth in
Appendix D.

3.12            Specialist Providers and the Referral Process

a.
The MCO shall contract with a sufficient number and mix of specialists so that
the Member population's anticipated specialty care needs can be substantially
met within the MCO's network of providers. The MCO will also be required to have
a system to refer Members to out-of-network specialists if appropriate
participating specialists are not available. The MCO shall make specialist
referrals available to its Members when it is medically necessary and medically
appropriate and shall assume all financial responsibility for any such referrals
whether they are in-network or out-of-network. The MCO must have policies and
written procedures for the coordination of care and the arrangement, tracking
and documentation of all referrals to specialty providers.

b.
For Members enrolled in HUSKY Plus Physical, the MCO is required to coordinate
the specialty care services and specialty provider referral process with the
HUSKY Plus Physical programs to ensure access to care. Refer to Section 3.19 for
specific guidance on the referral process.

3.13            PCP and Specialist Selection, Scheduling and Capacity

a.
The MCO shall provide Members with the opportunity to select a PCP within thirty
(30) days of enrollment. The MCO shall assign a Member to a PCP when a Member
fails to choose a PCP within thirty (30) days after being requested to do so.
The assignment must be appropriate to the Member's age, gender, and residence.

b.
The MCO shall ensure that the PCPs in its network adhere to the following PCP
scheduling practices:

1.
Emergency cases shall be seen immediately or referred to an emergency facility;

2.
Urgent cases shall be seen within forty-eight (48) hours of PCP notification;

3.
Routine cases shall be seen within ten (10) days of PCP notification;

4.
Well-care visits shall be scheduled within six (6) weeks of PCP notification;

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05 01 07 HUSKY B Final

5.
All well-child visits, comprehensive health screens and immunizations shall be
scheduled in accordance with the American Academy of Pediatrics' (AAP)
periodicity schedule and the Advisory Committee on Immunization Practices (ACIP)
immunization schedules; and
 

6.  Waiting times at PCP sites are kept to a minimum.

 
c.
The MCO shall report quarterly on each PCP's panel size, group practice and
hospital affiliations in a format specified by the DEPARTMENT. The DEPARTMENT
will aggregate reports received from all MCOs for both HUSKY A and HUSKY B. In
the event that the DEPARTMENT finds a PCP with more than 1,200 HUSKY (combined
HUSKY A and HUSKY B) panel Members, the DEPARTMENT will notify the MCO if the
PCP is part of the MCO's network. The DEPARTMENT expects that the MCO will take
appropriate action to ensure that patient access to the MCO is assured.

d.
The MCO shall maintain a record of each Member's PCP assignments for a period of
two (2) years.

e.
The MCO shall educate each Member on the benefits of a usual source of care.

f.
If the Member has not received any primary care services, the MCO shall contact
the Member to encourage regular well-care visits.

Performance Measure: PCP Appointment Availability. The DEPARTMENT or its agent
will routinely monitor appointment availability as measured by b(1) through b(5)
by using test cases to arrange appointments of various kinds with selected PCPs.

3.14    Family Planning Access and Confidentiality

a.
The MCO shall notify and give each Member, including adolescents,
the opportunity to use family planning services without requiring a referral
or authorization. The MCO shall make a reasonable effort to subcontract with all
local family planning clinics and providers, including those funded by Title X
of the Public Health Services Act.

b.
The MCO shall keep family planning information and records for each individual
patient confidential, even if the patient is a minor.

c.
Pursuant to federal law, 42 U.S.C. Section 1397ee(c)(1) and (7), 42 CFR 457.475
and the State of Connecticut's State Child Health Plan under Title XXI of the
Social Security Act, ("the HUSKY Plan"), the DEPARTMENT may seek federal funding
for abortions only if the pregnancy is the result of an act of rape or incest or
necessary to save the life of the mother.   The MCO shall cover all abortions
that fall within these circumstances.

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05 01 07 HUSKY B Final

d.
The DEPARTMENT and the MCO shall enter into a separate contract for abortions
that do not qualify for federal matching funds.

The MCO shall not charge co-payments for any abortion.

Sanction: If the MCO fails to comply with the provisions in (c), and fails to
accurately maintain and submit accurate records of those abortions which meet
the federal definition for funding, the DEPARTMENT may impose a Class A
sanction, pursuant to Section 9.05.

3.15           Pharmacy Access

a.
The MCO shall be responsible for payment for pharmacy services and all
associated charges, regardless of a Member's diagnosis. The only exception is
that the Partnership shall be responsible for methadone costs that are part of
the bundled reimbursement for methadone maintenance and ambulatory detox
providers. Prescribing behavioral health providers participating in the
Partnership will follow the applicable pharmacy program requirements, including
the formulary, of the MCO. These providers will provide the MCO with any
clinical information needed to support requests for authorization or the
preparation of summaries for administrative hearings. The MCO shall promptly
inform the Department of any changes to its pharmacy program requirements.

b.
Pharmacies must be available and accessible on a statewide basis. The MCO shall:

1.
Maintain a comprehensive provider network of pharmacies that will within
available resources assure twenty-four (24) hour access to a full range of
pharmaceutical goods and services;

2.
Have established protocols to respond to urgent requests for medications;

3.
Monitor and take steps to correct excessive utilization of regulated substances;

4.
Have established protocols in place to assure the timely provision of pharmacy
goods and to determine client eligibility and MCO affiliation services (by
contacting the DEPARTMENT or its agent via telephone or fax) when there is a
discrepancy between the information in the MCO's eligibility system and
information given to the pharmacists by the Member, the Member's physician or
other third party; and

5.
Monitor quality assurance measures to assure that Member abuse of pharmacy
benefits is corrected in a timely fashion.

b.
The MCO shall require that its provider network of pharmacies offers medically
necessary goods and services to the MCO's Members. The

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05 01 07 HUSKY B Final

MCO may have a drug management program that includes a prescription drug
formulary. If the MCO has a drug formulary, the MCO shall have a prior
authorization process to permit access at a minimum to all medically necessary
and appropriate drugs covered for the Medicaid fee-for-service population. The
MCO drug formulary must include only Food and Drug Administration approved drug
products and be sufficiently broad enough in scope to meet the needs of the
MCO's Members. The MCO drug formulary shall consist of a reasonable selection of
drugs which do not require prior approval for each specific therapeutic drug
class.

c.
The MCO shall submit a copy of its formulary to the DEPARTMENT no later than
thirty (30) days after the effective date of this contract. The MCO shall submit
any subsequent deletions to the formulary to the DEPARTMENT thirty (30) days
prior to making any change. The MCO shall also submit subsequent additions to
the formulary immediately without seeking prior approval by the DEPARTMENT.
The DEPARTMENT reserves the right to identify deficiencies in the content
or operation of the formulary. In this instance, the MCO shall have thirty
(30) days to address in writing the identified deficiencies to the DEPARTMENT'S
satisfaction. The MCO may request to meet with the DEPARTMENT prior to the
submission of the written response.

d.
The MCO shall ensure that Members using maintenance drugs (drugs usually
prescribed to treat long-term or chronic conditions including, but not limited
to, diabetes, arthritis and high blood pressure) are informed in advance, but no
less than thirty (30) days in advance of any changes to the prescription drug
formulary related to such maintenance drugs if the Member using the drug will
not be able to continue using the drug without a new authorization.

e.
The MCO shall require that its provider network of pharmacies adheres to the
provisions of Connecticut General Statutes Section 20-619 (b) and (c) related to
generic substitutions.

3.16    Mental Health and Substance Abuse Access

a.
Except as otherwise identified in this section and this Contract, mental health
and substance abuse services, for HUSKY A Members will be managed by the
Connecticut Behavioral Health Partnership (CT-BHP) and paid for by the
Department. The MCO shall coordinate services covered under this contract with
the behavioral health services managed by the Partnership as outlined in
Appendix X.

b.
The MCO may track utilization, including, but not limited to, primary
care behavioral health, laboratory, behavioral health pharmacy,
and transportation. The MCO shall bring any increases in the utilization
trend for any of these services to the attention of the Department.

c.
If there is a conflict between the MCO and the BHP as to whether a Member's
medical or behavioral health condition is primary, the MCO's

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0501 07 HUSKY B Final

medical director shall work with the BHP's medical director to reach a timely
and mutually agreeable resolution.   If the MCO and BMP are not able to reach a
resolution, the Department will make a determination and the Department's
determination shall be binding. Issues related to whether a Member's medical or
behavioral health condition is primary must not delay timely medical necessity
determinations. In these circumstances, the MCO must render a determination
within the standard timeframe required under this contract or its policies and
procedures.
 

d.
Ancillary Services
 

1.
The MCO shall retain responsibility for all ancillary services such
as laboratory, radiology, and medical equipment, devices and supplies regardless
of diagnosis.

2.
The MCO is not responsible for ancillary services that are part of the
Department's all-inclusive rate for inpatient behavioral health services.

 
e.
 
Co-Occuring Medical and Behavioral Health Conditions

 
The MCO shall continue programs and procedures designed to support the
identification of untreated behavioral health disorders in medical patients at
risk for such disorders.   The MCO shall:

1.
Contact the BMP ASO when co-management of a Member's care by the MCO and the BMP
ASO is indicated, such as for persons with special physical health and
behavioral health needs;

2.
Respond to inquiries by the BMP ASO regarding the presence of medical co-
morbidities; and
 

3. Coordinate with the BMP ASO, upon request.

 
4.
Assign a key contact person in order to facilitate timely coordination with the
ASO; and

5.
Participate in medical/behavioral co-management meetings at least once a month,
with the specific frequency to be determined by agreement between the MCO and
the ASO.

   

f.            Freestanding Primary Care Clinics

The MCO shall be responsible for primary care and other services providing by
primary care and medical clinics not affiliated with a hospital, regardless of
diagnosis. The only exception is that the MCO shall not be responsible for
behavioral health evaluation and treatment services billed un CPT codes
90801-90806, 90853, 90846, 90847 and 90862, when the Member has a primary
behavioral health diagnosis and the services are provided by a licensed
behavioral health professional.

g.            Home Health Services

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05 01 07 HUSKY B Final

1.
The MCO shall be responsible for management and payment of claims when home
health services are required for the treatment of medical diagnoses alone and
when home health services are required to treat both medical and behavioral
diagnoses, but the medical diagnosis is primary.

2.
The MCO shall also be responsible for authorization and payment of the medical
component of claims if a Member has both medical and behavioral diagnoses, and
the Member's medical treatment needs cannot be safely and effectively managed by
the psychiatric nurse or aide.

3.
the MCO shall manage and pay claims for home health physical therapy,
occupational therapy, and speech therapy, regardless of diagnosis to the extent
such services are otherwise covered under this contract.

4.
The MCO shall be responsible for the management and payment of claims for home
health services for Members with mental retardation when the Member does not
also have a diagnosis of autism.

 
h.
 
Hospital Inpatient Services.

 
1.
The MCO will share responsibility for inpatient general hospital services with
the BHP.

2.
The MCO shall be responsible for management and payment of claims for inpatient
general hospital services when the medical diagnosis is primary. The medical
diagnosis is primary if both the Revenue Center Code and primary diagnosis are
both medical.

3.
The MCO shall also be responsible for professional services and other charges
associated with primary medical diagnoses during a behavioral stay.

4.
The MCO shall also be responsible for ancillary services associated with
non-primary behavioral health diagnoses during a medical stay, as described in
subsection a. of this section.

5.
The MCO shall not be responsible for ancillary services that are included in the
hospital's per diem inpatient behavioral health rate.
 

i.
Hospital Outpatient Clinic Services
 
The MCO shall be responsible for all primary care and other medical services
provided by hospital outpatient clinics, regardless of diagnosis, including all
medical specialty services and all ancillary services.

j.  
Long Term Care
 
The MCO shall be responsible for all long term care services such as nursing
homes and chronic disease hospitals, regardless of a Member's diagnosis.

 
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05 01 07 HUSKY B Final

k.           Primary Care Behavioral Health Services

1.
The MCO shall be responsible for all primary care services and all associated
charges, regardless of diagnosis. Such responsibilities include:

 

a) Behavioral health related prevention and anticipatory guidance;

b)  Screening for behavioral health disorders;

c)
Treatment of behavioral health disorders that the primary care physician
concludes can be safely and appropriately treated in a primary care setting;

d)
Management of psychotropic medications, when the PCP determines it is safe and
appropriate to do so, and in conjunction with treatment by a BMP non-medical
behavioral health specialist when necessary; and

e)
Referral to a behavioral health specialist when the PCP concludes it is safe and
appropriate to do so.

2.
The BMP ASO will develop education and guidance for primary care physicians
related to the provision of behavioral health services in primary care settings.
The MCOs may participate with the ASO in the development of education and
guidance or they will be provided the opportunity for review and comment.
The education and guidance will address PCP prescribing with support and
guidance from the ASO or referring clinic. The BMP ASO will make telephonic
psychiatric consultation services available to primary care providers.
Consultation may be initiated by any primary care provider that is seeking
guidance on psychotropic prescribing for a HUSKY A or HUSKY B member.

3.
The BHP ASO will work with the MCO and provider organizations to sponsor
opportunities for joint training to promote effective coordination and
collaboration. MCO policies and provider contracts must support the provision of
behavioral health services by primary care providers and entry into coordination
agreements with Enhanced Care Clinics established by the Department.

I.            School Based Health Center Services

The HUSKY MCOs will be responsible for primary care services provided by
school-based health centers, regardless of diagnosis, but they will not be
responsible for behavioral health assessment and treatment services billed under
CPT codes 90801 - 90807, 90853, 90846 and 90847.

3.17           Children's Issues and Preventive Care and Services

The MCO shall ensure access to preventive care and services of the HUSKY B
benefit package as follows:

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05 01 07 HUSKY B Final

a.
The MCO shall provide preventive care and services consisting of the services
described in this section and in accordance with the standards and schedules
specified in Appendixes A and E. Any changes in the standards and schedule
subsequent to the effective date of this contract shall be provided to the MCO
sixty (60) days before the effective date of the change. The MCO shall not
require prior authorization of preventive care and services. Preventive care and
services consist of the following:

1.           Child preventive care consisting of:

a).
Periodic well-child visits based on the schedule for such visits recommended by
the American Academy of Pediatrics (AAP), see Appendix E, American Academy of
Pediatrics Recommendations for Preventative Periodic Health Care;

b). Office visits related to periodic well-child visits;

c). Routine childhood immunizations based on the recommendations of the Advisory
Committee on Immunization Practices (ACIP), see Appendix A;

d). Health screenings; and

e). Routine laboratory tests.

 

2.
Prenatal Care, including care of all complications of pregnancy;
 

3.
All healthy newborn inpatient physician visits, including routine inpatient and
outpatient screenings and attendance at high-risk deliveries;
 

4. WIC evaluations, as applicable;

 
5.
Child abuse assessments required under Sections 17a-106a and 46b-129a of the
Connecticut General Statutes;

6.
Preventive dental care based on the recommendations of the American Academy of
Pediatric Dentistry (AAPD) and consisting of:

a). Oral exams and prophylaxis;
b). Fluoride treatments;
c). Sealants, and
d). X-rays

b.
The MCO shall provide office visits related to periodic well-child visits when
medically necessary to determine the existence of a physical or mental illness
or condition. The MCO shall not require prior authorization of such visits:

c.
The MCO shall provide periodic well-child visits that at a minimum, include:

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05 01 07 HUSKY B Final

1.
A comprehensive health and developmental history (including assessment of both
physical and mental health development and assessment of nutritional status);
 

2. A comprehensive unclothed or partially draped physical exam;

 
3.
Appropriate immunizations as set forth in the ACIP recommendations and schedule
at Appendix A;

4.
Laboratory tests, as set forth in the AAP recommendations and schedule at
Appendix E;

5.
Vision and hearing screenings as set forth in the AAP schedule at Appendix E;

6.
Dental assessments as set forth in the AAP recommendations and schedule at
Appendix E; and
 

7.   Health education, including anticipatory guidance.

 
d.
No later than sixty (60) days after enrollment in the plan and
annually thereafter, the MCO shall use a combination of oral and written methods
including methods for communicating with Members with limited English
proficiency, Members who cannot read, and Members who are visually or hearing
impaired, to:

1.
Inform its Members about the availability of preventive care and services;

2.
Inform its Members about the importance and benefits of preventive care and
services;

3.
Inform its Members about how to obtain preventive care and services; and

4.
Inform its Members that assistance with scheduling appointments is available,
and inform them how to obtain this assistance.

The MCO shall require PCPs to obtain all available vaccines free of charge from
the Department of Public Health under the state-funded Vaccines for Children
program

3.18   Well-Care Services for Adolescents

On or before February 1, 2004, the MCO shall submit an action plan to improve
the delivery of well-child care to adolescents. This plan shall include measures
to increase the volume of well-child screenings provided to adolescent members
and to improve the quality and the completeness of those screenings according to
the guidelines provided by the American Academy of Pediatrics. Emphasis should
be placed on improving health risk assessment and anticipatory guidance during
these visits. Following the submission of these plans, the MCOs will meet with
the department and representatives of other state agencies to develop a best
practice model for the delivery of adolescent health care.

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05 01 07 HUSKY B Final

3.19           HUSKY PLUS: Physical

a.           Overview

1.
HUSKY Plus Physical is a supplemental health insurance program that provides
services to children whose intensive physical health care needs cannot be
accommodated within the benefit package offered under HUSKY B.

2.
HUSKY Plus Physical is administered by the Centers for Children with Special
Health Care Needs at Connecticut Children's Medical Center.

3.
HUSKY Plus Physical is available for children with intensive physical health
care needs who are enrolled in HUSKY B and fall within income bands 1 and 2.
HUSKY B Members who fall into income band 3 are excluded from the HUSKY Plus
Physical program.

4.
The MCO shall have final decision-making authority for those services for which
they are at financial risk. The HUSKY Plus Physical program shall have final
decision-making authority for those supplemental services for which they are at
financial risk. The HUSKY Plus Physical program shall be the documented payor
of last resort.

5.
Any dispute between the participating MCO and the HUSKY Plus Physical program
concerning the responsibility for reimbursement of a service authorized under
the treatment plan shall be referred to the DEPARTMENT for resolution.

b.
MCO's Responsibility to Maximize HUSKY Plus Physical Services

The MCO shall coordinate care with HUSKY Plus Physical so as to maximize the
Member's coverage of special health needs. Such coordination shall include, but
not be limited to, a monthly conference, either in person or by telephone or
other interactive means, between the MCO case manager, the HUSKY Plus Physical
case manager, and the Member or his/her representative.

c.           HUSKY B MCO Case Management Responsibilities

1.
The HUSKY Plus Physical case management team will develop a global plan of care
when a Member is receiving HUSKY Plus Physical services. A case manager with
appropriate qualifications, credentials and decision-making authority shall be
assigned by the MCO to the HUSKY Plus Physical case management team.

2.
The global plan of care shall be based on the comprehensive diagnostic needs
assessment, periodic reassessments, and treatment plans from the MCO and HUSKY
Plus Physical programs providing services to the Member.

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05 01 07 HUSKY B Final

3.
The global plan of care shall integrate HUSKY B services as set forth in
Appendix A and HUSKY Plus services as set forth in Appendices B. The MCO shall
be responsible for managing the utilization of HUSKY B services contained in the
global plan of care.

4.
The MCO case manager shall actively participate with the HUSKY Plus Physical
case management team to ensure that all medically necessary HUSKY Plus Physical
program services identified in the global plan of care, which are also covered
in the HUSKY B benefit package, are exhausted first under HUSKY B.

d.            Disenrollment

The MCO shall assign a liaison who will coordinate all communication related to
disenrollment to the HUSKY Plus Physical programs.

e.            Quality Assurance

1.
The MCO shall provide summary data reports to the DEPARTMENT or its agent in an
agreed upon format on the utilization of physical health services for HUSKY Plus
Physical Members on an as needed basis, but no more frequently.

2.
The MCO shall designate a representative to the HUSKY Plus Physical Quality
Assurance Subcommittees.

f.            Payment

Sanction: If the MCO fails to have a procedure to identify potential HUSKY Plus
Physical Members or fails to assign a case manager to the HUSKY Plus Physical
program, the DEPARTMENT may impose a strike towards a Class A sanction pursuant
to Section 9.05.

3.20           Prenatal Care

a.
In order to promote healthy birth outcomes, the MCO or its contracted providers
shall:

1.
Identify enrolled pregnant women as early as possible in the pregnancy;

2.
Conduct prenatal risk assessments in order to identify high-risk pregnant women,
arrange for specialized prenatal care and support services tailored to risk
status, and begin care coordination that will continue throughout the pregnancy
and early weeks postpartum;
 

3. Refer enrolled pregnant women to the WIC program, as applicable;

 
4.
Offer case management services with obtaining prenatal care appointments, WIC
services, as applicable, and other support services as necessary;

5.
Offer prenatal health education materials and/or programs aimed at promoting
health birth outcomes;

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05 01 07 HUSKY B Final

6.
Offer HIV testing and counseling and all appropriate prophylaxis and treatment
to all enrolled pregnant women;

7.
Refer any pregnant Member who is actively abusing drugs or alcohol to the CT BMP
ASO; and

8.
Educate new mothers about the importance of the postpartum visit and well-baby
care.

Performance Measure: Early access to prenatal care: Percentage of enrolled women
who had a live birth, who were continuously enrolled in the MCO for 280 days
prior to delivery who had a prenatal visit on or between 176 to 280 days prior
to delivery.

Performance Measure: Adequacy of prenatal care: Percentage of women with live
births who were continuously enrolled during pregnancy who had more than eighty
(80) percent of the prenatal visits recommended by the American College of
Obstetrics and Gynecology, adjusted for gestational age at enrollment and
delivery.

3.21           Dental Care

a.
The MCO shall contract with a sufficient number of dentists throughout the state
to assure access to oral health care. The MCO shall:

1.
Maintain an adequate dental provider network throughout the state's eight (8)
counties;

2.
For the purpose of enrollment capacity a dental hygienist meeting the criteria
of Connecticut General Statutes Section 20-1261 with two (2) years experience,
working in an institution (other than hospital), a community health center, a
group home or a school setting shall be counted as fifty (50) percent of a
general dentist. If the MCO's provider network includes dental hygienists
acting independently within their scope of practice to provide
preventive services to Members, the MCO shall require that dental
hygienists make appropriate referrals to in-network dentists for
appropriate restorative and diagnostic services and treatment;

3.
Implement a plan that includes a systematic approach for enhancing access to
dental care through monitoring appointment availability, provision of training
to providers around issues of cultural diversity and any other specialized
programs;

4.
Implement incentives and/or sanctions to ensure that access standards are met
with respect to dental screens and appointment availability. The MCO shall
ensure that the scheduling of a routine dental visit is six (6) weeks;

5.
Certify that all dentists in the MCO's network shall take Members and that MCO's
HUSKY Members shall be assured the same access to providers as non-HUSKY
Members. Nothing in this

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05 01 07 HUSKY B Final

section shall preclude the implementation of limits on panel size by providers;

6.
Implement procedures to provide all Members with the opportunity to choose a
general dentist;

7.
Educate Members about the importance of regular dental care, with a focus on
accessing preventive care such as screenings and cleanings at least twice a
year; and

8.
Provide for sufficient access to dental services for different age groups.

3.22            Pre-Existing Conditions

a.           There is no exclusion for pre-existing conditions.

b.
The MCO shall assume responsibility for all HUSKY B covered services as outlined
in Appendix A for each Member as of the effective date of coverage under the
contract.

3.23            Prior Authorization

a.
Prior authorization of services covered in the HUSKY B benefit package shall be
determined by the MCO based on individual care plans, medical necessity and
medical appropriateness, except that the following services in the benefit
package shall not require prior authorization.

1     Preventive care, including:
a)      Periodic and well-child visits;
b)      Immunizations; and
c)      Prenatal care;
 
2       Preventive family planning services including:
a)      Reproductive health exams;
b)      Member counseling;
c)      Member education;

d)
Lab tests to detect the presence of conditions affecting reproductive health;
and

e)
Screening, testing and treatment of pre and post-test counseling for sexually
transmitted diseases and HIV, and

f)      Emergency ambulance services or emergency care.

b.
Further details about HUSKY B prior authorization requirements are set forth in
Appendix A.

3.24        Newborn Enrollment and Minimum Hospital Stays

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05 01 07 HUSKY B Final

a.
The MCO shall accept Membership of a newborn child as of the child's date of
birth, if the application is submitted on behalf of the child with in thirty
(30) days of the child's date of birth in accordance with C.G.S. 17b- 292(f).
Additionally, the MCO shall be responsible for providing coverage of the benefit
package beginning with the child's date of birth.

b.
The MCO shall comply with requirements of the Newborns' and Mothers' Health
Protection Act of 1996 regarding requirements for minimum hospital stays for
mothers and newborns in accordance with 45 CFR. 146.130 and 148.170.

c.
The MCO shall provide the newborn Member's family with reasonable notice of any
premium to be paid for the first months of coverage, as provided by section
4.09.

3.25
Acute Care Hospitalization, Nursing Home or Chronic Disease Hospital Stay at
Time of Enrollment or Disenrollment

a.
The MCO is responsible to ensure continuation of care for acute care requiring
an inpatient stay at a hospital.

b.
The MCO shall be responsible for inpatient coverage as of the effective date of
enrollment for newly enrolled HUSKY B Members who were uninsured.

c.
The MCO shall be responsible to provide continuing coverage for an inpatient
hospital stay up to the point of discharge for any Member who was admitted as an
inpatient in a hospital while enrolled in the MCO and is disenrolled from the
MCO for any reason during the same inpatient stay, except as provided in
paragraph g below.

d.
The continuation of care for the disenrolled Member shall only pertain to the
daily inpatient rate charged by such hospital providing the Member's inpatient
care.

e.
The MCO shall participate in and coordinate the discharge planning process with
the MCO involved in the Member's care for Members who fall within sections b, c,
and d above.

f.
As outlined in Appendix J, upon recategorization of a Member's eligibility from
the HUSKY A to the HUSKY B program, the MCO shall provide continued coverage for
an inpatient hospital stay as part of the HUSKY A coverage as of the effective
date of the individual's enrollment into the MCO as a HUSKY B Member. In the
instances where the inpatient stay was covered through the HUSKY A reinsurance
program at the time of recategorization, the HUSKY A reinsurance ends effective
the date of disenrollment of the individual as a HUSKY A Member.

g.
As outlined in Appendix J, upon recategorization of Members eligibility from the
HUSKY B to the HUSKY A program, the MCO shall provide continued coverage for an
inpatient hospital stay as part of the HUSKY A coverage as

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05 01 07 HUSKY B Final

of the effective date of the individual's enrollment into the MCO as a HUSKY A
Member. In the instances where the inpatient stay qualifies for HUSKY A
reinsurance, the reinsurance day count starts with the individual's effective
date of enrollment as a HUSKY A Member.

3.26           Open Enrollment

a.
The MCO shall conduct continuous open enrollment during which the MCO shall
accept recipients eligible for coverage under this contract.

b.
The MCO shall not discriminate in enrollment activities on the basis of health
status or the recipient's need for health care services or on any other basis,
and shall not attempt to discourage or delay enrollment with the MCO or
encourage disenrollment from the MCO of eligible HUSKY B Members.

c.
If the MCO discovers that a Member's new or continued enrollment was in error,
the MCO shall notify the DEPARTMENT or its agent within sixty (60) days of the
discovery or sixty (60) days from the date that the MCO had the data to
determine that the enrollment was in error, whichever occurs first.
Disenrollment of the Member will be made retroactive to the month during which
the Member's circumstances changed to cause ineligibility, or if the Member
never met eligibility requirements, to the date of initial enrollment. Failure
to notify the DEPARTMENT or its agent within the parameters defined in this
section will result in the retention of the Member by the MCO for the erroneous
retroactive period of enrollment.

3.27           Special Disenrollment

a.
The MCO may request in writing and the DEPARTMENT may approve disenrollment for
specific persons when there is good cause. The request shall cite the specific
event(s), date(s) and other pertinent information substantiating the MCO's
request. Additionally, the MCO shall submit any other information concerning the
MCO's request that the DEPARTMENT may require in order to make a determination
in the case.

b.           Good cause is defined as a case in which a Member:

1.
Exhibits uncooperative or disruptive behavior.    If, however, such behavior
results from the Member's special needs, good cause may only be found  if
the  Member's continued enrollment seriously impairs the MCO's ability to
furnish services to either the particular Members; or

2.
Permits others to use or loans his or her Membership card to others to obtain
care or services.

c.           The following shall not constitute good cause:
 
1.           Extensive or expensive health care needs;
2.           A change in the member's health status;

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05 01 07 HUSKY B Final

3.           The Member's diminished mental capacity; or

4.
Uncooperative or disruptive behavior related to a medical condition, except as
described in b.1., above.

d.
The DEPARTMENT will notify an MCO prior to enrollment if a Member was previously
disenrolled for cause from another MCO pursuant to this section.

3.28           Linguistic Access

a.
The MCO shall take appropriate measures to ensure adequate access to services by
Members with limited English proficiency. These measures shall include, but not
be limited to the promulgation and implementation of policies on linguistic
accessibility for MCO staff, network providers and subcontractors; the
identification of a single individual at the MCO for ensuring compliance with
linguistic accessibility policies; identification of persons with limited
English proficiency as soon as possible following enrollment; provisions for
translation services; and the provision of a Member handbook, and information in
languages other than English.

b.
Member educational materials must also be available in languages other than
English and Spanish when more than five (5) percent of the MCO's HUSKY B Members
served by the MCO speaks the alternative language, provided, however, this
requirement shall not apply if the alternative language has no written form. The
MCO may rely upon initial enrollment and monthly enrollment data from the
DEPARTMENT or its agent to determine the percentage of Members who speak
alternative languages. All Member educational materials must be made available
in alternate formats to the visually impaired.

c.
The MCO shall also take appropriate measures to ensure access to services by
persons with visual and hearing disabilities

Sanction: For each documented instance of failure to provide appropriate
linguistic accessibility to Members, the DEPARTMENT may impose a strike towards
a Class A sanction pursuant to Section 9.

3.29           Services to Members

a.
The MCO shall have in place an ongoing process of Member education which
includes, but is not limited to, development of a Member handbook; provider
directory; newsletter; and other Member educational materials. All written
materials and correspondence to Members shall be culturally sensitive and
written at no higher than a seventh grade reading level. All Member educational
materials must be in both English and Spanish.

b.
The MCO shall mail the Member handbook and provider directory to Members within
one week of enrollment notification. The Member handbook shall address and
explain, at a minimum, the following:

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05 01 07 HUSKY B Final
 

1.   Covered services;

2.
Restrictions on services (including limitations and services not covered);

3. Prior authorization process;

4.
Definition of and distinction between emergency care and urgent care;

5.
Policies on the use of emergency and urgent care services including a phone
number which can be used for assistance in obtaining emergency care;

6.  How to access care twenty-four (24) hours;

7. Assistance locating an appropriate provider;

8. Member rights and responsibilities;

9. Member services, including hours of operation;

10.  Enrollment, disenrollment and plan changes;

11. Procedures for selecting and changing PCP;

12. Availability of provider network directory and updates;

13.  Limited liability for services from out-of-network providers;

14. Access and availability standards;

15.
Special access and other MCO features of the health plan's program;

16. Family planning services;

17. Case management services targeted to Members as medically necessary and
appropriate;

18. Copayments;

19.  Allowances;

20. Maximum annual aggregate cost-sharing;

21. Premiums;

22. Involuntary disenrollments;

23. Appeals and complaints (internal MCO appeal process, external DOI appeal
process);

24. Preventive health guidelines; and

25. Description of the drug formulary and prior approval process, if applicable.

26. Information on how to access services from the Partnership.

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05 01 07 HUSKY B Final

c.
All Member educational materials must be prior approved by the DEPARTMENT.
Educational materials include, but are not limited to Member handbook;
Membership card; introductory and other text language from the provider
directory; and all communications to Members that include HUSKY B program
information. The MCO must wait until receiving DEPARTMENT written approval or
thirty (30) days from the date of submittal before disseminating educational
materials to Members.

d.
The MCO must provide periodic updates to the handbook or inform Members, as
needed, of changes to the Member information discussed above. The MCO shall
update its Member handbook to incorporate all provisions and requirements of
this contract within six (6) weeks of the effective date. The MCO shall
distribute the Member handbook within six (6) weeks of receiving the
DEPARTMENT'S written approval.

e.
The MCO shall maintain an adequately staffed Member Services Department to
receive telephone calls from Members in order to answer Members' questions,
respond to Members' complaints and resolve problems informally.

f.
The MCO shall identify to the DEPARTMENT the individual who is responsible for
the performance of the Member Services Department.

g.
The MCO's Member Services Department shall include bilingual staff (Spanish and
English) and translation services for non-English speaking Members. The MCO
shall also make available translation services at provider sites either directly
or through a contractual obligation with the service provider.

h.
The MCO shall require members of the Member Services Department to identify
themselves to Members when responding to Members' questions or complaints.   At
a minimum, ninety (90) percent of all incoming calls shall be answered by a
staff Member within the first minute and the call abandonment rate shall not
exceed five (5) percent. The MCO shall submit call response and abandonment
reports for the preceding six (6) month period to the DEPARTMENT upon request.

i.
When Members contact the Member Services Department to ask questions about, or
complain about, the MCO's failure to respond promptly to a request for goods or
services, or the denial, reduction, suspension or termination of goods or
services, the MCO shall: attempt to resolve such concerns informally, and inform
Members of the MCO's internal appeal process.

j.
The MCO shall maintain a log of complaints resolved informally, which shall be
made available to the DEPARTMENT upon request, and which shall be a short dated
summary of the problem, the response and the resolution.

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At the time of enrollment and at least annually thereafter, the MCO shall inform
its Members of the procedural steps for filing an internal appeal and requesting
an external review.

k.
The MCO shall monitor and track PCP transfer requests and follow up on
complaints made by Members as necessary.

l.
The MCO will participate in two (2) Member surveys. The first such survey will
be an analysis of Members with special needs as defined by the DEPARTMENT after
consultation with the Children's Health Council, EQRO, and the MCO, to be
conducted at the DEPARTMENT'S expense. The survey will be developed and the
sample will be chosen by the Children's Health Council, with input from the MCOs
and the DEPARTMENT. The other survey will be an NCQA Consumer Assessment of
Health Plans Survey (CAHPS) of combined HUSKY A and B Members using an
independent vendor and paid for by the MCO.
 
The MCO's CAHPS survey shall continue to include behavioral health questions.

 
m.
The MCO may provide outreach to its current Members at the time of the Member's
renewal of eligibility. The outreach may involve special mailings or phone calls
as reminders that the Member must complete the HUSKY renewal forms to ensure
continued coverage.

n.
The MCO shall make appropriate referrals of Members who express the need for or
may require behavioral health services to the Partnership. If a Member is in
crisis, the MCO shall stay on the line with the member while connecting the
Member with the Partnership.

3.30           Information to Potential Members

a.
The MCO shall, upon request, make the following information available to
potential Members:

1.
The identity, locations, qualifications and availability of MCO's network;

2. Rights and responsibilities of Members;

3. Appeal procedures; and

4.
All covered items and services that are available either directly or indirectly
or through referral and prior authorization.

3.31           DSS Marketing Guidelines

The MCO may, at its option, market or promote their plan to potential members.
All marketing and marketing related activities must be in compliance with the
guidelines and restrictions as set forth in this section and Appendix D. DSS
marketing restrictions apply to subcontractors and providers of care as well as
to the MCOs. The MCO shall notify all its subcontractors and network providers
of the DEPARTMENT'S marketing restrictions. The detailed marketing guidelines
are set forth in Appendix D.

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05 01 07 HUSKY B Final
 

 a. 
 Prohibited Marketing Activities:
Appendix D describes permitted and prohibited marketing activities that apply to
all forms of communication, regardless of whether they are performed by the MCO
directly, by its contracted providers, or its subcontractors:
 

b.
Any type of marketing activity that has not been clearly specified
as permissible under the guidelines in Appendix D should be assumed to
be prohibited. The MCO shall contact the DEPARTMENT for guidance and approval
for any activity not clearly permissible under these guidelines.

c.
The MCO shall submit its annual marketing plan, revisions to the marketing plan
and all marketing materials to the DEPARTMENT for approval.   The DEPARTMENT
will provide comments on the marketing materials to the MCO within thirty (30)
days of receipt of the materials. MCOs, subcontractors and their providers must
wait until receiving DSS written approval or 31 days from submission to the
Department, if the Department has not responded by the 30th day before
disseminating any such information to potential Members. DSS reserves the right
to request revisions or changes in marketing materials at any time
 

d. The MCO shall distribute marketing materials on a statewide basis.

 
Sanction: If the MCO or its providers engage in inappropriate marketing
activities, the DEPARTMENT may impose a sanction up to and including a Class C
sanction pursuant to Section 9.05 as it deems appropriate.

Sanction: If the MCO engages in non-compliant marketing practices within one
year of a marketing related sanction, the Department shall impose a Class C
sanction of $25,000 for each determination of a marketing violation following
the initial sanction episode.

Sanction: Each marketing sanction episode shall include a mandatory enrollment
freeze of no less than three months in duration.

3.32        Health Education

The MCO must routinely, but no less frequently than annually, remind and
encourage Members to utilize benefits including physical examinations which are
available and designed to prevent illness. The MCO shall keep a record of all
activities it has conducted to satisfy this requirement.

3.33        Quality Assessment and Performance Improvement

a.
The MCO is required to provide a quality level of care for all services,  which
it provides and for which it contracts. These services are expected to be
medically necessary and may be provided by participating providers. The MCO
shall implement a Quality Assessment and Performance

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Improvement program to assure the quality of care. The EQRO shall monitor the
MCO's compliance with all requirements in this section.

b.
The MCO shall comply with DEPARTMENT requirements concerning Quality Assessment
and Performance Improvement set forth below. The MCO will develop and implement
an internal Quality Assessment and Performance Improvement program consistent
with the Quality Assessment and Performance Improvement program guidelines,
as provided in Appendix G.

c.
The MCO must have a Quality Assessment and Performance Improvement system which:

1.
Provides for review by appropriate health professionals of the processes
followed in providing health services;

2.
Provides for systematic data collection of performance and participant results;
 

3. 
Provides for interpretation of these data to the practitioners;
 

4. Provides for making needed changes;

 
5.
Provides for the performance of at least one performance improvement project of
the MCO's own choosing;

6.
Provides for participation in at least one performance improvement project
conducted by the EQRO; and

7.
Has in effect mechanisms to detect both under utilization and over utilization
of services.

d.
The MCO shall provide descriptive information on the operation, performance and
success of its Quality Assessment and Performance Improvement system to the
DEPARTMENT or its agent upon request.

e.
The MCO shall maintain and operate a Quality Assessment and Performance
Improvement program which includes at least the following elements:

1.
A quality assessment and performance improvement assurance plan;

2.
A Quality Assessment and Performance Improvement Director who is responsible for
the operation and success of the Quality Assessment and Performance Improvement
Program. This person shall have adequate experience to ensure successful
Quality Assessment and Performance Improvement, and shall be accountable for the
Quality Assessment and Performance Improvement systems for all the MCO's
providers, as well as the MCO's subcontractors;

3.
The Quality Assessment and Performance Improvement Director shall spend an
adequate proportion of time on Quality Assessment

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and Performance Improvement activities to ensure that a successful Quality
Assessment and Performance Improvement Program will exist. Under the Quality
Assessment and Performance Improvement program, there shall be access on an
as-needed basis to the full compliment of health professions (e.g., pharmacy,
physical therapy, nursing, etc.) and administrative staff. Oversight of the
program shall be provided by a Quality Assessment and Performance Improvement
committee which includes representatives from:

a)
Variety of medical disciplines (e.g., medicine, surgery, mental health, etc.)
and administrative staff; and

b)     Board of Directors of the MCO.

4.
The Quality Assessment and Performance Improvement committee shall be organized
operationally within the MCO such that it can be responsible for all aspects of
the Quality Assessment and Performance Improvement program.

5.
Quality Assessment and Performance Improvement activities shall be sufficiently
separate from Utilization Review activities, so that Quality Assessment and
Performance Improvement activities can be distinctly identified as such.

6.
The Quality Assessment and Performance Improvement activities of the MCO
providers and subcontractors, if separate from the MCO's Quality Assessment and
Performance Improvement activities shall be integrated into the overall MCO
Quality Assessment and Performance Improvement program, and the MCO shall
provide feedback to the providers/subcontractors regarding the operation of any
such independent Quality Assessment and Performance Improvement effort. The MCO
shall remain however, fully accountable for all Quality Assessment
and Performance Improvement relative to its providers and subcontractors.

7.
The Quality Assessment and Performance Improvement committee shall meet at least
quarterly and produce written documentation of committee activities to be shared
with the DEPARTMENT or its agent.

8.
The results of the Quality Assessment and Performance Improvement activities
shall be reported in writing at each meeting of the Board of Directors.

9.
The MCO shall have a written procedure for following up on the results of
Quality Assessment and Performance Improvement activities to determine success
of implementation. Follow-up shall be documented in writing.

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10.
If the DEPARTMENT determines that a Quality Assessment and Performance
Improvement plan does not meet the above requirements, the DEPARTMENT may
provide the MCO with a model plan. The MCO agrees to modify its Quality
Assessment and Performance Improvement plan based on negotiations with
the DEPARTMENT.

11.
The MCO shall monitor access to and quality of health care goods and services
for its Member population, and, at a minimum, use this mechanism to capture and
report all of the DEPARTMENT'S required utilization data. The MCO shall be
subject to an annual medical audit by the DEPARTMENT'S EQRO and shall
provide access to the data and records requested.

12.
To the extent permitted under federal and state law, the MCO certifies that all
data and records requested shall, upon reasonable notice, be made available to
the DEPARTMENT or its agent.

13.
The MCO will be an active participant in at least one of the EQRO's performance
improvement focus studies each year.

14.
The MCO must comply with external quality review that will be implemented by an
organization contracted by the DEPARTMENT. This may include participating in the
design of the external review, collecting data including, but not limited to,
administrative and medical data, HEDIS measures, and/or making data available
to the review organization.

15.
The MCO must conduct at least one performance improvement project that includes
the following:

a) The project shall focus upon at one of the following areas:
1)      Prevention and care of acute and chronic conditions;
2)      High volume services;
3)      Continuity and coordination of care;
4)      Appeals and complaints; and
5)      Access to and availability of services.
 
b). Measurement of performance using quality indicators that are:
1)  Objective;
2)  Clearly and unambiguously defined;
3)  Based on current clinical knowledge or health services research;
4)  Valid and reliable;
5)  Systematically collected; and

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6) Capable of measuring outcomes such as changes in health status or Member
satisfaction, or valid proxies of those outcomes.

c)
Implementation of system interventions to achieve quality improvement;
 

d) Evaluation of the effectiveness of the interventions;

 
e)
Planning and initiation of activities for increasing or sustaining improvement;
and

f)
Represent the entire population to which the quality indicator is relevant.

 
16.
With the approval of the DEPARTMENT, the MCO may conduct performance improvement
projects for the combined HUSKY A and HUSKY B population.

17.
At the invitation of the Partnership, the MCO may, at its
discretion, participate in a joint quality improvement initiative on an area
of mutual concern.

3.34            Inspection of Facilities

a.
The MCO shall provide the State of Connecticut and any other legally authorized
governmental entity, or their authorized representatives, the right to enter at
all reasonable times the MCO's premises or other places, including the premises
of any subcontractor, where work under this contract is performed to inspect,
monitor or otherwise evaluate work performed pursuant to this contract. The MCO
shall provide reasonable facilities and assistance for the safety and
convenience of the persons performing those duties. The DEPARTMENT and its
authorized agents will request access in advance in writing except in case of
suspected fraud and abuse.

b.
In the event right of access is requested under this section, the MCO
or subcontractor shall upon request provide and make available staff to assist
in the audit or inspection effort, and provide adequate space on the premises to
reasonably accommodate the State or Federal representatives conducting the audit
or inspection effort.

c.
The MCO shall be given ten (10) business days to respond to any findings of an
audit before the DEPARTMENT shall finalize its findings. All information so
obtained will be accorded confidential treatment as provided under applicable
law.

3.35            Examination of Records

a.
The MCO shall develop and keep such records as are required by law or other
authority or as the DEPARTMENT determines are necessary or useful for assuring
quality performance of this contract. The

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DEPARTMENT shall have an unqualified right of access to such records in
accordance with Part II Section 3.34.

b.
Upon non-renewal or termination of this contract, the MCO shall turn over or
provide copies to the DEPARTMENT or to a designee of the DEPARTMENT all
documents, files and records relating to persons receiving services and to the
administration of this contract that the DEPARTMENT may request, in accordance
with Part II Section 3.34.

c.
The MCO shall provide the DEPARTMENT and its authorized agents with reasonable
access to records the MCO maintains for the purposes of this contract. The
DEPARTMENT and its authorized agents will request access in writing except in
cases of suspected fraud and abuse. The MCO must make all requested medical
records available within thirty (30) days of the DEPARTMENT'S request. Any
contract with a subcontractor must include a provision specifically authorizing
access in accordance with the terms set forth in Part II 3.35.

d.
The MCO shall maintain the confidentiality of patients' records in conformance
with this contract and state and federal statutes and regulations, including,
but not limited to, the Health Insurance Portability and Accountability Act
(HIPAA), 42 U.S.C. 1320d-2 et seq.. 45 CFR pts. 160 and 164, the Connecticut
Insurance Information and Privacy Act, Section 38a-975 et secj. of the
Connecticut General Statutes, and as applicable the Gramm-Leach-Bliley Act, 15
U.S.C. 6801 et seq.

e.
The MCO, for purposes of audit or investigation, shall provide the State
of Connecticut, the Secretary of HHS and his/her designated agent, and any other
legally authorized governmental entity or their authorized agents access to all
the MCO's materials and information pertinent to the services provided under
this contract and Member health claims and payment data, at any time, until the
expiration of three (3) years from the completion date of this contract as
extended.

f.
The State and its authorized agents may record any information and make copies
of any materials necessary for the audit.

g.
Retention of Records: The MCO and its subcontractors shall retain financial
records, supporting documents, statistical records and all other records
supporting the services provided under this contract for a period of five (5)
years from the completion date of this contract.   The MCO shall make the
records available at all reasonable times at the MCO's general offices. The
DEPARTMENT and its authorized agents will request access in writing except in
cases of suspected fraud and abuse. If any litigation, claim or audit is started
before the expiration of the five (5) year period, the records must be retained
until all litigation, claims or audit findings involving the records have been
resolved.The MCO must make all requested records available within thirty (30)
days of the DEPARTMENT'S request.

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h.
The MCO shall not avoid costs for services covered in this contract by referring
Members to publicly supported health care resources.

3.36           Medical Records

a.
In compliance with all state and federal law governing the privacy
of individually identifiable health care information including the
Health Insurance Portability and Accountability Act (HIPAA), 42 USC
Sections 1320d-2 et seq.. 45 CFR pts. 160 and 164, the MCO shall establish
a confidential, centralized record, for each Member, which includes information
of all medical goods and services received. The MCO may delegate maintenance of
the centralized medical record to the Member's PCP, provided however, that the
record shall be made available upon request and reasonable notice, to the
DEPARTMENT or its agent(s) at a centralized location. The medical record shall
meet the DEPARTMENT'S medical record requirements as defined by the DEPARTMENT
in its regulations, and shall comply with the requirements of the
National Committee on Quality Assurance (NCQA) or other national
accrediting body with a recognized expertise in managed care. The MCO
shall establish a confidential, centralized record, which includes the
medical record, for all Members including all goods and services received.
The MCO may delegate maintenance of the centralized medical record to
the Member's PCP, provided however, that the record shall be made available upon
request and reasonable notice, to the DEPARTMENT or its agent(s) at a
centralized location. The MCO or PCP shall maintain the medical records in
compliance with all state and federal law governing the privacy of individually
identifiable health care information including the Health Insurance Portability
and Accountability Act (HIPAA), 42 U.S.C. 1320d-2 et seq.. 45 CFR pts. 160 and
164. The medical record shall meet the DEPARTMENT'S medical record requirements
as defined by the DEPARTMENT in its regulations, and shall comply with the
requirements of the NCQA.

b.
The MCO shall not turn over or provide documents, files and records pertaining
to a Member to another health plan unless the Member has changed enrollment to
the other plan and the MCO has been so notified by the DEPARTMENT or its agent.

c.
The MCO shall share information and provide copies of documents, files and
records pertaining to a Member to the CT BHP ASO and any subcontractor upon the
request of the Member, Department or ASO.

3.37           Audit Liabilities

In addition to and not in any way in limitation of the obligation of the
contract, it is understood and agreed by the MCO that the MCO shall be held
liable for any finally determined State or Federal audit exceptions and shall
return to the

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DEPARTMENT all payments made under the contract to which exception has been
taken or which have been disallowed because of such an exception.

3.38           Clinical Data Reporting

a.
Utilization Reporting: The MCO shall submit reports to the DEPARTMENT or its
agent in the areas listed below. The purpose of the reports is to assist the
DEPARTMENT in its efforts to assess and evaluate the performance of the HUSKY B
program and the MCO.

b.        Utilization reports shall cover, but not be limited to, the following
areas:
    1.           Well-child visits;
    2.           Immunizations;

    3.           Maternal and prenatal care;
    4.           Preventive care;
    5.           Inpatient and outpatient services;
    6.           Dental services;
    7.           HEDIS/CAHPS; and
8.           Other services.

c.
The DEPARTMENT shall consult with the MCO, through a workgroup comprised of the
DEPARTMENT, its agent, and MCO representatives that meets on a periodic basis,
or as needed, to discuss the necessary data, methods of collecting the data, and
the format and media for new reports or changes to existing reports.

d.
The MCO shall submit reports, which comply with the DEPARTMENT'S standards, to
the DEPARTMENT or its agent. For each report the DEPARTMENT shall consider using
any HEDIS standards promulgated by the NCQA which covers the same or similar
subject matter. The DEPARTMENT reserves the right to modify HEDIS standards, or
not use them at all, if in the DEPARTMENT'S judgment, the objectives of
the HUSKY B program can be better served by using other methods.

e.
The DEPARTMENT or its agent, will choose a random sample of administrative and
medical records each year, in order to measure utilization of services. The MCO
will make required records available to the DEPARTMENT or agent, at a location
upon reasonable notice. The agent shall review the records and report back to
the DEPARTMENT on the extent to which the reporting measure results are
validated through comparison with the records. Prior to making its report to
the DEPARTMENT, its agent shall afford the MCO reasonable opportunity to suggest
corrections to or comment upon the agent's findings.

f.
The DEPARTMENT shall provide the MCO with final specifications for submitting
all reports no less than ninety (90) days before the reports are due. The MCO
shall submit reports on a schedule to be determined by the DEPARTMENT, but not
more frequently than quarterly. Before the beginning of each calendar year, the
DEPARTMENT shall provide the MCO with a schedule of utilization reports, which
shall be due that calendar year. Due dates for the reports shall be at the
discretion of the DEPARTMENT, but not earlier than ninety (90) days after the
end of the period that they cover.

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g.           Daily and Monthly Reports

1.
The MCO shall provide to the BHP ASO daily and monthly reports and/or data as
mutually agreed upon with the ASO regarding the following:

a)      Behavioral health emergency department visits;
b)      Behavioral health emergency room recidivism;
c)      Substance abuse and neonatal withdrawal;
d)      Child and adolescent obesity and/or type II diabetes;
e)      Sickle cell;
f)      Eating disorders; and
g)      Medical detox.

2.
The Department shall provide-specific behavioral health encounter data to the
MCO upon request to support quality management activities and coordination. The
format of the data extract will be consistent with the encounter data reporting
format, or other format mutually agreed upon by the Department and the MCO.

Sanction: Failure to comply with the above reporting requirements in a complete
and timely manner may result in a strike towards a Class A sanction, pursuant to
Section 9.05.

3.39         Utilization Management

a.
The MCO and any subcontractor is required to be licensed by the Connecticut
Department of Insurance as a utilization review company. The MCO may subcontract
with a licensed utilization review company to perform some or all of the MCO's
utilization management functions.

b.
If the MCO subcontracts for any portion of the utilization management function,
the MCO shall provide a copy of any such subcontract to the DEPARTMENT and any
such subcontract shall be subject to the provisions of Section 7.08 of this
contract. The DEPARTMENT will review and approve the subcontract, subject to the
provisions of Section 3.44, to ensure the appropriateness of the subcontractor's
policies and procedures. The MCO is required to conduct regular and
comprehensive monitoring of the utilization management subcontractor.

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c.
The MCO and its subcontractors shall comply with the utilization
review provisions of Connecticut General Statutes Section 38a-226c.

d.
If the MCO disagrees with a clinical management decision made by the BMP ASO,
the MCO may raise the issue with the ASO on behalf of the Member and seek to
resolve the issue informally prior to a scheduled administrative hearing.

3.40        Financial Records

a.
The MCO shall maintain for the purpose of this contract, an accounting system of
procedures and practices that conforms to Generally Accepted Accounting
Principles.

b.
The MCO shall permit audits or reviews by the DEPARTMENT and HHS or their
agent(s), of the MCO's financial records related to the performance of this
contract and the MCO's subcontrators' financial records related to the
performance of this contract. In addition, the MCO will be required to provide
Claims Aging Inventory Reports, Claims Turn Around Time Reports, cost, and other
reports as outlined in sections (c) and (d) below or as directed by the
DEPARTMENT.

c.
Reports specific to the MCO's HUSKY line of business shall be provided in
formats developed by the DEPARTMENT. All reports described in Section 3.40
(c)(1) and 3.40(c)(2) shall contain separate sections for HUSKY A and B. It is
anticipated that the requirements in this area will be modified to enable the
DEPARTMENT to respond to inquiries that the DEPARTMENT receives regarding the
financial status of the HUSKY program, to determine the relationship of
capitation payments to actual appropriations for the program, and to allow for
proper oversight of fiscal issues related to the managed care programs. The MCO
will cooperate with the DEPARTMENT or its agent(s) to meet these objectives.
The following is a list of required reports:

1.
Audited financial reports per MCO HUSKY line of business. If the MCO is licensed
as a health care center or insurance company, both the annual audited financial
reports for the MCO and the audited financial reports per MCO HUSKY line of
business shall be conducted and reported in accordance with C.G.S. Section
38a-54. If the MCO is not licensed as a health care center or insurance company,
the annual audited financial reports for the MCO and the audited financial
reports per MCO line of business shall be completed in accordance with generally
accepted auditing principles.
 
The MCO may elect to combine HUSKY A and HUSKY B in the audited financial
statement. If this election is made, the MCO shall also submit the following: a
separate unaudited income statement for HUSKY A and HUSKY B, which will be
compared to the audited financial statement.

 

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2.
Unaudited financial reports, HUSKY line of business (formats shown in Appendix
H). The reports shall be submitted quarterly, forty-five (45) days subsequent to
the end of each quarter. Every line of the requested report must contain a
dollar figure or an indication that said line is not applicable.

3.
Annual and Quarterly Statements. If the MCO is licensed as a health care center
or insurance company, the MCO is required to submit Annual and Quarterly
Statements to the Department of Insurance in accordance with the C.G.S. Section
38a-53. One copy of each statement shall be submitted to the DEPARTMENT
in accordance with Department of Insurance submittal schedule.

4.
Claims Aging Inventory Report (format shown in Appendix H or any other format
approved by the DEPARTMENT). The report will include all HUSKY claims
outstanding as of the end of each quarter, by type of claim, claim status and
aging categories. If a subcontractor is used to provide services and adjudicate
claims or a vendor is used to adjudicate claims, the MCO is responsible
for providing a claims aging report in the required format for each current or
prior subcontractor who has claims outstanding. The Claims Aging Inventory
reports will be submitted to the DEPARTMENT forty-five (45) days subsequent to
the end of each quarter.

5.
Claims Turn Around Time Report (format shown in Appendix H or any other format
approved by the DEPARTMENT). For those claims processed in forty-six (46) or
more days, indicate if interest was paid in accordance with the Section 3.43 of
the contract. If a subcontractor is used to provide services and adjudicate
claims or a vendor is used to adjudicate claims, the MCO is responsible
for providing a Claims Turn Around Time Report for each current or prior
subcontractor who has claims outstanding. The Claims Turn Around Time Report
will be submitted to the DEPARTMENT forty- five (45) days subsequent to the end
of each quarter.

d.
The MCO shall maintain accounting records in a manner which will enable the
DEPARTMENT to easily audit and examine any books, documents, papers and records
maintained in support of the contract. All such documents shall be made
available to the DEPARTMENT at its request, and shall be clearly identifiable as
pertaining to the contract.

e.
The MCO shall make available on request all financial reports required by the
terms of any current contract with any other state agency(s) provided that said
agency agrees that such information may be shared with the DEPARTMENT.

 

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3.41           Insurance
 
a.
The MCO, its successors and assignees shall procure and maintain such insurance
as is required by currently applicable federal and state law and regulation.
Such insurance shall include, but not be limited to, the following:

1.
Liability insurance (general, errors and omissions, and directors and officers
coverage);

2.
Fidelity bonding or coverage of persons entrusted with handling of funds;
 

3. 
Workers compensation; and
 

4. Unemployment insurance.

 
b.
The MCO shall name the State of Connecticut as an additional insured party under
any insurance, except for professional liability, workers compensation,
unemployment insurance, and fidelity bonding maintained for the purposes of this
contract. However, the MCO shall name the State of Connecticut as either a loss
payee or additional insured for fidelity bonding coverage.

3.42           Subcontracting for Services

a.
Licensed health care facilities, group practices and licensed health
care professionals operating within the scope of their practice may contract
with the MCO directly or indirectly through a subcontractor who
directly contracts with the MCO. The MCO shall be held directly accountable
and liable for all of the contractual provisions under this contract regardless
of whether the MCO chooses to subcontract its responsibilities to a third party.
No subcontract shall operate to terminate the legal responsibility of the MCO to
assure that all activities carried out by the subcontractor conform to the
provisions of this contract. Subcontracts shall not terminate the legal
liability of the MCO under this contract.

b.
The MCO may subcontract for any function, excluding Member Services, covered by
this contract, subject to the requirements of this contract. All subcontracts
shall be in writing, shall include any general requirements of this contract
that are appropriate to the services being provided, and shall assure that all
delegated duties of the MCO under this contract are performed. All subcontracts
shall also provide for the right of the DEPARTMENT or another governmental
entity to enter the subcontractor's premises to inspect, monitor or otherwise
evaluate the work being performed as a delegated duty of this contract, as
specified in Section 3.33, Inspection of Facilities.

c.
With the exception of subcontracts specifically excluded by the DEPARTMENT, all
subcontracts shall include verbatim the HUSKY B definitions of Medical
Appropriateness/Medically Appropriate and Medically Necessary/Medical Necessity
as set forth in the Definitions, Part II, Section 1 of this contract. All
subcontracts shall require the use of these definitions by subcontractors in all
requests for approval of coverage of goods or services made on behalf of HUSKY B
Members. All subcontracts shall also provide that decisions concerning both
acute and chronic care must be made according to these definitions.

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d.
Within fifteen (15) days of the effective date of this contract the MCO
shall provide the DEPARTMENT with a report of those functions under
this contract that the MCO will be providing through subcontracts and copies of
the contracts between the MCO and the subcontractor.   Such report shall
identify the names of the subcontractors, their addresses and a summary of the
services they will be providing. If the MCO enters into any additional
subcontracts after the MCO's initial compliance with this section, the MCO shall
obtain the advance written approval of the DEPARTMENT. The MCO shall provide the
DEPARTMENT with a draft of the proposed subcontract thirty (30) days in advance
of the completion of the MCO's negotiation of such subcontract. In addition,
amendments to any such subcontract, excluding those of a technical nature, shall
require the pre-review and approval of the DEPARTMENT.

e.
All dental subcontracts, which include the payment of claims on behalf of HUSKY
B Members for the provision of goods or services to HUSKY B Members shall
require a performance bond, letter of credit, statement of financial reserves or
payment withhold requirements. The performance bond, letter of credit, statement
of financial reserves or payment withhold requirements shall be in a form to be
mutually agreed upon by the MCO and the subcontractor. The amount of the
performance bond shall be sufficient to ensure the completion of the
subcontractor's claims processing and provider payment obligations under the
subcontract in the event the contract between the MCO and the subcontractor is
terminated. The MCO shall submit reports to the DEPARTMENT upon the DEPARTMENT'S
request related to any payments made from the performance bonds or any payment
withholds.

f.
All subcontracts shall include provisions for a well-organized transition in the
event of termination of the subcontract for any reason. Such provisions shall
ensure that an adequate provider network will be maintained at all times during
any such transition period and that continuity of care is maintained for all
Members.

g.
Prior to the approval by the DEPARTMENT of any subcontract with a dental
subcontractor, the MCO shall submit a plan to the DEPARTMENT for the resolution
of any outstanding claims submitted by providers to the MCO's previous dental
subcontractor. Such plan shall meet the requirements described in subsection (h)
below.

h.
In the event that a subcontract is terminated, the MCO shall submit a written
transition plan to the DEPARTMENT sixty (60) days in advance of the scheduled
termination. The transition plan shall include provisions concerning financial
responsibility for the final settlement of provider claims and data reporting,
which at a minimum must include a claims aging report prepared in accordance
with Section 3.40 (c)(5) of this contract, with steps to ensure the resolution
of the outstanding amounts. This plan shall be submitted prior to the
DEPARTMENT'S approval.

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i.
All subcontracts shall also include a provision that the MCO will withhold a
portion of the final payment to the subcontractor, as a surety bond to ensure
compliance under the terminated subcontract.

j.
The MCO shall have no right to and shall not assign, transfer or delegate this
contract in its entirety, or any right or duty arising under this contract
without the prior written approval of the DEPARTMENT. The DEPARTMENT in its
discretion may grant such written approval of an assignment, transfer or
delegation provided, however, that this paragraph shall not be construed to
grant the MCO any right to such approval.

3.43           Timely Payment of Claims

If the MCO or any other subcontractor or vendor who adjudicates claims fails to
pay a clean claim within forty-five (45) days of receipt, or as otherwise
stipulated by a provider contract, the MCO, vendor or subcontractor shall pay
the provider the amount of such clean claims plus interest at the rate of
fifteen (15) percent per annum or as stipulated by a provider contract. In
accordance with Section 3.40 (c)(5), Financial Records, the MCO shall provide to
the DEPARTMENT information related to interest paid beyond the forty-five (45)
day timely filing limit, or as otherwise stipulated by provider contracts.

3.44           Insolvency Protection

The MCO must maintain protection against insolvency as required by the
DEPARTMENT including demonstration of adequate initial capital and ongoing
reserve contributions. The MCO must provide financial data to the DEPARTMENT in
accordance with the DEPARTMENT'S required formats and timing.

3.45           Fraud and Abuse

a.
The MCO shall not knowingly take any action or failure to take action that could
result in an unauthorized benefit to the MCO, its employees, its subcontractors,
its vendors, or to a Member.

b.
The MCO commits to preventing, detecting, investigating, and reporting potential
fraud and abuse occurrences, and shall assist the DEPARTMENT and HHS in
preventing and prosecuting fraud and abuse in the HUSKY B program.

c.
The MCO acknowledges that the DEPARTMENT and HHS, Office of the Inspector
General, has the authority to impose civil monetary penalties on individuals and
entities that submit false and fraudulent claims to the HUSKY B program.

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d.
The MCO shall immediately notify the DEPARTMENT when it detects a situation of
potential fraud or abuse, including, but not limited to, the following:

1.
False statements, misrepresentation, concealment, failure to disclose, and
conversion of benefits;

2.
Any giving or seeking of kickbacks, rebates, or similar remuneration;

3.
Charging or receiving reimbursement in excess of that provided by the
DEPARTMENT; and

4.
False statements or misrepresentation made by a provider, subcontractor, or
Member in order to qualify for the HUSKY program.

e.
Upon written notification of the DEPARTMENT, the MCO shall cease any conduct
that the DEPARTMENT or its agent deems to be abusive of the HUSKY program, and
to take any corrective actions requested by the DEPARTMENT or its agent.

f.
The MCO attests to the truthfulness, accuracy, and completeness of all data
submitted to the DEPARTMENT, based on the MCO's best knowledge, information, and
belief. This data certification requirement includes encounter data and also
applies to the MCO's subcontractors.

g.
The MCO shall establish a fraud and abuse plan, including, but not necessarily
limited to, the following efforts:

1.
Conducting regular reviews and audits of operations to guard against fraud and
abuse;

2.
Assessing and strengthening internal controls to ensure claims are submitted and
payments are made properly;

3.
Educating employees, providers, and subcontractors about fraud and abuse and how
to report it;

4.
Effectively organizing resources to respond to complaints of fraud and abuse;

5.
Establishing procedures to process fraud and abuse complaints; and

6.
Establishing procedures for reporting information to the DEPARTMENT.

h.
The MCO shall examine publicly available data, including but not limited to the
HCFA Medicare/Medicaid Sanction Report and the HCFA website
(http://www.oig.hhs.gov) to determine whether any potential or current
employees, providers, or subcontractors have been suspended or excluded or
terminated from the Medicare or Medicaid programs and shall

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comply with, and give effect to, any such suspension, exclusion, or termination
in accordance with the requirements of state and federal law.

i.
The MCO must provide full and complete information on the identity of each
person or corporation with an ownership or controlling interest (five (5)
percent) in the managed care plan, or any subcontractor in which the MCO has a
five (5) percent or more ownership interest.

j.
The MCO must immediately provide full and complete information when it becomes
aware of any employee or subcontractor who has been convicted of a civil or
criminal offense related to that person's involvement under Medicare, Medicaid,
or any other federal or state assistance program prior to entering into or
renewing this contract.

Sanction: The DEPARTMENT may impose a sanction up to an including a Class C
sanction for the failure to comply with any provision of this section, or take
any other action set forth in Section 9.05 of this contract, including
terminating or refusing to renew this contract, or any other remedy allowed by
federal or state law.

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4.
MCO RESPONSIBILITY CONCERNING PAYMENTS MADE ON BEHALF OF THE MEMBER

4.01
Deductibles, Coinsurance, Annual Benefit Maximums, and Lifetime Benefit Maximums

The MCO shall not apply deductibles, coinsurance, or annual or lifetime benefit
maximums to any covered goods and services provided to Members in HUSKY B.

4.02        Payments for Non-covered Services

a.
The MCO may allow a provider to charge for non-covered goods or services
provided to a Member only if the parent or applicant knowingly elects to receive
the goods or services and enters into an agreement in writing to pay for such
goods or services prior to receiving them. For purposes of this section,
non-covered services are services other than those described in Appendix A of
this contract, services that are provided in the absence of appropriate
authorization by the MCO, and services that are provided out-of-network unless
otherwise specified in the contract or regulation.

b.
No payment made for non-covered services shall be considered cost- sharing for
purposes of determining the family's maximum annual aggregate cost-sharing
limit.

4.03
Cost-Sharing Exemption for American Indian/Alaskan Native Children

a.
Families of American Indian/ Alaskan Native (AI/AN) children who are Members of
a Federally recognized tribe and who are in Income Band 1 or 2 are exempted from
paying any cost sharing for HUSKY B.

b.
The DEPARTMENT or its agent will determine each AI/AN family's eligibility for
HUSKY B and the appropriate Income Band, and will also determine whether or not
a family's children qualify for the AI/AN cost- sharing exemption. The
DEPARTMENT or its agent will then notify the MCO whether the Member is qualified
for the exemption and the appropriate Income Band for the family. The MCO shall
ensure that the family is not charged any premiums or co-payments for qualified
AI/AN children as of the date the DEPARTMENT or its agent makes
that determination.

c.
The MCO shall notify its providers and subcontractors of the AI/AN exemption
from cost sharing. Member handbooks and information handouts developed by the
MCO shall include information about the AI/AN exclusion from cost sharing. The
MCO shall refer any Members who

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believe they qualify for the AI/AN exemption to the DEPARTMENT or its agent for
a determination of their qualification.

d.
The MCO shall provide all qualified AI/AN children in Income Bands 1 and 2 with
Membership identification cards stating "no cost sharing" and the MCO shall
inform their HUSKY B providers and subcontractors that children with Membership
cards so noted shall not be charged any cost sharing.

e.
If the family has paid premiums and, co-payments or any other type of cost
sharing for qualified AI/AN children, it is the responsibility of the MCO to
repay their payments to the family within three (3) months of the
MCO's determination that they were paid. It is the responsibility of the MCO
to review the Member accounts quarterly to determine which families have paid
premiums and/or co-payments or any other cost sharing for qualified AI/AN
children. The quarterly review must be completed no later than fifteen (15) days
after the end of each quarter. The MCO shall make the review available to the
DEPARTMENT upon request.

Sanction: If the MCO fails to repay the overpayment to the family within three
(3) months of the determination that the cost sharing payment liability has been
reached or if the MCO fails to exempt AI/AN children from cost sharing, the
DEPARTMENT may impose a sanction up to and including a Class B sanction pursuant
to Section 9.05.

4.04         Co-payments

a.
The MCO shall allow providers to collect co-payments for the following goods and
services only:

1.  Outpatient physician visits, except for well child visits;
2.  Powered wheelchairs;
3.  Hearing examinations;
4.  Nurse midwife visits;
5.  Nurse practitioner visits;
6.  Podiatrist visits;
7.  Chiropractor visits;
8.  Naturopathic visits;
9.  Eye care exams;
10. Oral contraceptives;
11. Generic and brand name prescriptions; and
12. Non-emergency care provided in a hospital emergency department or urgent
care facility, except for a condition such that a prudent
 
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layperson, acting reasonably, would have believed that emergency medical
treatment is needed.

b.  The amounts of these co-payments are detailed in Appendix A.

4.05      Co-payments Prohibited No co-payment shall be charged for:
1. Ambulance for emergency medical conditions;
2. Durable medical equipment other than powered wheelchairs;
3. Emergency medical conditions; and
4.  Family planning services, excluding oral contraceptives;
5.  Home health services;
6.  Hospice and short-term rehabilitation;
7.  Inpatient hospital services;
8.  Inpatient physician services;
9.  Laboratory and x-ray services, including diagnostic and treatment radiology
and ultrasound treatment;
10. Occupational therapy;
11. Outpatient surgical visits;
12. Physical therapy,
13. Preadmission testing;
14. Preventive care and services, including all well-baby and
well-child services as described in 42 CFR 457.520;
15.  Prosthetic devices;
16.  Skilled nursing;
17.  Speech therapy;
18.  The following dental services: oral exams, prophylaxis, x-rays, fillings,
fluoride treatments, sealants, and oral surgery.
 
4.06            Maximum Annual Limits for Co-payments

a.
The maximum annual limit for co-payments is $760 for families in Income Bands 1
and 2.

b.
Effective February 1, 2004, the maximum aggregate cost-sharing limit for co-
payments will increase to $760 for families in Income Bands 1 and 2. For these
families, the MCO shall not allow co-payments to be charged once the family has
reached its maximum annual limit for co-payments.

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c.
The maximum annual limit applies to the entire family regardless of the number
of eligible children in such family who are enrolled in the MCO.

d.
The maximum annual limit applies to each eligibility period. The
eligibility period is the one-year period following the Member's initial
eligibility date or, for subsequent years, the one year-period following the
anniversary of the initial eligibility date.

e.
It is the responsibility of the MCO to review the Member accounts at a minimum
on a quarterly basis to determine which families have reached their maximum
annual limit for co-payments. The review must be completed no later than fifteen
(15) days after the end of each review period. The MCO shall make the review
available to the DEPARTMENT upon request.

f.
If the family has paid more than the allowed limits for co-payments, it is the
responsibility of the MCO to repay the overpayment to the family within three
(3) months of the MCO's determination that the maximum annual limit for
co-payments had been met.

g.
There is no maximum annual limit for co-payments for families in Income Band 3.

Sanction: If the MCO fails to have an effective tracking system for the maximum
annual co-payment provisions, the DEPARTMENT may impose a Class B sanction
pursuant to Section 9.05.

4.07           Tracking Co-payments

a.
The MCO shall establish and maintain a system to track the co-payments incurred
by each family in Income Bands 1 and 2 in order to adhere to the requirements of
the maximum annual aggregate cost-sharing limit for co- payments. The MCO shall
require their providers and subcontractors to verify whether a family has
reached the maximum annual limit for co-payments before charging a co-payment.

b.
The MCO shall carry over the tracking of the co-payment from one Income Band to
the other within the annual period for families who move between Income Bands 1
and 2. For families moving within the annual period into Income Bands 1 or 2
from Income Band 3, the tracking begins with the enrollment in Income Band 1 or
2.

c.
If the Member is disenrolled due to nonpayment of premiums, the MCO shall
maintain the tracked information on file for costs incurred through the date of
disenrollment in the event the Member is re-enrolled after payment of the
premium within the annual period. If the Member is re-enrolled within the annual
period, the MCO will resume tracking the co-payments paid by the family
throughout the remainder of the annual period.

d.
Families in Income Bands 1 and 2 shall not be charged co-payments once the
maximum annual limits have been met. When a family in Income

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Bands 1 or 2 reaches the maximum annual limits for co-payments, the MCO shall
inform the providers and subcontractors that the co-payment limit has been met,
that the providers and subcontractors cannot charge further co-payments within
the annual period, and the date when the annual period ends. The MCO shall
provide this same information to the parent and the applicant.

e.
The MCO shall send a monthly file to the DEPARTMENT or its agent showing the
premiums and co-payments paid by the family. The DEPARTMENT or its agent will
keep information regarding the amount of co-payments each family incurs within
the annual period and if the children of the family disenroll and enroll in
another MCO within the annual period, the DEPARTMENT or its agent will forward
the family co-payment totals for the annual period to the new MCO.

f.
If a family believes it has reached the maximum annual limit for co- payments,
it may request, in writing, that the MCO review the co- payments that have been
paid by the family. The MCO shall then review the co-payments made by the family
and respond to the family, in writing, within three (3) weeks of the date of the
family's written request. If the family disagrees with the MCOs determination,
the family may request, in writing, a review by the DEPARTMENT. The MCO and the
family shall abide by the decision of the DEPARTMENT. The MCO shall include
a summary of this right and the appropriate procedures to request the review in
its Member Handbook.

g.
If the family has paid more than the allowed limits for co-payments, it is the
responsibility of the MCO to repay the overpayment to the family within three
(3) months of the determination that the maximum annual limit has been met.

Sanction: Any one of the following may give rise to a strike toward a Class A
Sanction pursuant to Section 9.05:

a.
If the MCO fails to inform its subcontractors, providers, and the family when
the family has met its maximum annual limit for co-payments;

b.
If the MCO fails to submit a file to the DEPARTMENT or its agent reporting on
co-payment and premium amount of its Members within thirty (30) days of the
close of the preceding month; or

c.
If the MCO fails to monitor the tracking system to determine if any family has
reached the maximum annual limits.

4.08        Amount of Premium Payment

a.
The amount a family shall be required to pay in premium payments for the HUSKY B
benefit package shall vary according to the family income.

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b.
The premium charged and collected for families within Income Band 2 shall be $30
per month for families with one child or $50 per month for families with more
than one child.

c.
The premium charged and collected for families in Income Bands 1, 2 and 3 will
be the rate negotiated with the DEPARTMENT per month, per child

1.
The premium for families in Income Bands 1 and 2 will be based on Medical
coverage only

2.
The premium for families in Income Bands 3 will be based on both Medical and
Behavioral Health coverage.

d. 
The premium provisions and amount are subject to change. The DEPARTMENT will
give the MCO sixty (60) days advance notice of any premium changes unless a
statutory change precludes such advance notice.

4.09        Billing and Collecting the Premium Payments

a.
The MCO shall bill the applicant or member for the premium payments and shall
collect the premium payments. The applicant may be billed up to thirty (30) days
in advance of the coverage period. The coverage period shall be no less than one
month and no more than one year. The MCO shall offer all applicants or members
the option of a schedule of monthly premium payments. The initial bill to new
members may include billing for multiple months of membership to allow members
the opportunity to make payments current to the first prospective coverage
month.

4.10         Notification of Premium Payments Due

The MCO shall provide the applicant or member with reasonable prior notice of
any premiums to be paid. The notice shall contain: the amount of the premium
due; the date the premium is due; the effective date of disenrollment in case of
failure to pay the premium by the due date; information concerning lock-out if
there is disenrollment for failure to pay the premium; an instruction for the
applicant to immediately contact the DEPARTMENT or its agent if the applicant
cannot pay the premium by the due date because of a decrease in family income or
other changes in family circumstances; and any additional information required
to be included in the notice by the DEPARTMENT.

Sanction: If the MCO fails to provide prior notice as required in this Section,
the DEPARTMENT may impose a strike towards a Class A sanction pursuant to
Section 9.05.

4.11          Notification of Non-payment of the Premium Payments

a.
The MCO shall notify, in writing, the applicant or member and the custodial
parent, if applicable, if a premium is not received by the due date.

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b. The notice shall contain:
1.  The amount of the premium that is due;
2.  The date the premium was due;
3.  The effective date of disenrollment for failure to pay the premium;
4.  Information concerning lock-out;
5.  An instruction for the applicant to immediately contact the DEPARTMENT or
its agent if the applicant cannot pay the premium by the due date because of a
decrease in income or other change in family circumstances; and
6. Any additional information required to be included in the notice by the
DEPARTMENT.
 
b.
The MCO shall collaborate with the DEPARTMENT and its agent to establish billing
and collection procedures. The MCO shall notify the Department or its agent
pursuant to the agreed upon procedures if a premium is not received by the due
date.

Sanction: If the MCO fails to provide prior notice, as described above, or if
the MCO fails to notify the DEPARTMENT or its agent of failure to pay a premium
by the due date, the DEPARTMENT may impose a strike towards a Class A sanction
pursuant to Section 9.05.

4.12           Past Due Premium Payments Paid

If the MCO receives premium payments after the Member has been disenrolled, the
MCO shall notify the DEPARTMENT or its agent within fifteen (15) days of the
receipt of the payment that the payment was received and when it was received.

Sanction:  If the MCO fails to notify the DEPARTMENT or its agent as required in
this Section, the DEPARTMENT may impose a sanction pursuant to Section 9.

4.13           Resumption of Services if the Child is Re-enrolled

If a child is re-enrolled in HUSKY B, the MCO shall resume providing goods and
services to that child.

4.14       Overpayment of Premium

a.
The MCO shall not bill or collect premiums in excess of the monthly amounts set
forth in Section 4.08.

b.
If the MCO has received more than the allowed premium rate, it is
the responsibility of the MCO to repay the overpayment to the family
within three (3) months ,or apply the excess to future coverage
months, whichever is preferred by the applicant or member.

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Sanction: If the MCO fails to repay the overpayment to the family within three
(3) months of the determination that the premium payment liability has been
reached, the DEPARTMENT may impose a strike towards a Class A sanction pursuant
to Section 9.05.

4.15        Member Premium Share Paid by Another Entity

The MCO may accept funds from private or tribal organizations for the purpose of
subsidizing the payment of premiums. To ensure that the payment is not received
from an employer attempting to shift coverage from the employer to the HUSKY B
program, the MCO shall conduct periodic audits of received payments. The audits
shall be conducted in accordance with DSS and MCO agreed upon criteria and
schedule.

Sanction: If the MCO fails to conduct audits in accordance to the agreed upon
criteria and schedule, the DEPARTMENT may impose sanctions up to and including a
Class B sanction.

4.16        Tracking Premium Payments

a.
The MCO shall establish and maintain a system to track the premium payments
received for each family in Income Bands 1 and 2.

b.
The MCO shall cease tracking premium payments for families in Income Bands 1 and
2 who are moved into Income BandS when the move has been completed. For families
moving into Income Band 1 or 2 from Income BandS, the tracking begins when the
family moves into Income Band 1 or 2.

c.
The MCO shall send a monthly file to the DEPARTMENT or its agent showing the
premiums and co-payments received for the family. The DEPARTMENT or its agent
will maintain the information regarding the amount of premiums received for each
family within the annual period and if the children of the family disenroll and
then enroll in another MCO within the annual period, the DEPARTMENT or its agent
will forward the family premium totals for the annual period to the new MCO.

d.
If a family believes it has overpaid premiums, it may request that the
MCO review the premiums that have been paid by the family. This request shall be
in writing. The MCO shall then review the premium payments made by the family
and respond to the family, in writing, within three (3) weeks of the date of the
family's written request. If the family disagrees with the MCO's determination,
the family may request, in writing, a review by the DEPARTMENT. The MCO and
family shall abide by the decision of the DEPARTMENT. The MCO shall include a
summary of this right and the appropriate procedures to request the review in
its Member Handbook.

e.
If the Member is disenrolled due to nonpayment of premiums, the MCO may cease
tracking the premium payments, but will keep the tracked information on file in
case the Member is re-enrolled after payment of the

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premium within the annual period. If the Member is re-enrolled the MCO shall
resume tracking the premium payments paid, throughout the remainder of the
annual period.

Sanction: If the MCO fails to comply with any of the provisions of this section,
the DEPARTMENT may impose sanctions up to and including a Class B sanction
pursuant to Section 9.05.

4.17       Behavioral Health Payment Adjustment
 

a. 
placeholder for the amount.
 

b.
The MCO shall serve as the single point of premium collection for Band 3 members
by:

1)
Collecting a single premium for both Medical and Behavioral Health coverage, and

2)
Transferring to the Department on a quarterly basis the pro-rated Behavioral
Health portion of the premium collected commencing with those Behavioral Health
premiums collected on or after January 1, 2006.

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5.
LIMITED COVERAGE OF SOME GOODS AND SERVICES AND ALLOWANCES

5.01           Limited Coverage of Some Benefits

a.
Some goods and services are covered only up to a specified dollar limit, as set
forth in Appendix A. This dollar limit is the allowance for which the MCO is
responsible. If the Member decides to access these goods and services, the MCO
must cover them up to the specified allowance. The Member's family is
responsible for paying any remaining balance beyond the covered allowance.

b.
For the limited goods and services described in Appendix A, the MCO
is responsible for ensuring that the Member's family is not charged the amount
of the covered allowance.

c.
The amount a family pays toward the fee of the goods and services described in
this section shall not be considered when calculating the maximum annual
aggregate cost-sharing.

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6.           FUNCTIONS AND DUTIES OF THE DEPARTMENT

6.01       Eligibility Determinations

The DEPARTMENT or its agent will determine the initial and ongoing eligibility
for the HUSKY B program of each Member enrolled under this contract in
accordance with the DEPARTMENT'S eligibility policies.

6.02       Ineligibility Determinations

The MCO shall inform the DEPARTMENT or its agent within thirty (30) days of its
knowledge of information which may render a child ineligible for HUSKY B. The
information that shall be reported to the DEPARTMENT or its agent includes age,
residency, insurance status, and death.

6.03       Enrollment/Disenrollment

a.
Enrollment, disenrollment and initial selection of PGP's Members will be handled
by the DEPARTMENT through a contract with a central enrollment broker.

 

      1. 
Coverage for new Members will be effective the first of the month
 

2.
Coverage for disenrolled Members will terminate on the last day of the month.

3.
Members remain continuously enrolled throughout the term of this contract,
except in situations where clients change MCOs, become delinquent on their
premium payments or lose their HUSKY B eligibility.

4.
Disenrollments due to loss of eligibility become effective as of the last day of
the month during which the Member's circumstances changed to cause ineligibility
or, if the Member never met eligibility requirements, as of the date of initial
enrollment.

5.
The DEPARTMENT or its agent will notify the MCO of enrollments and
disenrollments specific to the MCO via a daily data file.

6.
The enrollments and disenrollments processed on any given day will be made
available to the MCO via the data file the following day (i.e. after the daily
overnight batching has been processed).

b.
In addition to the daily data file, a full file of all the Members will be
made available on a monthly basis. Both the daily data file and the monthly
full file can be accessed by the MCO electronically via dial-up.

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6.04        Lock-In/Open Enrollment

a.
Upon enrollment into an MCO, Members will be locked-in to that MCO for a period
of up to twelve (12) months. Members will not be allowed to change plan
enrollment during the lock-in period except for good cause, as defined below.
The lock-in period is subject to the following provisions:

1.
The first ninety (90) days of enrollment into a new MCO will be designated as
the free-look period during which time the Member may change plans.

2.
The last sixty (60) days of the lock-in period will be an open enrollment
period, during which time Members may change plans.

3.
Plan changes made during the open enrollment period will go into effect on the
first day of the month following the end of the lock-in period.

4.
Members who do not change plans during the open enrollment period will continue
the enrollment in the same MCO and be assigned to a new twelve (12) month
lock-in period.

b.
The following shall constitute good cause for a Member to disenroll from the
plan during the lock-in period.

1.
Unfavorable resolution of a Member complaint adjudicated through the MCO's
internal complaint process and continued dissatisfaction due to repeated
incidents of any of the following:

a) Documented long waiting times for appointments;
b) More than a forty-five (45) day wait for scheduling a well-care visit; 
c) More than a two (2) business day wait for non-urgent, symptomatic office
visit; 
d) Unavailability of same day office visit or same day referral to an emergency
provider for emergency care services;
e)  Documented inaccessibility of MCO by phone or mail;
f)  Phone calls not answered promptly;
g) Caller placed on hold for extended periods of time;
h) Phone messages and letters not responded to promptly; and i)   Rude and
demeaning treatment by MCO staff.

2.
Prior to pursuing the MCO's internal complaint process and without filing an
appeal through the plan, dissatisfaction due to any of the following:

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a)
Discriminatory treatment as documented in a complaint filed with the State of
Connecticut, Commission on Human Rights and Opportunities (CHRO) or the
DEPARTMENT'S Affirmative Action Division;

b)
PCP able to serve Member's specific individual needs (i.e. language or physical
accessibility) is no longer participating with the MCO and there is no other
suitable PCP within reasonable distance to the Member; or

c)
Member has a pending lawsuit against the MCO; verification of pending lawsuit
must be provided.

6.05           Capitation Payments to the MCO

a.
In full consideration of contract services rendered by the MCO, the DEPARTMENT
agrees to pay the MCO monthly payments based on the capitation rates specified
in Appendix I. The DEPARTMENT will make the payments in the month following the
month to which the capitation applies.

b.
Capitation payments to the MCO shall be based on a passive billing system. The
MCO is not required to submit claims for the capitation billing for its HUSKY B
Membership.

c.
Payments to the MCO shall be based on each month's enrollment data as determined
by the DEPARTMENT or its agent. The DEPARTMENT or its agent will supply to the
MCO, on a monthly basis a capitation roster, which includes all Members for whom
capitation payments are made to the MCO. The MCO will be responsible for
detecting any inconsistency between the capitation roster and the MCO Membership
records. The MCO must notify the DEPARTMENT of any inconsistency
between enrollment and payment data. The DEPARTMENT agrees to provide to the MCO
information needed to determine the source of the inconsistency within sixty
(60) working days after receiving written notice of the request to furnish such
information. The DEPARTMENT will recoup overpayments or reimburse underpayments.
The adjusted payment for each month of coverage shall be included in the next
monthly capitation payment and roster.

d.
Any retrospective adjustments to prior capitation payments will be made in the
form of an addition to or subtraction from the next month's capitation payment.

e.
In instances where enrollment is disputed the DEPARTMENT will be the final
arbiter of Membership status and reserves the right to recover inappropriate
capitation payments. Capitation payments for retroactive enrollment adjustments
will made to the MCO pursuant to rules outlined in Section c, noted above.

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6.06        Newborn Retroactive Adjustments

a.
The DEPARTMENT shall determine the eligibility of a newborn child retroactively
to the date of his or her birth, for an application filed within thirty (30)
days following birth.

b.
For the purpose of determining the capitation payment to the MCO for the month
in which the child was born, the effective date for such enrollment shall be the
first of the month in which the child was born.

6.07        Information

The DEPARTMENT will make known to each MCO information which relates to
pertinent statutes, regulations, policies, procedures, and guidelines affecting
the operation of this contract. This information shall be available either
through direct transmission to the MCO or by reference to public resource files
accessible to the MCO personnel.

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7.           DECLARATIONS AND MISCELLANEOUS PROVISIONS

7.01       Competition Not Restricted

In signing this Contract, the MCO asserts that no attempt has been made or will
be made by the MCO to induce any other person or firm to submit or not to submit
an application for the purpose of restricting competition.

7.02       Non-segregated Facilities

a.
The MCO certifies that it does not and will not maintain or provide for
its employees any segregated facilities at any of its establishments; and
that it does not permit its employees to perform their services at any
location, under its control, where segregated facilities are maintained.
As Contractor, the MCO agrees that a breach of this certification is a
violation of Equal Opportunity in Federal employment. In addition, Contractor
must comply with the Federal Executive Order 11246 entitled "Equal Employment
Opportunity" as amended by Executive Order 11375 and as supplemented in the
United States Department of Labor Regulations (41 CFR pt. 30). As used in this
certification, the term "segregated facilities" includes any waiting rooms,
restaurants and other eating areas, parking lots, drinking fountain, recreation
or entertainment areas, transportation, and housing facilities provided for
employees which are segregated on the basis of race, color, religion, or
national origin, because of habit, local custom, national origin or otherwise.

b.
The MCO further agrees, (except where it has obtained identical certifications
from proposed subcontractors for specific time periods) that it will obtain
identical certifications from proposed subcontractors which are not exempt from
the provisions for Equal Employment Opportunity; that it will retain such
certifications in its files; and that it will forward a copy of this clause to
such proposed subcontractors (except where the proposed subcontractors have
submitted identical certifications for specific time periods).

7.03       Offer of Gratuities

The MCO, its agents and employees, certify that no elected or appointed official
or employee of the DEPARTMENT has or will benefit financially or materially from
this contract. The contract may be terminated by the DEPARTMENT if it is
determined that gratuities of any kind were either offered to or received by any
of the aforementioned officials or employees of the MCO, its agent or employee.

7.04            Employment/Affirmative Action Clause

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The MCO agrees to supply employment/affirmative action information as required
for agency compliance with Title VI and VII of the Civil Rights Acts of 1964 and
Connecticut General Statutes, Section 46a-68 and Section 46a-71.

7.05        Confidentiality

a.
The MCO agrees that all material and information, and particularly information
relative to individual applicants or recipients of assistance through the
DEPARTMENT, provided to the Contractor by the State or acquired by the
Contractor in performance of the contract whether verbal, written, recorded
magnetic media, cards or otherwise shall be regarded as confidential information
and all necessary steps shall be taken by the Contractor to safeguard the
confidentiality of such material or information in conformance with federal and
state statutes and regulations.

b.
The MCO agrees not to release any information provided by the DEPARTMENT or
providers or any information generated by the MCO without the express written
consent of the Contract Administrator, except as specified in this contract and
permitted by applicable state law.

7.06        Independent Capacity

The MCO, its officers, employees, subcontractors, or any other agent of the
Contractor in performance of this contract will act in an independent capacity
and not as officers or employees of the State of Connecticut or of the
DEPARTMENT.

7.07         Liaison

Both parties agree to have specifically named liaisons at all times. These
representatives of the parties will be the first contacts regarding any
questions and problems which arise during implementation and operation of the
contract.

7.08         Freedom of Information

Due regard will be given for the protection of proprietary information contained
in all documents received by the DEPARTMENT; however, the MCO is aware that all
materials associated with the contract are subject to the terms of the state
Freedom of Information Act, Conn. Gen. Stat. Sections 1-200, et seq., and all
rules, regulations and interpretations resulting there from. When materials are
submitted by the MCO or a subcontractor to the DEPARTMENT and the MCO or
subcontractor believes that the materials are proprietary or confidential in
some way and that they should not be subject to disclosure pursuant to the
Freedom of Information Act, it is not sufficient to protect the materials from
disclosure for the MCO to state generally that the material is proprietary in
nature and, therefore, not subject to release to third parties. If the MCO or
the MCO or the subcontractor believes that any portions of the materials
submitted to the DEPARTMENT are proprietary or confidential or constitute
commercial of financial information, given in confidence, those portions or
pages or sections the

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MCO believes to be proprietary must be specifically identified as such.
Convincing explanation and rationale sufficient to justify each claimed
exemption from release, consistent with section 1-210 of the Connecticut General
Statutes, must accompany the documents when they are submitted to the
DEPARTMENT. The explanation and rationale must be stated in terms of the
prospective harm to the MCO's or subcontractor's competitive position that would
result if the identified materials were to be released and the reasons why the
materials are legally exempt from release pursuant to the above-cited statute.
The final administrative authority to release or exempt any or all material so
identified by the MCO or subcontractor rests with the DEPARTMENT. The DEPARTMENT
is not obligated to protect the confidentiality of materials or documents
submitted to it by the MCO or the subcontractor if said materials or documents
are not identified in accordance with the above-described procedure.

7.09        Waivers

Except as specifically provided in any section of this contract, no covenant,
condition, duty, obligation or undertaking contained in or made a part of the
Contract shall be waived except by the written agreement of the parties, and
forbearance or indulgence in any form or manner by the DEPARTMENT or the MCO 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
DEPARTMENT or the MCO; and not withstanding any such forbearance or indulgence,
until complete performance or satisfaction of all such covenants, conditions,
duties, obligations and undertakings, the DEPARTMENT or MCO shall have the right
to invoke any remedy available under the contract, or under law or equity.

7.10        Force Majeure

The MCO shall be excused from performance hereunderfor any period that is
prevented from providing, arranging for, or paying for services as a result of a
catastrophic occurrence or natural disaster including but not limited to an act
of war, and excluding labor disputes.

7.11        Financial Responsibilities of the MCO

The MCO must maintain at all times financial reserves in accordance with the
Connecticut Health Centers Act under Section 38a-175 et seq. of the Connecticut
General Statutes, and with the requirements outlined in the DEPARTMENT'S Request
for Application.

7.12        Capitalization and Reserves

a.
The MCO shall comply with and maintain capitalization and reserves as required
by the appropriate regulatory authority.

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b.
If the MCO is licensed by the State of Connecticut, the MCO shall establish and
maintain capitalization and reserves as required by the Connecticut DOI.

c.
If the MCO is majority-owned by federally qualified health centers (FQHCs) and
not licensed by the State of Connecticut, the MCO will establish and maintain
sequestere'd capital of $500,000 plus two (2) percent of ongoing annual
capitation premiums.

1.
These funds shall be placed in a restricted account for the duration of the FQHC
plan's existence, to be accessed only in the event such funds are needed to meet
unpaid claims liabilities.

2.
This restricted account shall be established such that any withdrawals or
transfers of funds will require signatures of authorized representatives of the
FQHC plan and the DEPARTMENT.

3.
The initial $500,000 must be deposited into the account by the beginning of the
MCO's first enrollment period.

4.
The MCO must make quarterly deposits into this account so that the account
balance is equal to $500,000 plus two (2) percent of the premiums received
during the preceding twelve (12) months.

7.13        Members Held Harmless
 
The MCO shall not hold a Member liable for:
 

a.
The debts of the MCO in the event of the MCO's insolvency;
 

b.
The cost of HUSKY B covered services provided pursuant to this contract, other
than cost-sharing permitted under this contract, to the Member if the MCO or
provider fails to receive payment; and/or

c.
Payments to a provider which exceed the amount that would be owed if the MCO
directly provided the service.

7.14        Compliance with Applicable Laws, Rules And Policies

The MCO in performing this contract shall comply with all applicable federal and
state laws, regulations and written policies, including those pertaining to
licensing.

7.15        Federal Requirements and Assurances

a.            General

1.
The MCO shall comply with those federal requirements and assurances for
recipients of federal grants provided in OMB Standard Form 424B (4-88) which are
applicable to the MCO. The MCO is responsible for determining which requirements
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05 01 07 HUSKY B Final

assurances are applicable to the MCO. Copies of the form are available from the
DEPARTMENT. The MCO shall comply with all applicable provisions of 45 CFR 74.48
and all applicable requirements of 45 CFR 74.48 Appendix A.

2.
The MCO shall provide for the compliance of any subcontractors with applicable
federal requirements and assurances.

b.           Lobbying

1. 
The MCO, as provided by 31 U.S.C. 1352 and 45 CFR 93.100 et seq.. shall not pay
federally appropriated funds to any person for influencing or attempting to
influence an officer or employee of any agency, a Member of the U.S. Congress,
an officer or employee of the U.S. Congress or an employee of a Member of the
U.S. Congress in connection with the awarding of any federal contract, the
making of any cooperative agreement or the extension, continuation, renewal,
amendment or modification of any federal contract, grant, loan or cooperative
agreement.

2. 
The MCO shall submit to the DEPARTMENT a disclosure form as provided in 45 CFR
93.110 and Appendix B to 45 CFR Pt. 93, if any funds other than federally
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 the
U.S. Congress, an officer or employee of the U.S. Congress or an employee of
a Member of the U.S. Congress in connection with this contract.

c.           Title XXI and SCHIP Regulations

The MCO shall comply with all applicable provisions of Title XXI of the Social
Security Act and 42 CFR pt. 457

d.           Clean Air and Water Acts

The MCO shall comply with all applicable standards, orders or regulations issued
pursuant to the Clean Air Act as amended, 42 U.S.C. 7401, et seq. and the
Federal Water Pollution Control Act as amended, 33 U.S.C. 1251 et seq.

e.           Energy Standards

The MCO shall comply with all applicable standards and policies relating to
energy efficiency which are contained in the state energy plan issued in
compliance with the federal Energy Policy and Conservation Act, 42 USC Sections
6231 - 6246. The MCO further covenants that no federally appropriated funds have
been paid or will be paid on behalf of the DEPARTMENT or the contractor to any
person for influencing or attempting to influence an officer or employee of any
federal agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with the awarding of any federal
contract, the making of any federal grant, the making of any federal loan,

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the entering into of any cooperative agreement, or the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan, or
cooperative agreement. If any funds other than federally appropriated funds have
been paid or will be paid to any person for influencing or attempting to
influence an officer or employee of any federal agency, a Member of Congress, or
an employee of a Member of Congress in connection with this contract, grant,
loan, or cooperative agreement, the contractor shall complete and submit
Standard Form - ILL, "Disclosure Form to Report Lobbying," in accordance with
its instructions.

f.           Maternity Access and Mental Health Parity

The MCO shall comply with the maternity access and mental health requirements of
the Public Health Services Act, Title XXVII, Subpart 2, Part A, Section 2704, as
added September 26, 1996, 42 U.S.C. Section 300gg-4, 300gg-5, and the
implementing regulations at 45 CFR 146.136, insofar as such requirements apply
to providers of group health insurance.

7.16      Civil Rights

a.           Federal Authority

The MCO shall comply with the Civil Rights Act of 1964 (42 U.S.C. Section 2000d,
et seq.). the Age Discrimination Act of 1975 (42 U.S.C. 6101, et sea.), the
Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101, etseg.) and
Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, et seq.

b.           Discrimination

Persons may not, on the grounds of race, color, national origin, creed, sex,
religion, political ideas, marital status, age or disability be excluded from
employment in, denied participation in, denied benefits or be otherwise
subjected to discrimination under any program or activity connected with the
implementation of this contract. The MCO shall use hiring processes that foster
the employment and advancement of qualified persons with disabilities.

c.           Merit Qualifications

All hiring done in connection with this contract must be on the basis of merit
qualifications genuinely related to competent performance of the particular
occupational task. The MCO, in accordance with Federal Executive Order 11246,
dated September 24, 1965 entitled "Equal Employment Opportunity", as amended by
Federal Executive Order 11375 and as supplemented in the United States
Department of Labor Regulations, 41 CFR Part 60-1, et seq., must provide for
equal employment opportunities in its employment practices.

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d.           Confidentiality

The MCO shall, in accordance with relevant laws, regulations and policies,
protect the confidentiality of any material and information concerning an
applicant for or recipient of services funded by the DEPARTMENT. Access to
patient information, records, and data shall be limited to the purposes outlined
in 42 CFR 434.6(a)(8). All requests for data or patient records for
participation in studies, whether conducted by the MCO or outside parties, are
subject to approval by the DEPARTMENT .

7.17      Statutory Requirements

a.
State licensed MCO shall retain at all times during the period of this contract
a valid Certificate of Authority issued by the State Commissioner of Insurance.

b.
The MCO shall adhere to the provisions of the Clinical Laboratory Improvement
Amendments of 1988 (CLIA) Public Law 100-578, 42 USC Section 1395aa.

7.18      Disclosure of Interlocking Relationships

An MCO which is not also a Federally-qualified Health Plan or a Competitive
Medical Plan under the Public Health Service Act must report on request to the
State, to the Secretary and the Inspector General of DHHS, and the Comptroller
General, a description of transactions between the MCO and parties in interest
including related parties as defined by federal and state law. Transactions that
must be reported include: (a) any sale, exchange, or leasing of property; (b)
any furnishing for consideration of goods, services or facilities (but not
salaries paid to employees); and (c) any loans or extensions of credit.

7.19      DEPARTMENT'S Data Files

a.
The DEPARTMENT'S data files and data contained therein shall be and remain the
DEPARTMENT'S property and shall be returned to the DEPARTMENT by the MCO upon
the termination of this contract at the DEPARTMENT'S request, except that any
DEPARTMENT data files no longer required by the MCO to render services under
this contract shall be returned upon such determination at the DEPARTMENT'S
request.

b.
The DEPARTMENT'S data shall not be utilized by the MCO for any purpose other
than that of rendering services to the DEPARTMENT under this contract, nor shall
the DEPARTMENT'S data or any part thereof be disclosed, sold, assigned, leased
or otherwise disposed of to third parties by the MCO unless there has been prior
written DEPARTMENT approval. The MCO may disclose material and information to
subcontractors and vendors, as necessary to fulfill the obligations of this
contract.

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c.
The DEPARTMENT shall have the right of access and use of any data files retained
or created by the MCO for systems operation under this contract subject to the
access procedures defined in Part II Section 3.34.

d.
The MCO shall establish and maintain at all times reasonable safeguards against
the destruction, loss or alteration of the DEPARTMENT'S data and any other data
in the possession of the MCO necessary to the performance of operations under
this contract.

7.20        Hold Harmless

a.
The MCO agrees to indemnify, defend and hold harmless the State of Connecticut
as well as all DEPARTMENTS, officers, agents and employees of the State from all
claims, losses or suits accruing or resulting to any contractors,
subcontractors, laborers and any person, firm or corporation who may be injured
or damaged through the fault of the MCO in the performance of the contract.

b.
The MCO, at its own expense, shall defend any claims or suits which are brought
against the DEPARTMENT or the State for the infringement of any patents,
copyrights, or other proprietary rights arising from the MCO's or the State's
use of any material or information prepared or developed by the MCO in
conjunction with the performance of this contract; provided any such use by the
State is expressly contemplated by this contract and approved by the MCO.

c.
The State, its DEPARTMENTS, officers, employees, contractors, and agents shall
cooperate fully in the MCO's defense of any such claim or suit as directed by
the MCO. The MCO shall, in any such suit, satisfy any damages for infringement
assessed against the State or the DEPARTMENT, be it resolved by settlement
negotiated by the MCO, final judgment of a court with jurisdiction after
exhaustion of available appeals, consent decree, or any other manner approved by
the MCO.

7.21        Executive Order Number 16

This contract is subject to Executive Order No. 16 of Governor John G. Rowland
promulgated August 4, 1999 and, as such, this contract may be cancelled,
terminated or suspended by the State for violation of or noncompliance with said
Executive Order No. 16. The parties to this contract, as part of the
consideration hereof, agree that:

a.
The MCO shall prohibit employees from bringing into the state work site, except
as may be required as a condition of employment, any weapon or dangerous
instrument as defined in b.

b.
Weapon means any firearm, including a BB gun, whether loaded or unloaded, any
knife (excluding a small pen or pocket knife), including a switchblade or other
knife having an automatic spring release device, a stiletto, any police baton or
nightstick or any martial arts weapon or

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electronic defense weapon. Dangerous instrument means any instrument, article or
substance that, under the circumstances, is capable of causing death or serious
physical injury.

c.
The MCO shall prohibit employees from using, attempting to use or threatening to
use any such weapon or dangerous instrument in the state work site and employees
shall be prohibited from causing or threatening to cause physical injury or
death to any individual in the state work site.

d.
The MCO shall adopt the above prohibitions as work rules, violations of which
shall subject the employee to disciplinary action up to and including discharge.
The MCO shall insure that all employees are aware of such work rules.

e.
The MCO agrees that any subcontract it enters into in furtherance of the work to
be performed hereunder shall contain the provisions (a) through (d).

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8.           MCO RESPONSIBILITIES CONCERNING INTERNAL AND EXTERNAL APPEALS

8.01
MCO Responsibilities Concerning Internal and External Appeals and Notices of
Denial

Members shall have the opportunity to request an internal appeal of a decision
made by the MCO regarding the denial of goods and services covered in the basic
benefit package. The MCO shall have an internal appeal process for receiving and
acting upon these requests. This internal appeals process may consist of more
than one level of review. In addition,, the MCO shall provide for an expedited
internal appeals process as set forth in Section 8.06 below. The MCO shall also
provide information to Members concerning the external appeal process available
through the State of Connecticut Department of Insurance (DOI). The MCO shall
also have a process for provider appeals, as set forth in Section 8.08.

8.02           Internal Appeal Process Required

a.
The MCO shall have a timely and organized internal appeal process. The internal
appeal process shall be available for resolution of disputes between the MCO or
MCO subcontractors and Members concerning the denial of a request for goods and
services covered under the HUSKY B benefit package.   In addition the MCO shall
provide for an expedited internal appeal process as set forth in Section 8.06
below. The MCO shall be responsible for ensuring compliance with the internal
appeal process requirements set forth herein, whether the goods or services are
denied by the MCO or one of its subcontractors.

b.
The MCO shall designate one primary and one back-up contact person for its
internal appeal process.

8.03           Denial Notice

a.
The MCO shall provide a written denial notice to the Member, which includes the
MCO's denial decision as well as notice of the Member's right to appeal. The
denial notice shall be sent to the Member's last known address.

b.          All denial notices shall clearly state or explain:
1.           What goods and/or services are being denied;
2.           The reasons for the denial;
3.           The contract section that supports the denial;

4.
The address and toll-free number of the MCO's Member Services Department;

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5.
The Member's right to challenge the denial by filing an internal appeal with the
MCO;

6.
The procedure and timeframe for commencing each level of the MCO's internal
appeals process, including the address to which any written request for appeal
may be mailed;
 

7.
The availability of expedited internal appeal;
 

8. The external appeal process available through the DOI;

 
9.
Specifications and assistance as to the format in which the Member may file a
request for an internal appeal.

10.
That the Member will lose his or her right to challenge the denial with the MCO
within sixty (60) days from the date the MCO mailed the denial notice;

11.
That for each level of its appeals process, the MCO must issue a decision
regarding an appeal no more than thirty (30) days following the date that the
MCO receives the request for review

12.
That the MCO must be responsive to questions which the Member may have about the
denial;

13.
That the Member may submit additional documentation or written material for the
MCO's consideration; and

14.
That the MCO's review may be based solely on information available to the MCO
and its providers, unless the Member requests a meeting or the opportunity to
submit additional information.

8.04      Internal Appeal Process

a.
The MCO shall develop written policies and procedures for each component of its
internal appeals process. The MCO's policies and procedures must include the
elements specified in this contract and must be approved by the DEPARTMENT in
writing. The MCO shall not be excused from meeting the requirements for the
policies, procedures and pending the DEPARTMENT'S written approval of these
documents.

b.
The MCO shall maintain a record keeping system for each level of its appeal
process, which shall include a copy of the Member's request for review, the
response and the resolution, which the MCO shall make available to the
DEPARTMENT upon request.

c.
The MCO shall clearly specify in its Member handbook/packet, the procedural
steps and timeframes for each level of its internal appeals process and for
filing an external appeal through the DOI. The MCO shall provide information on
its internal appeals process and on the external DOI appeal process to providers
and subcontractors, as it relates to Members.

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d.
The MCO shall develop and make available to Members and potential Members
appropriate alternative language versions of internal appeal materials,
including but not limited to, the standard information contained in denial
notices. Such materials shall be made available in Spanish, English and any
other language(s) if more than five (5) percent of the MCO's Members in the
State of Connecticut served by the MCO speak the alternative language. The MCO
must submit such alternative language materials to the DEPARTMENT and the
DEPARTMENT must approve any such materials in writing prior to use by the MCO.

e.
Internal appeals shall be filed by the applicant, the Member, the
Member's authorized representative, or the Member's conservator. The
Member Handbook shall state that requests for all levels of the internal
appeals process shall be mailed or faxed to a single address.

f.
If the internal appeal contains a request for expedited review, the MCO shall
follow the procedure described in Section 8.06 below.

g.
An individual or individuals having final decision-making authority
shall conduct the final level of the MCO's review. One or more physicians
who were not involved in the denial determination must decide any appeal arising
from an action based on a determination of medical necessity.

h.
The MCO may decide an appeal on the basis of written documentation available to
the MCO at the time of the request, unless the Member requests an opportunity to
meet with the individual or individuals conducting the internal appeal on behalf
of the MCO and/or requests the opportunity to submit additional written
documentation or other written material. The MCO shall inform the Member that
the MCO's review may be based solely on information available to the MCO and its
providers, unless the Member requests a meeting or the opportunity to submit
additional information.

i.
If the Member wishes to meet with the decisionmaker, the meeting may be held via
telephone or at a location accessible to the Member.

j.
The MCO shall date stamp the form when it is received by the MCO. The postmark
date on the denial notice envelope will be used to determine whether an appeal
was timely filed.

8.05        Written Decision

a.
The MCO shall issue a written decision for each level of its internal appeals
process. Each decision shall be mailed to the Member. The MCO shall send a copy
of each decision to the DEPARTMENT. The appeal decision shall be sent no later
than thirty (30) days from the date on which the MCO received the appeal.

b.
The MCO's written decision must include the Member's name and address; the
provider's name and address; the MCO name and address; a complete statement of
the MCO's findings and conclusions, including the

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section number and text of any statute or regulation that supports the decision;
a clear statement of the MCO's disposition of the appeal; a statement that the
Member has exhausted the MCO's internal appeal procedure concerning the denial
at issue; and relevant information concerning the external appeals process
available through the DOI, as described in Section 8.07, below.

c.
For each level of its internal appeals process, the MCO shall issue a decision
within thirty (30) days. If the MCO fails to issue a decision within thirty (30)
days, the DEPARTMENT will deem the decision to be a denial and the Member may
file an external appeal with the DOI, as more fully discussed in Section 8.07,
below.

d.
The MCO shall include a copy of the HUSKY B Program - State of Connecticut -
Insurance Department Request for External Appeal form approved by the DEPARTMENT
with each written decision.

8.06         Expedited Review

a.
Subject to Section 8.02 above, the internal appeals process must allow
for expedited review. If a Member requests an expedited review, the MCO must
determine within one business day of receipt of the request, whether to expedite
the review or whether to perform the review according to the standard
timeframes.

b.
An expedited review must be performed when the standard timeframes
for determining an appeal could jeopardize the life or health of the Member
or the Member's ability to regaining maximum functioning. The MCO must expedite
its review in all cases in which such a review is requested by the Member's
treating physician or primary care provider, functioning within his or her scope
of practice as defined under state law, or by the DEPARTMENT.

8.07         External Appeal Process through the DOI

a.
A Member who has exhausted the internal appeal mechanisms of the MCO and is not
satisfied with the outcome of the MCO's final decision may file an appeal with
the DOI.

b.
The MCO shall include the following information concerning the DOI external
appeal process in its member handbook:

1.
If the Member has exhausted the MCO's internal appeals process and has received
a final written decision from the MCO upholding the MCO's original denial of the
good or service, the Member may file an external appeal with the DOI within
thirty (30) days of receiving the final written appeal decision;

2.
The Member may be required to file a filing fee for the DOI appeal. The
DEPARTMENT shall pay the filing fee on behalf of any

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Member whose family economic filing unit income exceeds 185 percent of the
federal poverty level but does not exceed 300 percent of the federal poverty
level (Members in Income Bands 1 and 2). If the Member's family economic filing
unit's income exceeds 300 percent of the federal poverty level (Income Band 3),
the filing unit shall be responsible for the payment of the filing fee;

3.
The non-refundable filing fee for an external appeal through the DOI is $25;

4.
The Member will be asked to submit certain information in support of his or her
appeal request, including a photocopy of his or her HUSKY B enrollment card. The
Member (or the Member's legal representative) will also be asked to sign a
release of medical records;

5.
The DOI will assign the appeal to an outside, independent entity. The reviewers
will conduct a preliminary review and determine whether the appeal meets
eligibility for review. The Member will be notified within five (5) business
days of the DOI's receipt of the request whether the appeal has been accepted or
denied for full review;

6.
The MCO shall advise Members that they may obtain information about the external
review process from the DOI, P.O. Box 816, Hartford, CT 06142 or at (860)
297-3862; and

7.           A copy of the DOI External Appeal Consumer Guide.

c.           The MCO shall be bound by the DOI's external appeal decision.

8.08       Provider Appeal Process

a.
The MCO shall have an internal appeal process through which a health care
provider may grieve the MCO decision on behalf of a Member. The MCO shall
provide information on the availability of this process to the providers in the
MCO's network.

b.
The health care provider appeal process shall not include any appeal rights to
the DEPARTMENT or any rights to an external appeal through the DOI.

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9.           CORRECTIVE ACTION AND CONTRACT TERMINATION

9.01           Performance Review

a.
A designated representative of the MCO and a designated representative of the
DEPARTMENT shall meet on an annual basis, and as requested by either party, to
review the performance of the MCO under this contract. Written minutes of such
meetings shall be kept. In the event of any disagreement regarding the
performance of services by the MCO under this contract, the designated
representatives shall discuss the problem and shall negotiate in good faith in
an effort to resolve the disagreement.

b.
In the event that no such resolution is achieved within a reasonable time, the
matter shall be referred to the Contract Administrator as provided under Section
9.02, the Disputes clause of this contract. If the Contract Administrator
determines that the MCO has failed to perform as measured against applicable
contract provisions, the Contract Administrator may impose sanctions or any
other penalty, set forth in this Section including the termination of this
contract in whole or in part, as provided under this Section.

9.02           Settlement of Disputes

Any dispute arising under the contract that is not disposed of by agreement
shall be decided by the Contract Administrator whose decision shall be final and
conclusive subject to any rights the MCO may have in a court of law. The
foregoing shall not limit any right the MCO may have to present claims under
Connecticut General Statutes Section 4-141 et. seq. or successor provisions
regarding the Claims Commissioner, including without limitation Connecticut
General Statutes Section 4-160 regarding authorization of actions. In connection
with any appeal to the Contract Administrator under this paragraph, the MCO
shall be afforded an opportunity to be heard and to offer evidence in support of
its appeal. Pending final decision of a dispute, the MCO shall proceed
diligently with the performance of the contract in accordance with the Contract
Administrator's decision.

9.03           Administrative Errors

The MCO shall be liable for the actual amount of any costs in excess of $5,000
incurred by the DEPARTMENT as the result of any administrative error (e.g.,
submission of capitation, encounter or reinsurance data) of the MCO or its
subcontractors. The DEPARTMENT may request a refund of, or recoup from
subsequent capitation payments, the actual amount of such costs.

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9.04           Suspension of New Enrollment

Whenever the DEPARTMENT determines that the MCO is out of compliance with this
contract, unless corrective action is taken to the satisfaction of the
DEPARTMENT, the DEPARTMENT may suspend enrollment of new Members under this
contract. The DEPARTMENT, when exercising this option, must notify the MCO in
writing of its intent to suspend new enrollment at least thirty (30) days prior
to the beginning of the suspension period. The suspension period may be for any
length of time specified by the DEPARTMENT, or may be indefinite. The suspension
period may extend up to the contract expiration date as provided under PART I.
(The DEPARTMENT may also notify existing Members of MCO non-compliance and
provide an opportunity to disenroll from the MCO and to re-enroll in another
MCO.)

9.05           Sanctions

It is agreed by the DEPARTMENT and the MCO that if by any means, including any
report, filing, examination, audit, survey, inspection or investigation, the MCO
is determined to be out of compliance with this contract, damage to the
DEPARTMENT may or could result. Consequently, the MCO agrees that the DEPARTMENT
may impose any of the following sanctions for noncompliance under this contract.
Unless otherwise provided in this contract, sanctions imposed under this section
shall be deducted from capitation payment or, at the discretion of the
DEPARTMENT, paid directly to the DEPARTMENT.

a.           Sanctions for Noncompliance

1.
Class A Sanctions. Three (3) Strikes. Sanctions Warranted After Three (3)
Occurrences.

For noncompliance of the contract which does not rise to the level warranting
Class B sanctions as defined in subsection a (2) of this section or Class C
sanctions as defined in subsection (b) of this section, including, but not
limited to, those violations defined as Class A sanctions in any provision of
this contract, the following course of action will be taken by the DEPARTMENT:

a)
Each time the MCO fails to comply with the contract on an issue warranting a
Class A sanction, the MCO receives a strike.

b)
The MCO will be notified each time a strike is imposed. After the third strike
for the same contract provision a sanction may be imposed. If no specific time
frame is set forth in any such contractual provision, the time frame is deemed
to be the full length of the contract.

c)
The MCO will be notified in writing at least thirty (30) days in advance of any
sanction being imposed and will be given an opportunity to meet with the
DEPARTMENT to present its

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position as to the DEPARTMENT'S determination of a violation warranting a Class
A sanction. At the DEPARTMENT'S discretion, a sanction will thereafter be
imposed. Said sanction will be no more than $2,500 after the first three
strikes. The next strike for noncompliance of the same contractual provision
will result in a sanction of no more than $5,000 and any subsequent strike for
noncompliance of the same contractual provision will result in a Class A
sanction of no more than $10,000.

2.
Class B Sanctions. Sanctions Warranted Upon Single Occurrence.

For noncompliance with the contract which does not warrant the imposition of
Class C sanctions as defined in subsection (b) of this section, including, but
not limited to, those violations defined as Class B sanctions in any provision
of this contract, the following course of action will be taken by the
DEPARTMENT:

a) The DEPARTMENT may impose a sanction at the DEPARTMENT'S discretion if, after
at least thirty (30) days notice to the MCO and an opportunity to meet with the
DEPARTMENT to present the MCO's position as to the DEPARTMENT'S determination of
a violation warranting a Class B sanction, the DEPARTMENT determines that the
MCO has failed to meet a performance measure which merits the imposition of a
Class B sanction not to exceed $10,000.

b.
Class C Sanctions. Sanctions Related to Noncompliance Potentially Resulting in
Harm to an Individual Member

1.
The DEPARTMENT may impose a Class C sanction on the MCO for noncompliance
potentially resulting in harm to an individual Member, including, but not
limited to, the following:

a)
Failing to substantially authorize medically necessary items and services that
are covered (under law or under this contract) to be provided to a Member
covered under this contract, up to any applicable allowance;

b)
Imposing a premium or copay on Members in excess of that specifically permitted
under provisions of the contract;

c)
Discriminating among Members on the basis of their health status or requirements
for health care services, including expulsion or refusal to re-enroll an
individual, except as permitted by law or under this contract, or engaging in
any practice that would reasonably be expected to have the effect of denying or
discouraging enrollment with the MCO by eligible individuals whose medical
condition or history indicates a need for substantial future medical services;

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d)
Misrepresenting or falsifying information that is furnished to the Secretary,
the DEPARTMENT, Member, potential Member, or a health care provider; and

e)
Distributing directly or through any agent or independent contractor marketing
materials containing false or misleading information.

2.
Class C sanctions for noncompliance with the contract under this subsection
includes the following:

a)
Withholding the next month's capitation payment to the MCO in full or in part;
 

           b) Assessment of liquidated damages:

 
1)
For each determination that the MCO fails to substantially provide medically
necessary services, not more than $25,000;

2)
For each determination that the MCO discriminates among Members on the basis of
their health status or requirements for health care services or engages in any
practice that has the effect of denying or discouraging enrollment with the MCO
by eligible individuals based on their medical condition or history that
indicates a need for substantial future medical services, or the MCO
misrepresents or falsifies information furnished to the Secretary, DEPARTMENT,
Member, potential Member or health care provider, not more than $100,000;

3)
For each determination that the MCO has discriminated among Members or engaged
in any practice that has denied or discouraged enrollment, $15,000 for each
individual not enrolled as a result of the practice up to a total of
$100,000; for a determination that the MCO has imposed premiums or co-payments
on Members in excess of the premiums or co- payments permitted, double the
excess amount. The excess amount charged in such a circumstance must be
deducted from the penalty and returned to the Member concerned;

 
c)
Freeze on new enrollment and/or alter the current enrollment; or

d)
Appointment of temporary management upon a finding by the DEPARTMENT that there
is continued egregious behavior by the MCO or there is a substantial risk to the
health of the Members. After a finding pursuant to this subsection,
Members enrolled with the MCO must be permitted to terminate enrollment without
cause and the MCO shall be responsible for notification of such right to
terminate enrollment. Nothing in this subsection shall preclude the DEPARTMENT
from proceeding under the termination provisions of the contract rather than

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appointing temporary management. If however, the DEPARTMENT chooses not to first
terminate the contract and repeated violations occur, the DEPARTMENT must than
appoint temporary management of the MCO and allow individuals to disenroll
without cause.

3.
Prior to imposition of any Class C sanction, the MCO will be notified at least
thirty (30) days in advance and provided, at a minimum, an opportunity to meet
with the DEPARTMENT to present its position as to the DEPARTMENT'S determination
of a violation warranting a Class C Sanction. For any contract violation under
this subsection, at the DEPARTMENT'S discretion, the MCO may be permitted to
submit a corrective action plan within twenty (20) days of the notice to the MCO
of the violation. Immediate compliance (within thirty (30) days) under any such
corrective action plan may result in the imposition of a lesser sanction on the
MCO. If any sanction issued under this subsection is equivalent to termination
of the contract, the MCO shall be offered a hearing to contest the imposition of
such a sanction.

c.           Other Remedies

1.
Notwithstanding the provisions of this section, failure to provide required
services will place the MCO in default of this contract, and the remedies in
this section are not a substitute for other remedies for default which the
DEPARTMENT may impose as set forth in this contract.

2.
The imposition of any sanction under this section does not preclude the
DEPARTMENT from obtaining any other legal relief to which it may be entitled
pursuant to state or federal law.

9.06         Payment Withhold, Class C Sanctions

a.
The DEPARTMENT may withhold capitation payments from the MCO as provided in
Section 9.05 or terminate the contract for cause. Cause shall include, but not
be limited to:

1.
Use of funds and/or personnel for purposes other than those described in the
HUSKY B program and this contract and

2.
If a civil action or suit if federal or state court involving allegations
of health fraud of violation of 18 U.S.C. Section 1961 et seq is brought on
behalf of the DEPARTMENT.

b.
Whenever the DEPARTMENT determines that the MCO has failed to provide one or
more of the medically necessary contract services required, the DEPARTMENT may
withhold an estimated portion of the MCO's capitation payment in subsequent
months, such withhold to be equal to the amount of money the DEPARTMENT expects
to pay for such services, plus any administrative costs involved. The MCO may
not elect

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to withhold any required services in order to receive adjusted payment levels.
Failure to provide required services will place the MCO in default of this
contract, and the remedies in this section are not a substitute for other
remedies for default which the DEPARTMENT may impose as set forth in this
contract. The MCO shall be given at least seven (7) days written notice prior to
the withholding of any capitation payment.

c.
When it withholds payments under this section, the DEPARTMENT must submit to the
MCO a list of the Members for whom payment is being withheld, the nature of
service(s) denied, and payments the DEPARTMENT must make to provide medically
necessary services. When all payments have been made by the DEPARTMENT for the
MCO contracted services, the DEPARTMENT will reconcile the estimated withhold
against actual payments.

d.
The DEPARTMENT may also adjust payment levels accordingly if the MCO has failed
to maintain or make available any records or reports required under this
contract which the DEPARTMENT needs to determine whether the MCO is providing
required contract services. The MCO will be given at least thirty (30) days
notice prior to taking any action set forth in this paragraph.

9.07        Emergency Services Denials

If the MCO has a pattern of inappropriately denying payments for emergency
services as defined in Part II, Definitions, it may be subject to suspension of
new enrollments, withholding of capitation payments, contract termination, or
refusal to contract in a future time period. This applies not only to cases
where the DEPARTMENT has ordered payment after appeal, but also to cases where
no appeal has been made (i.e., the DEPARTMENT is knowledgeable about documented
abuse from other sources.)

9.08       Termination For Default

a.
The DEPARTMENT may terminate performance of work under this contract in whole,
or in part, whenever the MCO materially defaults in performance of this contract
and fails to cure such default or make progress satisfactory to the DEPARTMENT
toward contract performance within a period of thirty (30) days (or such longer
period as the DEPARTMENT may allow). Such termination shall be referred to
herein as "Termination for Default."

b.
If after notice of termination of the contract for default, it is determined
by the DEPARTMENT or a court that the MCO was not in default, the notice of
termination shall be deemed to have been rescinded and the contract reinstated
for the balance of the term.

c.
In the event the DEPARTMENT terminates the contract in full or in part
as provided in this clause, the DEPARTMENT may procure services similar

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to those terminated, and the MCO shall be liable to the DEPARTMENT for any
excess costs for such similar services for any calendar month for which the MCO
has been paid to provide services to HUSKY B Members. In addition, the MCO shall
be liable to the DEPARTMENT for administrative costs incurred by the DEPARTMENT
in procuring such similar services. Provided, however, that the MCO shall not be
liable for any excess costs or administrative costs if the failure to perform
the contract arises out of causes beyond the control and without error or
negligence of the MCO or any of its subcontractors.

d.
In the event of a termination for default, the MCO shall be
financially responsible for Members in the current month at the applicable
capitation rate.

e.
The rights and remedies of the DEPARTMENT provided in this clause shall not be
exclusive and are in addition to any other rights and remedies provided by law
or under this contract.

f.
In addition to the termination rights under Part I Section 8, the MCO
may terminate this contract on ninety (90) days written notice in the event
that the DEPARTMENT fails to (a) pay capitation claims in accordance with Part
II Section 6.05 and Part III Section 3.01 of this contract (b)
provide eligibility or enrollment/disenrollment information and shall fail to
cure such default or make progress satisfactory to the MCO within a period of
sixty (60) days of such default.

9.09         Termination for Mutual Convenience

The DEPARTMENT and the MCO may terminate this contract at any time if both
parties mutually agree in writing to termination. At least sixty (60) days shall
be allowed. The effective date must be the first day of a month. The MCO shall,
upon such mutual agreement being reached, be paid at the capitation rate for
enrolled Members through the termination of the contract.

9.10         Termination for Financial Instability of the MCO

In the event of financial instability of the MCO, the DEPARTMENT shall have the
right to terminate the contract upon the same terms and conditions as a
Termination for Default.

9.11         Termination for Unavailability of Funds

a.
The DEPARTMENT at its discretion may terminate at any time the whole or any part
of this contract or modify the terms of the contract if federal or state funding
for the contract or for the HUSKY B program as a whole is reduced or terminated
for any reason. Modification of the contract includes, but is not limited to,
reduction of the rates or amounts of consideration, reducing services covered by
the MCO or the alteration of the manner of the performance in order to reduce
expenditures under the

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05 01 07 HUSKY B Final

contract. Whenever possible, the MCO will be given thirty (30) days notification
of termination.

b,
In the event of a reduction in the appropriation from the state or
federal budget for the Division of Health Care Financing of the Department
of Social Services or an across-the-board budget reduction affecting
the Department of Social Services, the DEPARTMENT may either re­ negotiate this
contract or terminate with thirty (30) days' written notice. Any reduction in
the capitation rates that is agreed upon by the parties or any subsequent
termination of this contract by the DEPARTMENT in accordance with this provision
shall only affect capitation payments or portions thereof for covered services
purchased on or after the effective date of any such reduction or termination.
Should the DEPARTMENT elect to renegotiate the contract, the DEPARTMENT will
provide the MCO with those contract modifications, including capitation rate
revisions, it would deem acceptable.

c.
The MCO shall have the right not to extend the contract if the new
contract terms are deemed to be insufficient notwithstanding any other provision
of this contract. The MCO shall have a minimum of sixty (60) days to notify the
DEPARTMENT regarding its desire to accept new terms. If the new capitation rates
and any other contract modifications are not established at least sixty (60)
days prior to the expiration of the initial or extension agreement, the
DEPARTMENT will reimburse the MCO at the higher of the new or current capitation
rates for that period during which the new contract period had commenced and the
MCO's 60-day determination and notification period had not been completed, and
the MCO will be held to the terms of the executed contract.

9.12       Termination for Collusion in Price Determination

a.
In competitive bidding markets, the MCO has previously certified that the prices
presented in its proposal were arrived at independently, without consultation,
communication, or agreement with any other bidder for the purpose of restricting
competition; that, unless otherwise required by law, the prices quoted have not
been knowingly disclosed by the MCO, prior to bid opening, directly or
indirectly to any other bidder or to any competitor; and that no attempt has
been made by the MCO to induce any other person or firm to submit or not to
submit a proposal for the purpose of restricting competition.

b.
In the event that such action is proven, the DEPARTMENT shall have the right to
terminate this contract upon the same terms and conditions as a Termination for
Default.

9.13       Termination Obligations of Contracting Parties

A
The MCO shall be provided the opportunity for a hearing prior to any termination
of this contract pursuant to any provision of this contact. The

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05 01 07 HUSKY B Final

DEPARTMENT may notify Members of the MCO and permit such Members to disenroll
immediately without cause during the hearing process.

b.
Upon contract termination, the MCO shall allow the DEPARTMENT, its agents and
representatives full access to the MCO's facilities and records to arrange the
orderly transfer of the contracted activities. These records include the
information necessary for the reimbursement of any outstanding HUSKY B claims.
 

c.  If this contract is terminated for any reason other than default by the MCO:

 
1.
The MCO shall ensure that an adequate provider network will be maintained at all
times during the transition period and that continuity of care is maintained for
all Members;

2.
The MCO shall submit a written transition plan to the DEPARTMENT sixty (60) days
in advance of the scheduled termination;

3.
The DEPARTMENT shall be responsible for notifying all Members of the date of
termination and process by which the Members will continue to receive services;

4.
The DEPARTMENT shall be responsible for all expenses relating to said
notification;

5.
The MCO shall notify all providers and be responsible for all expenses related
to such notification; and

6.
The DEPARTMENT shall withhold a portion, not to exceed $100,000, of the last
month's capitation payment as a surety bond for a six (6) month period to ensure
compliance under the contract.

9.14     Waiver of Default

Waiver of any default shall not be deemed to be a waiver of any subsequent
default. Waiver of breach of any provision of the contract shall not be deemed
to be a waiver of any other or subsequent breach and shall not be construed to
be a modification of the terms of the contract unless stated to be such in
writing, signed by an authorized representative of the DEPARTMENT, and attached
to the original contract.

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05 01 07 HUSKY B Final

10.       OTHER PROVISIONS

10.01  Severability

If any provision of this procurement or the resultant contract is declared or
found to be illegal, unenforceable, or void, then both parties shall be relieved
of all obligations under that provision. The remainder of this procurement or
the resultant contract shall be enforced to the fullest extent permitted by law.

10.02  Effective Date

This contract is subject to review for form and substance by and will not become
effective until it is approved by the DEPARTMENT.

10.03  Order of Precedence

This contract shall be read together to achieve one harmonious whole. However,
should any irreconcilable conflict arise between Part I and Part II of this
contract, Part II shall prevail.

10.04  Correction of Deficiencies

This contract does not release the MCO from its obligation to correct any and
all outstanding certification deficiencies. Failure to correct all outstanding
material deficiencies may cause the MCO to be determined in Default of this
contract.

10.05  This is not a Public Works Contract

The DEPARTMENT and the MCO as parties to this purchase of service Contract
mutually covenant, acknowledge and agree that this contract does not constitute
and shall not be construed to constitute a public works contract. The DEPARTMENT
and the MCO's mutual agreement that this contract is not a public works contract
shall have full force and effect on Part I Section 32 and other Sections of this
contract as applicable.

108
 

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HUSKY B - APPENDIX A: Covered Benefits
 
Benefit Features
HUSKY Coverage
 
Outpatient Physician Visits
$5 co-pay
*
Preventive Care
No co-pay
Periodic and well child visits, immunizations, WIC evaluations as applicable,
and prenatal care covered in full with $5 co-pay on other visits.
Periodicity schedule and reporting based on the American Academy of Pediatrics
(AAP) as amended from time to time:
Age Category  # of Exams
Birth to Age 1  6 exams
Ages 1-5           6 exams
Ages 6-10         1 exam every 2 years
Ages 11-19       1 exam every year.
Immunization schedule per the Advisory Committee on Immunization Practices
(ACIP), as amended from time to time. As of January 1, 2001, the schedule is as
follows:
Age CategoryVaccine Type
BirthHepatitis B-1st dose
1-4 monthsHepatitis B-2nd dose
2 monthsDiphtheria, Tetanus, Pertussis (DTP) 1st dose; Haemophilus Influenza
Type B (hib)-1st dose; Polio (OVP)-1st dose
4 monthsDiphtheria, Tetanus, Pertussis (DTP) 2nd dose; Haemophilus Influenza
Type B (hib)- 2nd dose; Polio (OVP)- 2nd dose
6 monthsDiphtheria, Tetanus, Pertussis (DTP) 3rd dose; Haemophilus Influenza
Type B (hib)-3rd dose
6-12 monthsHepatitis B-3rd dose; Polio (OVP)-3rd dose
12-15 monthsHaemophilus Influenza Type B (hib)-3rd dose; Measles, Mumps, Rubella
(MMR)-1st dose
12-18 monthsChicken Pox (Var)-single dose; Diphtheria, Tetanus, Pertussis (DTP)
4th dose
4-6 yearsDiphtheria, Tetanus, Pertussis (DTP) 5th dose; Measles, Mumps, Rubella
(MMR)-2nd dose; Polio (OVP)-4th dose
11-12 yearsTetanus Diphtheria (Td)
Influenza: Every year beginning at 6 months for children who have serious
long-term health problems such as heart disease, lung disease, kidney disease,
metabolic disease, diabetes, asthma, anemia, and/or are on long term aspirin
treatment
Pneumococcal: Vaccinate children 2 years and older who are at risk of
pneumococcal disease or its complications
*
Family Planning
100%
Family Planning Services include:
Reproductive health exams;
Patient Counseling;
Patient Education;
Lab tests to detect the presence of conditions affecting reproductive health;
Screening, testing and treatment;
Pre and post-test counseling for sexually transmitted diseases and HIV;
Abortions that are necessary to save the life of the mother or if the pregnancy
resulted from rape or incest or if pregnancy resulted from rape or incest and
other medically necessary abortions as defined in Section 3.14 of the contract.
 
Preventative Family Planning Services
100%
*
Oral Contraceptives
$5 co-pay (included in prescription drugs)
*
Inpatient Physician
100%
*
Inpatient Hospital
100%
 
Outpatient Surgical Facility
100%
 
Ambulance
100% if determined to be an emergency in accordance with state law
 
Pre-Admission /Continued Stay
Arranged through provider.
 
Prescription Drug
$3 co-pay on generics
$5 co-pay on oral contraceptives
$6 co-pay on brand-name formularies
*
Short Term Rehabilitation
100%
For conditions where significant improvement is expected within 60 days
including:
Physical Therapy;
Speech Therapy;
Occupational Therapy; and
Skilled Nursing Care (excludes private duty nursing)
 
Home Health Care
100%
Includes                    Disposable medical supplies for homebound members
Excludes:                      Custodial care, homemaker care or care that may
be provided in a medical office, hospital or skilled nursing facility and
offered to the member is such setting.
 
Hospice
100% provided to members who are diagnosed as having a terminal illness with a
life expectancy of six months or less.  Covered care includes
Nursing care;
Physical therapy, Speech therapy, and Occupational therapy;
Medical social services;
Home health aides and homemakers;
Medical supplies;
Drugs;
Appliances;
DME;
Physician services;
Short-term inpatient care, including respite care and care for pain control and
acute and chronic symptom management; services of volunteers and other benefits
when ordered by a physician.
Limitations on short-term therapies do not apply.
 
Long Term: Rehabilitation; Physical Therapy; Skilled Nursing Care
Not covered under HUSKY B.
Supplemental coverage available under HUSKY Plus Physical for medically eligible
children.
 
Lab and X-Ray
100%
 
Pre-Admission Testing
100%
 
Emergency Care
100% if determined to be an emergency in accordance with state law.  $25 co-pay
if determined a non-emergency. $25 co-pay waived if the patient is admitted.
*
Durable Medical Equipment (DME)
DME means equipment that is furnished by a supplier or home health agency that:
1.can withstand repeated use;
2.is primarily and customarily used to serve a medical purpose;
3.is generally not useful to an individual in the absence of an illness or
injury; and
4.is appropriate for use in the home
100 % covered except DME does not include:
· Power wheelchairs for members who are eligible for HUSKY Plus Physical;
· Devices not medical in natures such as:
· whirlpools,
· saunas,
· elevators,
· vans,
· van lifts,
· home convenience items (e.g., air cleaners, filtration units and related
apparatus, exercise bicycles and other types of exercise equipment),
· insulin injectors,
· non-rigid appliances and supplies, such as, sheets, self-help devices,
experimental or investigational research equipment, and
· items for personal comfort and or usefulness to the member’s household.
Supplemental coverage available under HUSKY Plus Physical for medically eligible
children.
 
Hearing Aids
 
Hearing aids for children twelve years of age or younger, limited to $1,000.00
within a 24-month period.
Supplemental coverage available under HUSKY Plus for medically eligible children
 
Prosthetics
100%
Includes:                      Devices whether worn anatomically or surgically
implanted, which replace all or part of a body organ or structure and which
correct, strengthen or provide necessary support to the body will be covered
when medically necessary.
Excludes:                      Orthopedic shoes, foot orthotics, wigs or
hairpieces.
Supplemental coverage available under HUSKY Plus Physical for medically eligible
children
 
Eye Care
Eye Exams
 
5$ co-pay
*
Hearing Exam
$5 co-pay
*
Nurse Midwives
$5 co-pay (except for preventative services)
*
Nurse Practitioners
$5 co-pay (except for preventative services)
*
Podiatrists
$5 co-pay
*
Chiropractors
$5 co-pay
*
Naturopaths
$5 co-pay
*
Dental
100%
Dental Services include:
Exams, 1 every 6 months;
X-rays,
Fillings;
Fluoride Treatments;
Oral Surgery
*

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

      

Limited Benefits
Benefit Features
HUSKY Coverage
 
Eye Care
Eyeglass frames and lenses or contact lenses
Once every 2 consecutive eligibility periods with an allowance of $100 toward
the purchase of these goods.  The optical hardware must be provided without
charge under the following conditions:
(i)One pair of contact lenses every 2 consecutive eligibility periods when such
lenses are determined to be the primary and the best method for aiding the
member vision and the lenses are not needed solely for the correction of vision;
(ii)Eyeglass frames and lenses and contact lenses that are determined to be
medically necessary after eye surgery, the initial pair only; and
(iii)Contact lenses, as needed, for the treatment of Keratonconus.
 
Dental
Orthodontia
 
$725 allowance per orthodontia case.
 
Bridges or crowns; root canals; full or partial dentures; or extractions
$50 allowance per procedure, per member but no more than an aggregate allowance
for all such procedures of $250 per eligibility period.
 
Contraceptives
Intruterine Devices (IUD) and insertion of the IUD
 
$50 allowance per member
 
*
Internally implantable time-release devices and their insertion
$50 allowance per member
*
Time-released contraceptive injections
$15 allowance per member per injection
*
Nutritional Formulas
100%
Limited to medically necessary amino acid modified preparations and low protein
modified food products for the treatment of inherited metabolic diseases when
ordered by a participating physician
*

Annual co-payments cannot exceed $760/$1350 (Income Band 1/Income Band 2)
including premiums, per year.

`Note: Prior authorization may be required by the MCO unless otherwise noted by
an asterisk (*).  Co-payment not required for preventive services.           

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

 

EXCLUSIONS AND LIMITATIONS
1.
Services and/or procedures considered to be of an unproven, experimental, or
research nature or cosmetic, social, habilitative, vocational, recreational, or
educational.

2.
Services in excess of those deemed medically necessary to treat the patient’s
condition.

3.
Services for a condition that is not medical in nature.

4.
Devices required by third parties, such as school or employment physicals,
physicals for summer camp, enrollment in health, athletic, or similar clubs,
premarital blood work or physicals, or physicals required by insurance companies
or court ordered alcohol or drug abuse course.

5.
Cosmetic and reconstructive surgery is excluded, except when surgery is required
for:

a) 
reconstructive surgery in connection with the treatment of malignant tumors or
other destructive pathology that causes dysfunction;

b) 
reduction mammoplasty in females when Medically Necessary and breast surgery in
males only in cases of suspected malignancy. Surgery must be necessary to
achieve normal physical or bodily function.

6.
Routine foot care rendered:

a)  
in the examination, treatment or removal of all or part of corns, callosities,
hypertrophy or hyperplasia of the skin or subcutaneous tissues of the foot.

b) 
in the cutting, trimming or other non-operative partial removal of toenails,
except when Medically Necessary in the treatment of neuro-circulatory
conditions.

7.
Evaluation, treatment and procedures related to, and performance of, sex-change
operations.

8.
Surgical treatment or hospitalization for the treatment of morbid obesity except
where prior authorized Medically Necessary.

9.
Care, treatment, procedures, services or supplies that are primarily for dietary
control including, but not limited to, any exercise weight reduction programs,
whether formal or informal, and whether or not recommended by an In-network
Physician or Out-of-Network Physician.

10.
Acupuncture, biofeedback, or hypnosis.

11.
Treatment at pain clinics unless determined to be Medically Necessary.

12.
Ambulatory blood pressure monitoring.

13.
Any court order for testing, diagnosis, care, or treatment deemed not Medically
Necessary.

`Note: Prior authorization may be required by the MCO unless otherwise noted by
an asterisk (*).  Co-payment not required for preventive services.           

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

Appendix B
Husky Plus Behavioral - Deleted
 
 

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Appendix C
HUSKY Plus

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

   

HUSKY PLUS
SUPPLEMENTAL INSURANCE COVERAGE
 
On October 29, 1997, the Connecticut legislature authorized the establishment of
the HUSKY, Part B and HUSKY Plus insurance programs to provide health care
coverage for uninsured children pursuant to Title XXI of the Social Security
Act. HUSKY, Part A is the program for children’s coverage under Title XIX of the
Social Security Act. The HUSKY Plus program was originally comprised of two
supplemental health insurance programs to provide services to children whose
intensive medical and/or behavioral health needs cannot be accommodated within
the basic benefit package offered under HUSKY, Part B.  Effective January 1,
2006 the supplemental health insurance program that covered children with
intensive behavioral health needs, HUSKY Plus Behavioral (HPB) was eliminated.
Emergency mobile, case management, and rehabilitative services previously
covered under HPB are now covered under the core HUSKY B benefit package (see
Sec. 6.2 and Appendix 6.1). This appendix only addresses the HUSKY Plus Physical
program, the program designed to provide coverage to children with intensive
physical health needs.  General Features of the HUSKY Plus Physical Program
 
The HUSKY Plus Physical (HPP) Plan is a supplemental benefit package for
children who are eligible for and enrolled in HUSKY, Part B, with household
incomes under 300% of the federal poverty limit (Income bands 1 and 2 only).
Children may not apply for coverage under HUSKY Plus unless they have already
been determined to be eligible under HUSKY, Part B, and have enrolled in HUSKY,
Part B.
Children who are eligible under HPP will be dually eligible. That is, children
who are determined to be eligible under HPP will continue to receive benefits
under HUSKY, Part B, including those physical health services for their special
needs diagnoses or conditions that are covered under Part B.
 
As described below, these services will be coordinated by a case
management/treatment team composed of case managers from both HUSKY, Part B and
one or both of the HUSKY Plus Physical plan, which will maximize the
coordination of benefits under both plans and other sources of coverage through
federal, state and private support. The case management/treatment team will need
to coordinate the development of the Global Plan of Care (GPC) so that services
included do not replicate special education services authorized under an
Individual Education Plan (I.E.P.) or Individualized Family Service Plan
(I.F.S.P.).
In the event that the child is eligible for HUSKY, Part B and HPP, the case
management team leader of HPP will need to coordinate with the HUSKY, Part B
case manager to assure that the HPP GPC’s complements services provided under
HUSKY, Part B.
 
However, ultimate utilization management decisions will rest with the
utilization managers of the plan that is financially at risk; i.e., HUSKY, Part
B utilization managers will have final decision making authority for those
services for which they are at risk and HPP utilization managers will have the
decision making authority for those supplemental services included in their
benefit package.
In the event there is a dispute between the participating HUSKY, Part B managed
care plan and the HPP concerning the responsibility for reimbursement of a
service authorized under the treatment plan, the dispute will be referred to the
Commissioner (or his/her designee) for resolution.
 
Eligible children will be able to receive services under both the basic and one
or both supplemental benefit package simultaneously in order to allow both plans
to provide services to the child to the fullest extent possible in the least
restrictive setting.
 
HPP services may supplement HUSKY, Part B services once a child has exhausted
his or her annual benefit limits under Part B. However, HPP will always be the
payer of last resort. The case management/treatment team will always look to
exhaust all medically necessary coverage benefits under HUSKY, Part B, including
conversion options when appropriate, before these services are supplanted or
replaced by services available under HPP .
 
II.  HUSKY Plus Plan for Children with Special Physical Health Care Needs
 
Program Administration
The HUSKY Plus Plan for Children with Special Physical Health Care Needs (HPP)
will be administered by the Connecticut Children’s Medical Center. The advisory
committee established by the Department of Public Health for Title V of the
Social Security Act will be the Steering Committee for the HPP plan along with
representatives from the Departments of Social Services (DSS) and Children and
Families (DCF). The Steering Committee shall be named the Steering and Advisory
Committee for Children with Special Health Care Needs and HUSKY Plus Physical
(SASH).
 
Eligibility
Children enrolled in HUSKY, Part B, Income Bands 1 and 2, who have intensive
physical health needs that cannot be met within the Part B benefit package will
be eligible for supplemental services under the HPP plan if they meet the
clinical eligibility standard. The clinical eligibility standard is based on
diagnostic and/or acuity criteria and shall be the same as those for the Title V
program currently operating in the state.
Clinical eligibility will be determined:
 
1.  
By documentation of clinical information which meets the “Medical Eligibility
Criteria” of the Department of Public Health Title V Program; or

 
2.  
By meeting the approved definition of Children with Special Health Needs with
documentation of clinical evidence. The definition adopted by the Steering
Committee but subject to change is as follows:

 
 “Children with Special Health Care Needs are those who have or are at elevated
risk for (biologic or acquired) chronic physical or developmental conditions and
who also require health and related (not educational and not recreational)
services of a type and amount not usually required by children of the same age
(beyond Connecticut’s EPSDT periodicity schedule). The age of eligibility is
birth to 18 years, but may include those to age 21 (for those determined
eligible before age 18) for purposes of transition to adult services.” . In
addition, eligibility for HPP will end at age 19, when eligibility for HUSKY,
Part B also ends.
For the purposes of determining acuity of a child who meets the Medical
Eligibility Criteria or who may qualify as a Child with Special Health Care
Needs, the HPP Center will use the Children with Special Health Care Needs
Screening Tool, or others as approved by the Department (See attached).
 
Referral and Application Process
Children who may be at risk may be identified by their parents, their primary
care provider, or another provider in the HUSKY, Part B Plan in which the child
is enrolled. Referral made by made in writing or by telephone by any of the
above parties. However, the application process for HPP will be coordinated by
the HUSKY, Part B Plan.
Children will be assessed for eligibility consistent with the practices and
procedures currently in place under the Title V Program.
 
Covered Services
All children determined eligible for HPP will receive care coordination,
advocacy, family support and case management services as well as comprehensive
multidisciplinary evaluation once a year and up to 3 follow-up visits per year
with members of the multidisciplinary group as needed. In addition, the range of
services will include the following to the extent that they are not covered
under the HUSKY, Part B benefit package:
 
·  
Adaptive Seating, Specialized:   One evaluation, fabrication and completion per
year. Fees are inclusive of one adjustment every 2 weeks until family is
satisfied.

 
·  
Audiometry:  Includes BAER, OAE; two per year.

 
·  
Cast Room:  Cast room visits as necessary to maintain integrity of cast or to
implement treatment plan.

 
·  
Diagnostic Imaging (i.e., MRI, CT):

 
·  
Durable Medical Equipment:   Exclusive of the basic HUSKY B plan and include
items that assist in the activities of daily living

 
·  
EEG/telemetry: Two per year.

 
·  
EKG/Holter:  Two per year.

 
·  
Emergency Care: Exclusive of the basic plan; directly related to condition that
qualifies child for HPP.

 
·  
Gait Analysis: One per year.

 
·  
General Dental, Orthodontic: Only for children who have malocclusive disorders
or periodontal disease resulting from their underlying qualifying condition or
related treatment.

 
·  
Hearing Aids:  One (or one pair) analog hearing aid(s) as prescribed per year;
One (or one pair) digital hearing aid(s) as prescribed every 5 years

 
·  
Home Health Aide:   Total of ten hours/week

 
·  
Laboratory

 
·  
Medical and Surgical Supplies

 
·  
Medical Nutrition Services

 
·  
Medical 23 Hour and Day Surgery

 
·  
Occupational, Physical and Speech Therapies

 
·  
Orthotic Devices:   No more than one a year or one pair per year per prescribed
type, including all delivery fees, fittings and adjustments.

 
·  
Pharmacy: Over the Counter medications will be covered if medically necessary
and directly related to the condition that qualifies the child for the program.
Prior authorization by DSS required.

 
·  
Physician Fees for Inpatient Care: Visits must be requested as consultations by
the admitting physician and be specifically related to the qualifying condition.

 
·  
Physician Fees for Outpatient Care: Covered as per care plan.

 
·  
Prosthetics/Prosthetic Devices: No more than one per year including all delivery
fees, fittings and adjustments/repairs. Excludes myoelectric devices.

 
·  
Pulmonary Function Testing:  One per year.

 
·  
Radiology

 
·  
Skilled Intermittent Nursing:  One visit per day for evaluation, treatment, and
education. Must be provided by a licensed home health agency.

 
·  
Sleep Study/Polysomography:  One per year.

 
·  
Special Nutritional Formulas or Supplements/ PKU Foods: Nutritional habilitative
and/or rehabilitative sustenance of a type or amount not usually required by
children. Prescribed by an authorized professional within acceptable standards
of the American Dietetic Association.

 
· 
Transportation:  2 round trips per year to any health care appointment by
ambulance, chair-vans and/or other licensed medical transportation for
non-emergent visits.

 
·  
Wheelchairs:  One new manual wheelchair no more than every three years. One new
motorized wheelchair no more than every five years.

 
This list may be revised from time to time as recommended by the Steering
Committee and approved by the Department.
 
Service Providers
The Connecticut Children’s Medical Center will serve as the coordinating
organization. but services will be provided by the entities under contract to
provide Title V services.
 
Service Utilization Management
Service utilization will be managed through a clear definition of medical
necessity. “Medical Necessity” or “medically necessary” is defined as health
care provided to correct or diminish the adverse effects of a medical condition
or mental illness; to assist an individual in attaining or maintaining an
optimal level of health; to diagnose a condition; or prevent a medical condition
from occurring.
All services will be subject to prior authorization by the utilization
management staff at the Connecticut Children’s Medical Center. These decisions
will be subject to the process for Grievances and Appeals (see below).
 
Coordination of HPP Services with HUSKY, Part B
In order to ensure that HPP will be the documented payer of last resort, the HPP
Center shall assign each enrollee with a case manager and provide care
coordination services. The HPP case manager shall coordinate with the HUSKY,
Part B case manager to ensure that all medically necessary HPP covered services
identified in the global plan of care (GPC), which are also covered in the
HUSKY, Part B basic benefit package, are exhausted first under HUSKY, Part B.
The HPP Center shall designate a Lead Case Manager who will be responsible for
convening a case management/treatment team that will develop an individualized
GPC for each enrollee. The case management/treatment team may be composed of,
but not limited to, the enrollee or enrollee’s parent(s), treating clinicians
and/or providers, the HUSKY, Part B Case Manager, and the Lead Case Manager. The
case management/treatment team will coordinate the development of the GPC so
that covered services included in the GPC do not replicate special education
services authorized under an I.E.P. or I.F.S.P.
In the event that the enrollee is also eligible for HPB, the case
management/treatment team shall include the case manager from HPB. The case
management/treatment team shall develop a GPC that integrates services from
HUSKY, Part B, HPP and HPB as appropriate.
 
Global Plan of Care (GPC)
HPP will ensure that the case management/treatment team completes the GPC for
each enrollee within 30 days of the date of eligibility determination. The case
management/treatment team on at least a semi-annual basis will reassess the GPC.
The GPC will be based on the comprehensive need assessment, periodic
reassessments, and treatment plans from the HUSKY, Part B Plan and HPP
Contractor providing services to the child. The GPC will include medical
management recommendations reflecting the level of involvement of the HPP staff
and the scope of clinical practice of the clinical staff, estimates of the need
and frequency of specific clinical services and a designation of who is
responsible for the specific elements of the GPC.
 
The GPC will be mailed or faxed to the enrollee’s HUSKY, Part B Plan and to the
child’s primary care physician.  A written copy of the GPC will be kept on file
at HPP, as part of the child’s case file.
 
Program Quality
Both HPP will be reviewed annually by an external quality review organization
(EQRO) pursuant to the goals identified in the Title XXI State Plan. Pursuant to
this review, the Commissioner will submit a report to the Governor and the
General Assembly on the HUSKY Plus Programs which will include an evaluation of
the special health outcome and access measures identified for HUSKY Plus
enrollees.
In addition, the Department will review the HPP Center at least annually. Based
on the EQRO report and the Department review, recommendations for program
quality improvement will be identified. Corrective action plans and quality
improvement projects will be initiated by the Centers in conjunction with the
Department.
 
Grievance and Appeals Process
In accordance with 42 CFR 457 part(s) 1120 – 1180, a HUSKY Plus applicant has
the right to request an administrative review regarding a decision made on their
HUSKY Plus application. Whenever possible, HPP will attempt to resolve
grievances informally. However, parents and providers will be encouraged and
supported in the filing of appeals without fear of compromised service. A copy
of the appeals procedure, written in a manner easily understood by the lay
public, will be distributed to every family at the time of their application to
HPP.
 
The state ensures that all enrollees and applicants receive timely written
notice of any determinations required to be subject to review, as outlined
below.  Written notices at each level include the reasons for the determination,
an explanation of applicable rights to review of that determination, the
standard and expedited time frames for review, the manner in which a review can
be requested, and the circumstances under which enrollment may continue pending
review.  However, the State will not provide an opportunity for review of a
matter if the sole basis for the decision is a provision in this plan or in
federal or State law requiring automatic change in eligibility, enrollment, or a
change in coverage under the health benefits package that affects all applicants
or enrollees or a group of applicants or enrollees without regard to their
individual circumstances.
The following decisions can be appealed through the grievance process:
 
·  
Denial of eligibility for Income Bands One and Two only;

 
·  
Failure to make a determination of eligibility within 21 days of application;

 
·  
Suspension or termination of enrollment in HPP for enrollees enrolled in Income
Band One or Income Band Two of HUSKY B;

 
·  
Delay, denial, reduction, suspension or termination of goods or services,
including determination regarding level of services;

 
·  
Failure to approve, furnish or provide payment for services in a timely manner;

 
·  
Medical necessity of a type of service or setting; and

 
·  
Choice of provider

 
While an appeal regarding suspension or termination of eligibility or enrollment
is being considered, the enrollee will remain eligible for HPP and their goods
and/or services will be continued until the grievance is decided, so long as the
enrollee remains in Income Band 1 and 2. An enrollee who has been enrolled in
Income Band 3 of the HUSKY B program shall be disenrolled from HPP.
While an appeal regarding delay, denial, reduction, suspension or termination of
goods and/or services is being considered, the enrollee will continue to receive
such goods and/or services until the appeal is decided, so long as the child
remains in Income Band 1 or 2.
 
Applicants or enrollees requesting to review their files or other information
relevant to the appeal review will be provided access to their files at a
mutually convenient date and time, but no later than four days prior to the
decision being issued. Additionally, the State will ensure that applicants or
enrollees have opportunities to represent themselves or have representatives of
their choosing in the review process, and to fully participate in the review
process.
The grievance and appeals process will have three levels of appeal: the first to
HPP’s medical director (who was not involved in the prior decision), the second
to a sub-group of the Steering Committee, and the third to the Commissioner.
 
Whenever a decision is made regarding an enrollee’s eligibility, enrollment or
goods and/or services, a letter is sent from the HPP Center to the parent
describing the decision. Letters, which deny, reduce, suspend or terminate
eligibility or enrollment, or goods and/or services (as listed above), will also
include a one page Appeal Form and a copy of the Appeals Procedure Summary. To
begin the appeals process, the parent or provider should complete the Appeals
Form. The form should be mailed or delivered to the HPP Center but must be
received by the Center within 45 days of the date of the letter describing the
decision that is being appealed.
 
Level One Appeal:
The HPP Center will send a letter that acknowledges receipt of the appeal form
to the parent or provider. The letter will identify a HPP staff member as the
Appeals Manager. The Appeals Manager will track the appeal, act as the contact
person for questions and updates, and will attempt to resolve the appeal within
ten days. If the appeal is resolved to the satisfaction of the parent or
provider by the Appeals Manager, a letter will be sent describing the
resolution, and there will be no further action. If the appeal cannot be
resolved at this level, the Appeals Subcommittee will review the appeal.
 
Level Two Appeal:
The Appeals Subcommittee of the Steering and Advisory Committee for Children
with Special Health Care Needs and HUSKY Plus Physical (SASH) for HPP has three
members, one each from:
 
·  
The Department of Social Services (DSS)

 
·  
The Department of Public Health (DPH) and

 
·  
The Connecticut Children’s Medical Center

 
No one directly involved in the decision being appealed will be a member of this
subcommittee. The Appeals Manager is not a member of this subcommittee but will
attend to provide needed information.
A letter will be sent to the parent or provider that gives the time and date of
the Appeals Subcommittee meeting. The meeting will be scheduled to occur within
ten business days of receipt of the written appeal. The parent or provider may
reschedule this meeting, for any reason, once. However, the Appeals Committee
meeting must occur within 25 business days of the receipt of the appeal.
The parent or provider may bring support persons to the Appeals Subcommittee
meeting, including legal counsel, a person with special knowledge or training
with respect to the problems of the enrollee, and one or two individuals for
support.
 
In the Appeals Subcommittee, the Appeals Manager will present the appeal; along
with any documents involved in the initial decision. The Appeals Manager will
also present a summary of the efforts to this point to resolve the appeal. The
parent, provider or accompanying support persons may also present arguments and
documents, which support the appeal. Once all appeal arguments are completed,
the Appeals Subcommittee will either make a decision regarding the appeal, or if
necessary, continue the case until more information is obtained or until
documents are reviewed. The Appeals Subcommittee must render a final decision no
later than 30 days from the date of the Appeals Subcommittee meeting. The
Appeals Subcommittee chairperson will send the parent or provider a letter
describing the Appeal Committee’s decision no later than 30 days from the date
of the Appeals Subcommittee meeting.
 
Level Three Appeal:
If the parent or provider does not agree with the Appeal Subcommittee’s
decision, he/she may continue the appeal process by writing a letter to the
Commissioner of the Department of Social Services (DSS) or designee. In this
case, the parent or provider must send a copy of the original Appeal Form, the
Appeals Subcommittee letter and any other pertinent documents to the
Commissioner or designee within ten business days of the date of the Appeals
Subcommittee letter. The Appeals Manager will continue to help the parent or
provider with this next step. The DSS Commissioner or designee shall make a
determination and provide a written decision to the parent no later than 90 days
from the initial request date.
If the enrollee has been enrolled in the HPP program and is found to be
ineligible for HPP, and this decision is appealed, the enrollee will continue to
be eligible for HPP services so long as the child remains eligible for and
enrolled in HUSKY, Part B, Income Bands 1 and 2, until the appeal process is
completed. Enrollees of HUSKY, Part B who are in Income Band 3 are not eligible
for the HUSKY Plus Program and shall be immediately disenrolled from HPP
 
Expedited Appeal:
Pursuant to 42 CFR 457.1160, the appeal process for HPP must allow for expedited
review. This process applies to both eligibility and enrollment matters as well
as for goods and/or services. If an enrollee requests an expedited review, HPP
must determine within one business day of receipt of the request, whether to
expedite the review or whether to perform the review according to the standard
timeframes. The review may be expedited if the Medical Director of HPP
determines that the standard time frame could seriously jeopardize life or
health or ability to attain, maintain or regain maximum function. If the Medical
Director of HPP determines that the appeal should be expedited, the Level One
review must be completed within 72 hours of receipt of the appeal request by
HPP. A Level Two review of an expedited appeal must be completed within 72 hours
after completion of the Level One review. An expedited Level Three review must
be completed within 72 hours after completion of the Level Two expedited review.
The above timeframe may be extended upon request of the parent up to a maximum
of 14 days.

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Appenndix D
 
Provider Credentialing and Enrollment Requirements

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

        

HUSKY B
PROVIDER CREDENTIALING AND ENROLLMENT REQUIREMENTS
1. Provider Credentialing, and Enrollment Distinction
Provider Credentialing and provider enrollment are separate and distinct
processes in the HUSKY Programs. However, credentialing and enrollment are
linked in that these requirements affect direct service providers as well as the
manner in which MCOs submit provider network information to the Department of
Social Services.
 
2. Credentialing Definition
For the purpose of the HUSKY programs, the term credentialing means the
requirements for provider participation specified in the contracts between the
Department of Social Services (DSS or the Department) and the MCO (Part II,
3.11, Provider Credentialing and Enrollment). In this section of the contract,
the Department specifies the minimum criteria that the MCOs must require for
provider participation in a health plan. The MCOs must ensure that their
providers meet the Department's credentialing requirements.
 
3. Other Sources Credentialing
Credentialing is sometimes used to refer to a variety of requirements or
entities, which issue credentialing standards. Examples include: the MCO's
individual credentialing requirements; the managed care subcontractor's
credentialing requirements; an accreditation organization requirements, such as
the National Committee on Quality Assurance (NCQA); the licensure process; a
trade organization or association such as the Joint Commission on Accreditation
of Health Organizations (JCAHO).
 
4. DSS Requirements and Other Credentialing Sources
DSS credentialing requirements represent the minimum criteria for provider
participation in a health plan. The Department will allow flexibility to the
MCOs to use more stringent criteria, particularly as it concerns quality level
of care for clients. While the MCOs may require additional, more stringent
criteria, the Department is concerned with the impact on access to care.
Therefore, DSS expects the MCOs to balance the need for stringent credentialing
standards with the need to assure accessibility and continuity of care.
 
5. Delegated Credentialing
The contract between the Department and the MCOs permits the plan to delegate
credentialing of individual providers to a facility. However, the MCO is
ultimately responsible and accountable to DSS for compliance with the
Department's credentialing requirements.
For the purpose of HUSKY, delegated credentialing means that the MCO entrusts
the Department's credentialing requirements to another entity. MCOs delegate
credentialing to a variety of entities depending on the nature of the services
and the type of provider.
In delegated credentialing, the MCO remains responsible to DSS to verify and
monitor compliance with the Department's credentialing requirements. The
Department views delegated credentialing as a form of subcontract, therefore,
similar oversight issues arise in the performance of the credentialing
requirements. The Department requires the plans to demonstrate and document to
DSS the plan's strong oversight of its delegated credentialing facilities. (Part
II, Section 3.41 in B 3.44 in A, Subcontracting for Services).
 
6. Implications of Delegated Credentialing
In some instances, the MCO credentials the individual provider directly or
delegates credentialing of the providers to the following entities:
 
·  
A subcontractor providing specific services (e.g., dental care);

 
·  
A credentialing subcontractor; or

 
·  
A facility (e.g., a freestanding clinic or hospital)

The relationship between the MCO and the delegated entity as well as the
interplay with various credentialing requirements may take any number of
configurations. Currently, the Department reiterates that the MCO may delegate
credentialing of individual providers to a facility (e.g., a school based health
center, freestanding clinic or hospital). However, the Department emphasizes
that the MCO is ultimately responsible and accountable to DSS for compliance
with all of the Department's credentialing requirements.
 
7.  Oversight of Delegated Credentialing
The Department requires the MCO to demonstrate strong oversight of their
delegated credentialing facilities, as with any subcontract. - Therefore, the
Department reiterates that these arrangements are subject to the Department's
review and approval. For the purpose of delegated credentialing, the MCOs must
provide assurances to DSS at a minimum of the following:
 
•
The MCO and the delegated entity should clearly identify in detail each party's
responsibility for credentialing of providers.

•
The Department's credentialing requirements should be clearly identified as well
as each party's role in adhering to these requirements.

•
The *credentialing files must be available to the plan in order to perform its
oversight of the credentialing requirements. The Department must also have
adequate access to credentialing files for the purposes of administering the
managed care contracts.

(DSS/MCO HUSKY A Contract, Part II, Section 3.45 “Subcontracting for Services”
and in HUSKY B Section 3.42 “Subcontracting for Services”.)
 
8.  Provider Enrollment Clarifications
For the purpose of HUSKY, the Department refers to provider enrollment as the
process of capturing information on providers participating with MCOs contracted
by DSS to provide services to clients. This process results in a profile of an
MCO's provider network.    The MCOs submit the provider network information to
DSS via the Department's agent on a continuous basis. The Department utilizes
the provider network information to facilitate the administration of managed
care contracts and- the Medicaid program.
 
Provider enrollment information serves the following purposes:
 
a)
To evaluate each MCO's service area and access to services which areused to
establish enrollment ceiling or cap (currently summarized by plan submittals of
provider tables);

b)
To provide accurate infori-nation to clients for the purpose of client
enrollment in an MCO; and

c)
To maintain each plan's provider network information consistent with the
provider directory.

 
Based on the previous discussion of credentialing, the Department clarifies the
relationship between credentialing or delegated credentialing and provider
enrollment as follows:
a)
Enrollment for purposes of cap determination.

 
•
The MCO must credential and enroll individual providers when the providers are
counted towards the member enrollment ceiling.

 
•
DSS credentialing requirements and provider enrollment processes also apply to
individual providers in a facility when the individual provider is included in
the count for cap determination.

 
•
The MCO may delegate credentialing of individual providers to a facility (e.g.,
a clinic or hospital) and enroll the facility as such. In this case, -neither
the facility nor the individual providers are provided in the count for cap
determination.

b)           Enrollment for purposes of accurate information to clients
·  
The MCO must enroll and credential individual providers as well as facilities in
order to maintain accurate and updated information on the providers
participating with a health plan. The provider network information is used by
the Department's enrollment broker during enrollment.

·  
The Department stresses the importance of maintaining provider network
information accurate and up-to-date. It is crucial that clients should have
access to provider network information during the MCO select-ion process.

c)           Enrollment for purposes of inclusion in the provider network
directory.
 
•
The MCO must credential and enroll individual providers when the providers are
included and listed as individual providers in the health plan's provider
directory.

 
•
DSS credentialing requirements and provider enrollment processes also apply to
individual providers in a facility when the individual provider is included and
listed in the provider directory.

 
•
If the 14CO delegates credeintialing of individual providers to a       facility
and enrolls the facility, the facility is included and listed in the provider
directory. The facility's individual providers are listed in the provider
directory. The facility's providers are not listed in the provider directory.

 
9.  
Specific Issues and DSS Credentialing Requirements

 
a)
Medicaid participation

The MCO or the delegated credentialing entity is responsible for the
determination and verification that the provider meets the minimum requirements
for Medicaid participation. The MCO or its -subcontractors may not delegate this
provision to the Department nor require providers to enroll or participate in
fee-for-service Medicaid to fulfill the requirement. While the Department
encourages the MCO to contract with traditional and existing Medicaid providers,
Medicaid participation in itself is not a requirement of the HUSKY contracts.
 
b)
Allied Health Professional Licensed Clinics or Hospitals

The Department pays freestanding clinics participating in the Medicaid program
for a variety of services. In Connecticut, clinic services include for example,
medical services, well-child care, dental care, mental health and substance
abuse services, rehabilitation services and other services. Clinic providers
must meet federal and state requirements for participation in the Medicaid
program. In accordance with Title 42 of the Code of Federal Regulations, Part
440.90 and Section 171 of the Medical Services Policy of the Connecticut Medical
Assistance Program, clinic services are provided by or under the direction or a
physician, dentist or psychiatrist.
 
The physician direction requirement means that the free-standing clinic's
services may be provided by the clinic's allied health professionals whether or
not the physician is physically present at the time that the services are
provided. An allied health professional is further defined as an individual,
employed in a clinic, who is qualified by special education and training,
skills, and experience in providing care and treatment. The clinic is staffed by
physicians and allied health professionals who are directly involved in the
facility's programs. The allied health professionals provide services under the
direction of a physician who is a licensed practitioner performing within the
scope of his/her practice.
 
Based on the Department's definition of clinic services, the services provided
by allied health professionals are included under the terms of the contracts
between the Department and the MCOs.
As with all services, clinic services must be properly credentialed according to
the Department's requirements, including licensure and certification standards.
Allied health professionals may have licensure or certification requirements,
such as Certified Addition Counselors or Licensed Social Workers. In accordance
with the Department's definition, other allied health professions may qualify by
virtue of their skills or experience and must function under the direction of a
physician. In this case- the directing physician, as opposed to the allied
health professional, is subject to the credentialing requirements as well as
provider enrollment. The MCO may credential the physician directly or may
delegate credentialing.
 
The Department's provisions for credentialing, delegated and provider enrollment
would remain in effect for the directing physician (please refer to Section 8,
Provider Enrollment Clarifications).
 
c)
NCQA Standards and DSS requirements

 
While NCQA standards do not address credentialing of allied health
professionals, services provided by allied health professionals may qualify for
reimbursement by virtue of their skills or experience, however, the allied
health professionals must function under the direction of a physician. In this
case, the directing physician is subject to the credentialing requirements.

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Appendix E
 
American Academy of Pediatrics - Recommendations for Preventive Pediatric Health
Care

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[huskyapediatrichealthcare.jpg]

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Appendix F
 
DSS Marketing Guidelines

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Appendix F
 
Detailed Marketing Guidelines
1)  General HUSKY marketing materials
 
Marketing materials are defined as all media, including brochures and leaflets;
newspaper, magazine, radio, television, billboard and yellow pages
advertisements; and presentation materials used by MCO representatives.
The DEPARTMENT will not restrict the MCO's general communications to the public.
However, the MCO must obtain prior approval from the DEPARTMENT prior to any
written material or advertisement that is mailed to, distributed to, or aimed at
HUSKY recipients or individuals potentially eligible for HUSKY, specifically,
material that mentions Medicaid, Medical Assistance, Title XIX, Title XXI State
Children's Health Insurance Program (SCHIP) or HUSKY. Examples of HUSKY-specific
materials would be those which are in any way targeted to HUSKY populations
(such as billboards or bus posters disproportionately located in low-income
neighborhoods); those that mention the MCO's HUSKY product name; or those that
contain language or information specifically designed to attract HUSKY
enrollment.
 
2)  General MCO marketing/advertising
All MCO-specific marketing activities for the HUSKY population, as defined
above, and all marketing materials /advertising put forth by HUSKY-only MCO
require DEPARTMENT prior approval.
In determining whether to approve a particular marketing activity, the
DEPARTMENT will apply a variety of criteria, including, but not limited to:
 
a)
Accuracy: The content of the material must be accurate. Any information that is
deemed inaccurate will be disallowed.

b)
Misleading references to the MCO's positive attributes: Misleading information
will be disallowed even if it is accurate. For example, the MCO may seek to
advertise that its health care services are free to its Medicaid (HUSKY A)
Members. In this situation, DEPARTMENT would disallow the language since this
could be construed by Members as being a particular advantage of the plan (e.g.
they might believe they would have to pay for health services if they chose
another MCO or remained in fee-for-service).

c)
Threatening Messages: MCOs shall not imply that the managed care program or the
failure to join a particular MCO would endanger the Member's health status,
personal dignity, or the opportunity to succeed in various aspects of their
lives. MCOs are strictly prohibited from creating threatening implications about
the State's mandatory assignment process for HUSKY A Members or other aspects of
the HUSKY A or HUSKY B programs.

d)
MCO's Legitimate Strengths: MCOs may differentiate themselves by promoting their
legitimate positive attributes.

 
3) MCO advertising at provider care sites
Promotional and health education materials at care delivery sites (including
patient waiting areas) are permitted, subject to prior DEPARTMENT content
approval. MCO member services staff may provide member services (e.g.
face-to-face member education) at provider care sites, however, face-to-face
meetings, for purposes of marketing, at care delivery sites between individual
Members and MCO staff are not permitted.
 
4)  MCO advertising in DEPARTMENT eligibility offices
 
MCOs may make their materials available at DEPARTMENT offices only through the
DEPARTMENT or its agent. This restriction applies to all eligibility offices,
including those based in hospitals. MCO marketing staff and provider staff are
not permitted to solicit Member enrollment by positioning themselves at or near
eligibility offices. Note that the only face-to-face marketing activities
allowed are those directly permitted under items #5, #7, #11 and #12 of these
guidelines. All other face-to-face marketing activities are prohibited.
 
5) Provider communications with HUSKY patients about MCO options
 
DEPARTMENT marketing restrictions apply to the MCO's participating providers as
well as to the MCOs. MCOs must notify all of their participating providers of
the DEPARTMENT marketing restrictions and provide them with a copy of this
document.
 
Each provider entity is allowed to notify its patients of the HUSKY-certified
MCOs it participates in, and to explain that the patients must enroll in one of
these MCOs if they wish to preserve their existing relationship. This must be
done through written materials prior-approved by DEPARTMENT, and must be
distributed to HUSKY patients without regard to health status. Providers must
not indicate a preference between the MCOs in which they participate.
 
6) Member-initiated telephone conversations with MCOS and providers
 
These conversations are permitted and do not require prior approval by the
DEPARTMENT, but information given to potential Members, during such telephone
conversation must be in accordance with the DEPARTMENT's marketing guidelines.
However, telephone conversations must be initiated by the potential Member, not
by the MCO staff (or provider staff). MCOs and providers may return calls to
Members and potential Members when Members and potential Members leave a message
requesting that this occur.
 
7)  Member-initiated one-on-one meetings with MCO staff prior to enrollment
Such meetings, when requested by the Member, are permitted but may not occur at
a participating provider's care delivery site or at the Member's residence.
These meetings must occur at the MCO's offices or another mutually-agreed upon
public location. All verbal interaction with the Member must be in compliance
with the DEPARTMENT's marketing guidelines.
 
8) Mailings by MCO in response to Member requests
 
MCO mailings are permitted in response to Member verbal or written requests for
information. The content of such mailings must be prior-approved by the
DEPARTMENT. MCOs may include gifts of nominal value (unit cost less than $2,
e.g. magnets, pens, bags, jar grippers, etc.) in these mailings.
 
9) Unsolicited MCO mailings
 
MCOs are permitted to send unsolicited mailings. The content of such mailings
must be prior-approved by DEPARTMENT. In addition, the target audiences must be
prior-approved by DEPARTMENT, and the MCOs must explain how they obtained the
list of names, addresses and phone numbers.
 
10)  Telemarketing
 
Telemarketing is not a permitted marketing activity
 
11) MCO group meetings held at MCO
 
These meetings must be prior approved by the DEPARTMENT. The MCO may not notify
prospective Members until DEPARTMENT prior approval has been obtained
 
12) MCO group meetings held in public facilities, churches, health fairs, or
other community sites
 
These are permitted activities as long as DEPARTMENT approved materials are
utilized in the presentations and the DEPARTMENT's marketing guidelines are
followed. The DEPARTMENT reserves the right to monitor such meetings on an ad
hoc basis. MCOs are required to notify the DEPARTMENT sufficiently in advance to
allow DEPARTMENT representatives to attend such meetings in order to monitor MCO
activities if desired. As soon as the MCO has scheduled these activities, the
DEPARTMENT should be notified.
 
13)  MCO group meetings held in private clubs or homes
 
These activities are prohibited. The only permitted group meetings are those
described under items #11 and #12.
 
14)   Individual solicitation, residences
 
MCO (and provider) staff are not permitted to visit potential Members at their
places of residence for purposes of explaining MCO features and promoting
enrollment. This prohibition is absolute, and applies even in situations where
the potential Member desires and/or requests a home visit. MCO staff can visit
Member homes after enrollment becomes effective, as part of their
orientation/education efforts.
 
15) Gifts, cash incentives, or rebates to potential Members and members.
 
MCOs (and their providers) are prohibited from disseminating gift items, except
those of a nominal value (pens, key chains, magnets, etc.), to potential
Members. DEPARTMENT-approved written materials may also be disseminated to
prospective Members along with similar nominal value gifts. MCOs may give items
of nominal value (unit cost less than $2), with their logo on it, to persons
(potential Members and others) attending health fairs, presentations at
community forums organized through or other sanctioned events, with DEPARTMENT
approval. Such items would include magnets, pens, bags, plastic band-aid
dispensers, etc. Pre-approved nominal value items may also be included with new
Member information packets.
 
16)  Gifts to Members for specific health-related events
 
Gifts to Members are allowed for medically "good" behavior (e.g. baby T-shirt
showing immunization schedule once a woman completes targeted series of prenatal
visits). All such gifts, including any written materials included with them (or
on them), must be prior-approved by the DEPARTMENT. The criteria for providing
such gifts must also be prior-approved by DEPARTMENT. MCOs must not provide
gifts in any situations other than those that have been prior-approved by
DEPARTMENT. Additional DEPARTMENT prior approval is required for all additional
uses of the gift items or for new gifts.
 
The DEPARTMENT may approve magnets, phone labels, and other nominal items that
reinforce a MCO's care coordination programs (e.g. through advertising the
Member Services hotline and/or the PCP office phone number). All such items must
be prior-approved by the DEPARTMENT. The criteria for disseminating this
information must also be prior-approved, although the DEPARTMENT is likely to be
amenable to the MCOs' inclusion of this information in "welcome" packets sent to
new Members.
 
Health education videos are also allowed, but must be prior-approved by
DEPARTMENT.
 
17)           Phoning by Members from health care provider locations
 
Providers may provide the use of a phone to potential HUSKY Members or HUSKY
Members subject to the following restrictions:
 
a)
MCO or provider staff may not coach or instruct the caller;

b)
Privacy must be given to the MEMBER during their phone conversation with the
HUSKY application and enrollment center.

 
18)
Non-alcoholic beverages and light refreshments for potential Members at meetings

Non-alcoholic beverages and light refreshments are permitted at DEPARTMENT
approved group meetings.
 
19.
Use of HUSKY Name; HUSKY Logo and Mandatory Language Requirements

 
MCOs will be allowed use of the HUSKY logo and name for use in their marketing
materials, subject to the following:
a)
must be used in conjunction with the following language unless alternative
language has been prior approved by the DEPARTMENT.
 
HUSKY gives families the freedom of choice to enroll in one of several
participating health plans. Toll-free information: 1-877-CT-HUSKY;

b)
the above mandatory language must be placed in the vicinity of the HUSKY logo;
and

c)
the font size for the HUSKY phone number cannot be smaller than the MCOs member
services phone number.

 
Type of Marketing Activity
Permitted
Not Permitted
Permitted With DEPARTMENT Approval
1
General HUSKY marketing materials
   
X
2
General, MCO advertising/marketing
   
X
3
MCO advertising in provider care sites
   
X
4
MCO advertising in all DEPARTMENT- eligibility offices, including hospital-based
(Must be made available only through the DEPARTMENT or its agent)
   
X
5
Provider communications with Medicaid patients about MCO options
   
X
6
Member-initiated telephone conversations with MCO and Provider staff
X
   
7
Member-initiated one-on-one meetings with MCO staff prior to enrollment
X
   
8
Mailings by MCO in response to Member requests
   
X
9
Unsolicited MCO mailings to Members
   
X
10
Telemarketing
 
X
 
11
MCO group meetings, held at MCO
   
X
12
MCO group meetings held in public facilities such as churches, health fairs, WIC
program or other community sites
   
X
13
MCO group meetings held in private clubs or homes
 
X
 
14
Individual solicitation at residences
 
X
 
15
Items of nominal value along with written information about the MCO or general
health education information to potential Members (given at such places as
health fairs, community forums or other events approved by the Department) or
included in new Member information packets.
   
X
16
Gifts to Members (e.g. baby T-shirt showing immunization schedule) based on
specific health events unrelated to enrollment
   
X
17
Phoning by Members from health care provider locations
X
   
18
Non-alcoholic beverages and light refreshments (e.g. fruit, cookies) for
potential Members at meetings (may not mention refreshments in advertisements
for meetings)
X
   

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

Appendix G
 
Standards for Internal Quality Assurance Programs for Health Plans
 

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

 
STANDARDS FOR INTERNAL QUALITY ASSURANCE PROGRAMS FOR HEALTH PLANS
 
Standard I:
Written QAP Description

 
The organization has a written description of its Quality Assurance Program
(QAP).  This written description meets the following criteria:
A.
Goals and objectives - There is a written description of the QA program with
detailed goals and annually developed objectives that outline the program
structure and design and include a timetable for implementation and
accomplishment.

B.           Scope
 
1.
The scope of the QAP is comprehensive, addressing both the quality of clinical
care and quality of non-clinical aspects of services, such as and including:
availability, accessibility, coordination, and continuity of care.

 
2.
The QAP methodology provides for review of the entire range of care provided by
the organization, by assuring that all demographic groups, care settings (e.g.
inpatient, ambulatory, [including care provided in private practice offices] and
home care), and types of services (e.g. preventive, primary, specialty care and
ancillary) are included in the scope of the review.  This review should be
carried out over multiple review periods and not on just a concurrent basis.

C.
Specific activities - The written description specifies quality of care studies
and other activities to be undertaken over a prescribed period of time, and
methodologies and organizational arrangements to be used to accomplish
them.  Individuals responsible for the studies and other activities are clearly
identified and are appropriate.

D.
Continuous activity - The written description provides for continuous
performance of the activities, including tracking of issues over time.

E.   Provider review - The QAP provides:

        
 
1.
Review by physicians and other health professionals of the process followed in
the provision of health services;

 
2.
Feedback to health professionals and health plan staff regarding performance and
patient results.

F.
Focus on health outcomes - The QAP methodology addresses health outcomes to the
extent consistent with existing technology.

Standard II:
Systematic Process of Quality Assessment and Improvement

 
The QAP objectively and systematically monitors and evaluates the quality and
appropriateness of care and service provided members, through quality of care
studies and related activities, and pursues opportunities for improvement on an
ongoing basis.
 
A.
Specification of clinical or health services delivery areas to be monitored

 
1.
Monitoring and evaluation of clinical issues reflects the population served by
the health plan, in terms of age groups, disease categories, and special risk
status.

 
2.
For the Medicaid population, the QAP monitors and evaluates at a minimum, care
and services in certain priority areas of concern selected by the State.  It is
recommended that these be taken from among those identified by the Health
Care Financing Administration's (HCFA's) Medicaid Bureau and jointly determined
by the State and the Managed Care Organization (MCO).

 
3.
At its discretion and/or as required by the State Medicaid agency, the MCO's QAP
also monitors and evaluates other aspects of care and service.

 
B.           Use of quality indicators
Quality indicators are measurable variables relating to a specified clinical or
health services delivery area, which are reviewed over a period of time to
monitor the process of outcomes of care delivered in that area.
 
1.
The MCO identifies and uses quality indicators that are measurable, objective,
and based on current knowledge and clinical experiences.

 
2.
For the priority area selected by the State from the HCFA Medicaid Bureau's list
of priority clinical and health service delivery areas of concern, the MCO
monitors and evaluates quality of care through studies, which include, but are
not limited to, the quality indicators also specified by the HCFA Medicaid
Bureau.

 
3.
Methods and frequency of data collection are appropriate and sufficient to
detect need for program change.

 
C.           Use of clinical care standards/practice guidelines
 
1.
The QAP studies and other activities monitor quality of care against clinical
care or health services delivery standards or practice guidelines specified for
each area identified.

 
2.
The clinical standards/practice guidelines are based on reasonable scientific
evidence and are developed or reviewed by plan providers.

 
3.
The clinical standards/practice guidelines focus on the process and outcomes of
health care delivery, as well as access to care.

 
4.
A mechanism is in place for continuously updating the standards/practice
guidelines.

 
5.
The clinical standards/practice guidelines shall be included in provider manuals
developed for use by  HMO providers or otherwise disseminated to the providers
as they are adopted.

 
6.
The clinical standards/practice guidelines address preventive health services.

 
7.
The clinical standards/practice guidelines are developed for the full spectrum
of populations enrolled in the plan.

 
8.
The QAP shall use these clinical standards/practice guidelines to evaluate the
quality of care provided by the MCO's providers, whether the providers are
organized in groups, as individuals, as IPAs, or in a combination thereof.

 
D.
 
Analysis of clinical care and related services

 
1.
Appropriate clinicians monitor and evaluate quality through review of individual
cases where there are questions about care and through studies analyzing
patterns of clinical care and related service.  For quality issues identified in
the QAP's targeted clinical areas, the analysis includes the identified quality
indicators and uses clinical care standards or practice guidelines.

 
2.
Mulitdisciplinary teams are used, where indicated, to analyze and address system
issues.

 
3.
For the D.1. and D.2. above, clinical and related services requiring improvement
are identified.
 

 E.     Implementation of remedial/corrective actions

    The QAP includes written procedures for taking appropriate remedial action
whenever, as determined under the QAP, inappropriate or substandard services are
furnished, or services that should have been furnished were not.
These written remedial/corrective action procedures include:

         
 
1.
Specification of the types of problems requiring remedial/corrective action.

 
2.
Specification of the person(s) or body responsible for making the final
determinations regarding quality problems.

 
3.
Specific actions to be taken.

 
4.
Provision of feedback to appropriate health professionals, providers and  staff.

 
5.
The schedule and accountability for implementing corrective actions.

 
6.
The approach to modify the corrective action if improvements do not occur.

 
7.
Procedures for terminating the affiliation with the physician, or other health
professional or provider.
 

F.
Assessment of effectiveness of corrective actions

 
1.
As actions are taken to improve care, there is monitoring and evaluation of
corrective actions to assure that appropriate changes have been made.  In
addition, changes in practice patterns are tracked.
 

 
2.
The MCO assures follow-up on identified issues to ensure that actions for
improvement have been effective.
 
 

G.
Evaluation of continuity and effectiveness of the QAP

 
1.
The MCO conducts a regular and periodic examination of the scope and content of
the QAP to ensure that it covers all types of services in all settings, as
specified in standard I-B-2.
 
 

 
2.
At the end of each year, a written report on the QAP is prepared which
addresses: QA studies and other activities completed, trending of clinical and
services indicators and other performance data; demonstrated improvements in
quality; areas of deficiency and recommendations for corrective action; and an
evaluation of the overall effectiveness of the QAP

 
3.
There is evidence that QA activities have contributed to significant
improvements in the care and services delivered to members.

 
Standard III:
Accountability to the Governing Body

 
The QA committee is accountable to the governing body of the managed care
organization.  The governing body should be the board of directors, or a
committee of senior management may be designated in instances in which the
board's participation with QA issues is not direct.  There is evidence of a
formally designated structure, accountability at the highest levels of the
organization, and ongoing and/or continuous oversight of the QA
program.  Responsibilities of the Governing Board for monitoring, evaluating,
and making improvements to care include:
 
A.
Oversight of the  QAP - There is documentation that the governing body has
approved the overall QAP and  the annual QAP.

B.
Oversight of entity - The Governing Body has formally designated an accountable
entity or entities within the organization to provide oversight of QA, or has
formally decided to provide such oversight as a committee of the whole.

C.
QAP progress reports - The Governing body routinely receives written reports
from the QAP describing actions taken, progress in meeting QA objectives, and
improvements made.

D.
Annual QAP review - The Governing Body formally reviews on a periodic basis (but
no less frequently than annually) a written report on the QAP which includes:
studies undertaken, results, subsequent actions, and aggregate data on
utilization and quality of services rendered, to assess the QAP's continuity,
effectiveness and current acceptability.

E.
Program modification - Upon receipt of regular written reports from the QAP
delineating actions taken and improvements made, the Governing Body takes
actions when appropriate and directs that the operational QAP be modified on an
ongoing basis to accommodate review findings and issues of concern within the
MCO.  Minutes of the meetings of the Governing Board demonstrate that the Board
has directed and followed up on necessary actions pertaining to QA.

 
Standard IV:
Active QA Committee

 
The QAP delineates an identifiable structure responsible for performing QA
functions within the MCO.  The committee or other structure has:
 
A.
Regular meetings - The structure/committee meets on a regular basis with
specified frequency to oversee QAP activities.  This frequency is sufficient to
demonstrate that the structure/committee is following up on all findings and
required actions, but in no case are such meetings less frequent than quarterly.

B.
Established parameters for operating -The role, structure and function of the
structure/committee are specified.

C.
Documentation - There are contemporaneous records documenting the
structure's/committee's activities, findings, recommendations and actions.

D.
Accountability - The QAP committee is accountable to the Governing Body and
reports to it (or its designee) on a scheduled basis on activities, findings,
recommendations and actions.

E.
Membership - There is active participation in the QA committee from health plan
providers, who are representative of the composition of the health plan's
providers.

 
Standard V:
QAP Supervision

 
There is a designated senior executive who is responsible for program
implementation. The organization's Medical Director has substantial involvement
in QA activities.
 
Standard VI:
Adequate Resources

 
The QAP has sufficient material resources, and staff with the necessary
education, experience, or training; to effectively carry out its specified
activities.
 
Standard VII:
Provider Participation in the QAP

A.
Participating physicians and other providers are kept informed about the written
QA plan.

B.
The MCO includes in all its provider contracts and employment agreements, for
both physicians and nonphysician providers, a requirement securing cooperation
with the QAP.

C.
Contracts specify that hospitals, physicians, and other contractors will allow
the MCO access to the medical records of their members.

 
Standard VIII:
Delegation of QAP Activities

The MCO remains accountable for all QAP functions, even if certain functions are
delegated to other entities.  If the MCO delegates any QA activities to
contractors.
A.
There is a written description of delegated activities; the delegate's
accountability for these activities; and the frequency of reporting to the MCO.

B.
The MCO has written procedures for monitoring the implementation of the
delegated functions and for verifying the actual quality of care being provided.

C.
There is evidence of continuous and ongoing evaluation of delegated activities,
including approval of quality improvement plans and regular specified reports.

 
Standard IX:
Enrollee Rights and Responsibilities

The MCO demonstrates a commitment to treating members in a manner that
acknowledges their rights and responsibilities.
 
           

 A.    Written policy on enrollee rights

    The MCO has a written policy that recognizes the following rights of
members:
 

 
1.
To be treated with respect, and recognition of their dignity and need for
privacy;

 
2.
To be provided with information about the MCO, its services, the practitioners
providing care, and members' rights and responsibilities;

 
3.
To be able to choose primary care practitioners, within the limits of the plan
network, including the right to refuse care from specific practitioners;

 
4.
To participate in decision-making regarding their health care;

 
5.
To voice grievances about the MCO or care provided;

 
6.
To formulate advance directives; and

 
7.
To have access to his/her medical records on accordance with applicable Federal
and State laws.
 

B.
Written policy enrollee responsibilities - The MCO has a written policy that
addresses members' responsibility for cooperating with those providing health
care services. This written policy addresses members' responsibility for:

 
1.
Providing, to the extent possible, information needed by professional staff in
caring for the member; and

 
2.
Following instructions and guidelines given by those providing health care
services.
 

C.
Communication of policies to providers - A copy of the organization's policies
on members' rights and responsibilities is provided to all participating
providers.
 

D.
Communication of policies to enrollees/members - Upon enrollment, members are
provided a written statement that includes information on the following:

 
1.
Rights and responsibilities of members;

 
2.
Benefits and services included and excluded as a condition of memberships, and
how to obtain them, including a description of:

 
a.
Any special benefit provisions (example, co-payment, higher deductibles,
rejection of claim) that may apply to service obtained outside the system; and

 
b.
The procedures for obtaining out-of-area coverage;

 
3.
Provisions for after-hours and emergency coverage;

 
4.
The organization's policy on referrals for specialty care;

 
5.
Charges to members, if applicable, including:

 
a.
Policy on payment of charges; and

 
b.
Co-payment and fees for which the member is responsible.

 
6.
Procedures for notifying those members affected by the termination or change in
any benefit services, or service delivery office/site;

 
7.
Procedures for appealing decisions adversely affecting the members' coverage,
benefits, or relationship with the organization;

 
8.
Procedures for changing practitioners;

 
9.
Procedures for disenrollment; and

 
10.
Procedures for voicing complaints and/or grievances and for recommending changes
in policies and services.
 

E.
Enrollee/member grievance procedures - The organization has a system(s) linked
to the QAP, for resolving members' complaints and formal grievances. This system
includes:

 
1.
Procedures for registering and responding to complaints and grievances in a
timely fashion (organizations should establish and monitor standards for
timeliness);
 

 
2.
Documentation of the substance of the complaint or grievances, and actions
taken;

 
3.
Procedures to ensure a resolution of the compliant or grievance;

 
4.
Aggregation and analysis of complaint and grievance data and use of the data for
quality improvement; and

 
5.
An appeal process for grievances.
 

F.
Enrollee/member suggestions - Opportunity is provided for members to offer
suggestions for changes in policies and procedures.
 

G.
Steps to assure accessibility of services - The MCO takes steps to promote
accessibility of services offered to members. These steps include:

 
1.
The points of access to primary care, specialty care and hospital services are
identified for members;

 
2.
At a minimum, members are given information about:

 
a.
How to obtain services during regularly hours of operation

 
b.
How to obtain emergency and after-hours care; and

 
c.
How to obtain the names, qualifications, and titles of the professionals
providing and/or responsible for their care.
 

H.
Written information for members

 
1.
Member information is written in prose that is readable and easily understood;
and

 
2.
Written information is available, as needed, in the languages of the major
population groups served.  A "major" population group is one which represents at
least 10% of plan's membership.
 

I.
Confidentiality of patient information - The MCO acts to ensure that the
confidentiality of the specified patient information and records is protected.

 
1.
The MCO has established in writing, and enforced, policies and procedures on
confidentiality of medical records.

 
2.
The MCO ensures that patient care offices/sites have implemented mechanisms that
guard against the unauthorized or inadvertent disclosure of confidential
information to persons outside of the medical care organization.

 
3.
The MCO shall hold confidential information obtained by its personnel about
enrollees related to their examination, care and treatment and shall not divulge
it without the enrollee's authorization, unless:

 
a.
it is required by law;

 
b.
it is necessary to coordinate the patient's care with physicians, hospitals, or
other health care entities, or to coordinate insurance or other matters
pertaining to payment; or

 
c.
it is necessary in compelling circumstances to protect the health or safety of
an individual.

 
4.
Any release of information in response to a court order is reported to the
patient in a timely manner; and

 
5.
Enrollee records may be disclosed, whether or not authorized by the enrollee, to
qualified personnel for the purpose of conducting scientific research, but these
personnel may not identify, directly or indirectly, any individual enrollee in
any report of the research or otherwise disclose participant identity in any
manner.
 

J.
Treatment of minors - The MCO has written policies regarding the appropriate
treatment of minors.
 

K.
Assessment of member satisfaction - The MCO conducts periodic surveys of member
satisfaction with its services.

 
1.
The surveys include content on perceived problems in the quality, accessibility
and availability of care.

 
2.
The surveys assess at least a sample of:

 
a.
All Medicaid members;

 
b.
Medicaid member requests to change practitioners and/or facilities; and

 
c.
Disenrollment by Medicaid members.

 
3.
As a results of the surveys, the organization:

 
a.
Identifies and investigates sources of dissatisfaction;

 
b.
Outlines action steps to follow-up on the findings; and

 
c.
Informs practitioners and providers of assessment results.

 
4.
The MCO reevaluates the effects of the above activities.

 
Standard X:
Standards for Availability and Accessibility

The MCO has established standards for access (e.g. to routine, urgent and
emergency care; telephone appointments; advice; and member service
lines).  Performance on these on these dimensions of access are assessed against
the standards.
 
Standard XI:
Medical Records Standards

A.
Accessibility and availability of medical records - The MCO shall include
provision in provider contracts for appropriate access to the medical records of
its enrollees for purposes of quality reviews conducted by the Secretary, State
Medicaid agencies, or agents thereof.
 

B.
Record keeping - Medical records may be on paper or electronic. The plan takes
steps to promote maintenance of medical records in a legible, current, detailed,
organized and comprehensive manner that permits effective patient care and
quality review as follows:
 

 
1.
Medical records standards- The MCO sets standards for medical records. The
records reflect all aspects of patient care, including ancillary services. These
standards shall at a minimum, include requirements for:

 
a.
Patient identification information - Each page or electronic file in the record
contains the patient's name or patient ID number.

 
b.
Personal/biographical data - Personal/biographical data includes: age, sex,
address; employer; home and work telephone numbers; and martial status.

 
c.
Entry date - All entries are dated.

 
d.
Provider identification - All entries are identified as to author.

 
e.
Legibility - The record is legible to someone other than the writer.  Any record
judged illegible by one physician reviewer should be evaluated by a second
reviewer.

 
f.
Allergies - Medication allergies and adverse reactions are prominently noted on
the record.  Absence of allergies (no known allergies-NKA) is noted in an easily
recognizable location.

 
g.
Past medical history - (for patients seen 3 or more times) Past medical history
is easily identified including serious accidents, operations, illnesses.  For
children, past medical history relates to prenatal care and birth.

 
h.
Immunizations- For pediatric records (ages 12 and under) there is a completed
immunization record or a notation that immunizations are up-to-date.

 
i.
Diagnostic information

 
j
Medication information

 
k.
Identification of current problems - Significant illness, medical conditions and
health maintenance concerns are identified in the medical record.

 
l.
Smoking/ETOH/substance abuse - Notation concerning cigarettes and alcohol use
and substance abuse is present (for patients 12 years and over and seen three or
more times).  Abbreviations and symbols may be appropriate.

 
m.
Consultations, referral and specialist reports - Notes from consultations are in
the record. Consultation, lab, and x-ray reports filed in the chart have the
ordering physicians initials or other documentation signifying
review.  Consultation and significantly abnormal lab and imaging study results
have an explicit notation in the record and follow-up plans.

 
n.
Emergency care

 
o.
Hospital discharge summaries - Discharge summaries are included as part of the
medical record for (1) all hospital admissions which occur while the patient is
enrolled in the MCO and (2) prior admissions as necessary.

 
p.
Advance directives - For medical records of adults, the medical record documents
whether or not the individual has executed an advance directive.  An advance
directive is a written instruction such as a living will or durable power of
attorney for health care relating to the provision of health care when the
individual is incapacitated.

 
2.
Patient visit data - Documentation of individual encounters must provide
adequate evidence of, at a minimum;

 
a.
History and physical examination - Appropriate subjective and objective
information is obtained for the presenting complaints.

 
b.
Plan of treatment

 
c.
Diagnostic tests

 
d.
Therapies and other prescribed regimens; and

 
e.
Follow-up - Encounter forms or notes have a notation, when indicated, concerning
follow-up care, call, or visit.  Specific time to return is noted in weeks,
months, or PRN. Unresolved problems from previous visits are addressed in
subsequent visits.

 
f.
Referrals and results thereof; and

 
g.
All other aspects of patient care, including ancillary services.

 
3.
Record review process-

 
1.
The MCO has a system (record review process) to assess the content of medical
records for legibility, organization, completion and conformance to its
standards.

 
2.
The record assessment system addresses documentation of the items listed in B,
above.

Standard XII:
Utilization Review
 

A.
Written program description- The MCO has a written utilization management
program description which includes, at a minimum, procedures to evaluate medical
necessity, criteria used, and approve the provision of medical information
sources and the process used to review services
.

B.
Scope - The program has mechanisms to detect underutilization as well as
overutilization.

C.
Preauthorization and concurrent review - For MCO with preauthorization or
concurrent review programs:

 
1.
Preauthorization and concurrent review decisions are supervised by qualified
medical professionals;

 
2.
Efforts are made to obtain all necessary information, including pertinent
clinical information, and consult with the treating physician as appropriate;

 
3.
The reasons for decisions are clearly documented and available to the member.

 
4.
There are well-publicized and readily available appeals mechanisms for both
providers and patients. Notification of a denial includes a description of how
file an appeal;

 
5.
Decisions and appeals are made in a timely manner as required by the exigencies
of the situation;

 
6.
There are mechanisms to evaluate the effects of the program using data on member
satisfaction, provider satisfaction or other appropriate; and

 
7.
If the MCO delegates responsibilities for utilization management, it has
mechanisms to ensure that these standards are met by the delegate.

 
Standard XIII:
Continuity of Care System
 

The MCO has put a basic system in place which promotes continuity of care and
case management.
 
Standard XIV:
QAP Documentation
 

A.
Scope - The MCO shall document that it is monitoring the quality of care across
all services and all treatment modalities, according to its written QAP.

B.
Maintenance and availability of documentation - The MCO must maintain and make
available to the State, and upon request to the Secretary of HHS, studies,
reports, appropriate, concerning the activities and corrective actions.

 
Standard XV:
Coordination of QA Activity with other Management Activity
 

The findings, conclusions, recommendations, actions taken, and results of
actions taken as a result of QA activity, are documented and reported to
appropriate individuals within the MCO and through established QA channels.
A.
QA information is used in recredentialing, recontracting, and/or annual
performance evaluations.
 

B.
QA activities are coordinated with other performance monitoring activities,
including utilization management, risk management, and resolution and monitoring
of member complaints and grievances.

C.
There is a linkage between QA and other management functions of the MCO, such
as: network changes, benefit redesign, medical management systems, practice
feedback to providers, patient education and member services.

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

Appendix H
 
Claims Inventory, Aging and Unaudited Quarterly Financial Reports
 

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

HUSKY B Appendix H
(document 1 of 5)
Report #1
HUSKY A & B Unprocessed Claims in Dollars
 
Plan Name
             
Qtr. Ending:
                             
Claim Type
Claims In Process During Qtr. (In Dollars) (1)
       
1-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Claims Outstanding At The End Of The Qtr.
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             
Claim Type
Unpaid Adjudicated Claims (In Dollars) (2)
         
1-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Unpaid Adjudicated Claims (In Dollars) At The End Of The Qtr.
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             
1.   Claims in process-all claims that are in a pending status (data, medical,
COB edits) and require review by a claim examiner prior to being released for
adjudication.  Because the final pay amount is unknown, the amounts are recorded
at the billed amount
2.  Unpaid adjudicated claims-claims which have been adjudicated and have a
known pay amount, however, a check has not been issued for these
claims.  Because the final pay amount is known, the amounts are recorded using
net amount + withhold.
               
UB92 - In general these claim forms represent hospital based claims (inpatient
and outpatient).
     
HCFA 1500 - These claim forms are used for outpatient services provided by
non-hospital facilities.
                     
Other items to note about report #1 and #2:
           
*  If a claim does not include the information specified in Bulletin HC-56 it is
rejected.  This claim would not appear in the inventory
after it was rejected.
*   A claim could contain all of the information specified by Bulletin HC-56,
but it is incorrect.  In this instance it could have been included in the
pending claims prior to identifying it as a claim with incorrect data.  Examples
of incorrect data would be using a discontinued code.
*  If a claim is submitted for a service which requires prior authorization, but
none if found by the MCO, it is denied.
   
    At the point of denial the claim would be excluded from the report.
         
*  The pending claims could include duplicates which have not been identified by
the MCO.  If a duplicate is identified, one is paid and
 
     all of the duplicates are rejected.
             
*   The pending category may include claims which have been pended for a medical
records review.  As per the guidelines in Bulleting HC-56,
if additional information is needed from the provider, the MCO has 30 days to
request additional information. After the information is received, the MCO has
30 days to pay the claim without interest.
*   If a claim is denied and subsequently reversed on appeal, the  clock would
start on the date of the appeal determination.
   
*  If a credit balance exists for a provider, the time to process the claim is
still measured.  To the extent that processing exceeds 45 days
it would accrue interest as any other claim would.
If a rejected or denied claim is subsequently resubmitted, it would take on a
new claim number.  The clock would begin from the date of re-submissions.
 
The only time a processed claim is re-opened is for an adjustment to amount
paid.
         

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

 
HUSKY B Appendix H
document 2 of 5)
Report #2
HUSKY A & B Volume of Unprocessed Claims

Plan Name
             
Qtr.  Ending:
                             
Claim Type
Claims In Process During Qtr. (# of claims) (1)
   
Total Claims In Process During Qtr.
 
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
 
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                                             
Claim Type
Unpaid Adjudicated Claims (# of claims) (2)
   
Total Unpaid Adjudicated Claims (# of claims) At The End Of The Qtr.
 
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
 
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             
Claim Type
Total Unprocessed And Unpaid Adjudicated Claims (3)
   
Total Unprocessed & Unpaid Adjudicated Claims
 
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
 
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             

 
Claims Inventory
EQUAL OR Less than 45 Days
Greater than 45 Days
     
MCO Claims
%
%
Pharmacy
%
%
Dental
%
%
Vision
%
%
Mental Health
%
%
Total
%
%

 

               
Claim Type
Estimated Claims Received but not in system (# of claims) (4)
     
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Claims Received But Not In System
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Mental Health
             
Subtotal Vendor Claims
             
Total
                                                             
Tick Mark Legend:
                             
1.   Claims in process-all claims that are in a pending status (data, medical,
COB edits) and require review by a claim examiner prior to being released for
adjudication.
 
         
2. Unpaid adjudicated claims-claims which have been adjudicated and have a known
pay amount, however, a check has not been issued for these claims.
 
 
         
3.  Total of estimated claims in process, and unpaid adjudicated claims.
 
     
4.  Estimated claims received but not in system-includes any claim that has been
received and not input in the system(I.e. claims in the mailroom).

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

 
HUSKY B Appendix H
(document 3 of 5)
Report #3
HUSKY A & B Turn Around Time - Claims Processed

Plan Name
             
Qtr. Ending:
                             
Claim Type
Paper Claims Processed During Qtr.
           
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Paper Claims Processed During Qtr.
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             
Claim Type
Electronic Claims Processed During Qtr.
           
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Electronic Claims Processed During Qtr.
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             
Claim Type
Total Paper and Electronic Claims Processed During Qtr.
         
01-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Paper & Electronic Claims Processed During Qtr.
UB92 Claims
             
HCFA 1500 Claims
             
Subtotal MCO Claims
             
Pharmacy
             
Dental
             
Vision
             
Subtotal Vendor Claims
             
Total
                             

 
Turn Around Statistics
EQUAL OR Less than 45 Days
Greater than 45 Days
     
MCO Claims
%
%
Pharmacy
%
%
Dental
%
%
Vision
%
%
Mental Health
%
%
Total
%
%

 
Note:  This report includes only paid claims, therefore it excludes denied
claims.

 

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

 
(document 5 of 6)
Appendix H
Unaudited Quarterly Financial Reports

 
Current Assets:
Current Year
Previous Year
1
Cash and Cash Equivalents
   
2
Short-Term Investments
   
3
Premiums Receivable
   
4
Investment Income Receivables
   
5
Health Care receivables
   
6
Amounts Due from Affiliates
   
7
Aggregate Write-Ins for Current Assets
   
8
TOTAL CURRENT ASSETS (items 1-7)
             
Other Assets
   
9
Restricted Cash and Other Assets
   
10
Long Term Investments
   
11
Amounts Due from Affiliates
   
12
Aggregate Write-Ins for Other Assets
   
13
TOTAL OTHER ASSETS (items 9-12)
             
Property and Equipment
   
14
Land, building and Improvements
   
15
Furniture and Equipment
   
16
Leasehold Improvements
   
17
Aggreate Write-Ins for Other Equipment
   
18
TOTAL PROPERTY (items 7-14)
   
19
TOTAL ASSETS 9items 8, 13, and 18)
             
Details of Write-Ins Aggregated at item 7 for Current Assets
   
701
     
702
     
703
     
704
     
705
     
798
Summary of remaining write-ins for item 7 from overflow page
   
799
TOTALS: (items 701 through 705 plus 798 page 2, item 7)
             
Details of Write-Ins Aggregated at item 12 for Other Assets
   
1201
     
1202
     
1203
     
1204
     
1205
     
1298
Summary of remaining write-ins for item 12 from overflow page
 
1299
TOTALS: (items 1201 through 1205 plus 1298 page 2, item 12)
           
Details of Write-Ins Aggregated at item 17 for Other Equipment
 
1701
     
1702
     
1703
     
1704
     
1705
     

 
 
(document 5 of 6)
Appendix H
Unaudited Quarterly Financial Reports
 
1798
Summary of remaining write-ins for item 17 from overflow page
 
1799
TOTALS: (items 1701 through 1705 plus 1798 page 2, item 17)
           
Current Liabilities
   
1
Accounts Payable (Schedule G)
   
2
Claims Payable (Reported and Unreported) (Schedule H)
   
3
Accrued Medical Incentive Pool (Schedule H)
   
4
Unearned Premiums
   
5
Amounts Due to Affiliates (Schedule J)
   
6
     
7
Aggregate Write-Ins for Current Liabilities
   
8
TOTAL CURRENT LIABILITIES (items 1-7)
             
Other Liabilities
   
9
Loans and Notes Payable (Schedule I)
   
10
Amounts Due to Affiliates (Schedule J)
   
11
Aggregate Write-Ins for Other Liabilities
   
12
TOTAL OTHER LIABILITIES (items 9-11)
   
13
TOTAL LIABILITIES (items 8 and 12)
             
Net Worth
   
14
Common Stock
   
15
Preferred Stock
   
16
Paid in Surplus
   
17
Contributed Capital
   
18
Surplus Notes (Schedule K)
   
19
Contingency Reserves
   
20
Retained Earnings/Fund Balance
   
21
Aggregate Write-Ins for Other Net Worth Items
   
22
TOTAL NET WORTH (items 13 and 22)
   
23
TOTAL LIABILITIES AND NET WORTH (items 13 and 22)
             
Details of Write-Ins Aggregated at item 7 for Current Liabilities
 
701
Payroll and Related Liabilities
   
702
Accrued Audit and Actuarial Fees
   
703
     
704
     
705
     
798
Summary of Remaining Write-Ins for item 7 from overflow page
 
799
TOTALS (items 0701 through 0705 plus 0798 Page 3, item 7)
             
Details of Write-Ins Aggregated at item 11 for Other Liabilities
   
1101
     
1102
     
1103
     
1104
     
1105
     
1198
Summary of remaining write-ins for item 11 from overflow page
 
1199
TOTALS: (items 1101 through 1105 plus 1198 page 3, item 11)
           
Details of Write-Ins Aggregated at item 21 for Other Net Worth Items
 
2101
     

 
 
(document 5 of 6)
Appendix H
Unaudited Quarterly Financial Reports
 
2102
     
2103
     
2104
     
2105
     
2198
Summary of remaining write-ins for item 21 from overflow page
 
2199
TOTALS: (items 2101 through 2105 plus 2198 page 3, item 21)
           
Member months
     
Revenues
   
1
Premium
   
2
Fee-For-Service
   
3
Title XVIII - Medicare
   
4
Title XIX - Medicaid
   
5
Investment
   
6
Aggregate Write-Ins for Other Revenues
   
7
TOTAL REVENUES (items 1-6)
             
Expenses
   
8
Medical and Hospital
   
9
Other Professional Services
   
10
Outside Referrals
   
11
Emergency Room and Out-of-Area
   
12
Occupancy, Depreciation and Amortization
   
13
Inpatient
   
14
Incentive Pool and Withhold Adjustments
   
15
Aggregate Write-Ins for other Medical and Hospital Expenses
   
16
Subtotal (items 8-15)
   
17
Reinsurance Expenses of Net of Recoveries
             
Less
   
18
Copayments
   
19
COB and Subrogation
   
20
Subtotal (items 18 and 19)
   
21
Total Medical and Hospital (items 16 and 17 less 20)
             
Administration
   
22
Compensation
   
23
Interest Expense
   
24
Occupancy, Depreciation and Amortization
   
25
Marketing
   
26
Aggregate Write-Ins for Other Administration Expenses
   
27
TOTAL ADMINISTRATION (items 22-26)
   
28
TOTAL EXPENSES (items 21 and 27)
   
29
Income (LOSS) (item 21 and 27)
   
30
Cumulative Effect of Accountin Change)
   
31
Provision for Federal Income Taxes
   
32
NET INCOME (item 29, less items 30 and 31)
             
Details or Write-Ins Aggregated at item 6 for other Revenues
   
601
Other Income
   
602
     
603
     

 
(document 5 of 6)
Appendix H
Unaudited Quarterly Financial Reports
 

 

604
     
605
     
698
Summary of remaining write-ins for item 6 from overflow page
   
699
TOTALS: (items 601 through 605 plus 698 page 4, item 6)
             
Member months
     
Details of Write-Ins Aggregated at Item 6 for Other Revenues
   
1501
Drugs
   
1502
Outpatient
   
1503
     
1504
     
1505
     
1598
Summary of remaining write-ins for item 15 from overflow page
           
Details of Write-Ins Aggregated at Item 26 for Other Administration Expenses
 
2601
MGMT Fee Income - SWWA
   
2602
MGMTFee Expense GOHS
   
2603
Other Administration Expense
   
2604
MGMT Fee Expense Corp.
   
2605
Accrued Audit and Actuarial Expense
   
2698
Summary of remaining write-Ins for item 26 from ovrflow page
   
2699
TOTALS (items 2601 through 2605 plus 2698) (page 4, item 26)
 

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

Appendix I
 
Capitation Payment Amount
 
 

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

 
SFY 2007 Rates for Husky B Band 1 & 2
 
Includes BHP Carve out, 3.88% Rate Increase, Hosp Adjustment and Dental
Adjustment
 
 

 
 (Hardcoded)
SFY 2007 Rate
 FirstChoice
 $155.73

 
 

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

 
Appendix J
 
Inpatient / Eligibility Recategorization Chart

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

HUSKY B - Appendix J
HUSKY A & B
Medical Acute Care Primary Inpatient/Eligibility Recategorization Changes
         
Description
Admitting MCO
New/Continued MCO
Responsible Entity
HUSKY A, different MCO
A1
A2
A1
 
HUSKY A to FFS
A1
FFS
FFS
 
HUSKY A to HUSKY B, same MCO
A1
B1
A1
 
HUSKY A to HUSKY B, different MCO
A1
B2
A1
 
HUSKY B, different MCO
B1
B2
B1
 
HUSKY A to disenrolled due to loss
of eligibility (Out of Program)
A1
x
A1
 
HUSKY B to disenrolled due to loss
of eligibility (Out of Program)
B1
x
B1
 
HUSKY B to A (Same MCO,
different coverage)
B1
A1
A1
 
HUSKY B to A (different MCO,
different coverage)
B1
A2
A2
 
HUSKY B to FFS
B1
FFS
FFS
 

 
Code
       
A1 = HUSKY A, MCO #1
       
A2 = HUSKY A, MCO #2
       
B1 = HUSKY B, MCO #1
       
B2 = HUSKY B, MCO #2
       
FFS = Fee-for-service
       
x= Disenrolled due to loss of eligibility
       

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

Appendix K
 
Abortion Reporting
 

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

   

HUSKY B Non-Hyde Amendment Abortions
 
Name of MCO: ___________________________
Quarter Ended: ___________________________ 
                                                                                 
This report shall include all abortions that do not meet the HYDE Amendment
criteria, and that are paid by the MCO during the quarter (e.g. July 1 -
September 30). These reports shall be submitted by the 15th of the month
following the end of the quarter (e.g. October 15). The reports shall be
submitted in hard copy, as well as electronically to Lee Voghel, Division of
Fiscal Analysis.

Date of Service
CPT Code
Medicaid Recipient ID#
Provider ID#
Provider Name
Date Paid
Amount Paid
     
 
 
Total
     

I hereby certify that to the best of my knowledge the information contained
herein is true and accurate.
 
Signature:                                                                                     
Printed
Name:                                                                                     
Title:                                                                                     
Date:                                                                                     
 

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

 
Appendix L
 
Blank
 
Reserved for Possible Future Use
 
 

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

Appendix M
 
Blank
 
Reserved for Possible Future Use
 
 

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

APPENDIX N

HUSKY BEHAVIORAL HEALTH CARE-OUT COVERAGE
AND COORDINATION OF MEDICAL AND BEHAVIORAL SERVICES

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

HUSKY A - 05/07 - Appendix N

HUSKY BEHAVIORAL

Health Carve-Out

Coverage and Coordination of Medical and Behavioral Services

DEPARTMENT OF SOCIAL SERVICES DEPARTMENT OF CHILDREN AND FAMILIES

Updated January 26, 2006

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

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

Contents

Introduction
3
Ancillary Services
3
Co-Occurring Medical and Behavioral Health Conditions - Screening, Referral, and
Coordination
4
Freestanding Medical/Primary Care Clinics
5
Home Health Services
5
Hospital Emergency Department
7
Hospital Inpatient Services
8
Hospital Outpatient Clinic Services
9
HUSKY Plus Behavioral
9
Long Term Care
9
Member Services
10
Mental Health Clinics
10
Methadone Maintenance
11
Multi-Disciplinary Examinations
11
Notice of Action
11
Operations
12
Outreach
12
Pharmacy
12
Primary Care Behavioral Health Services
13
Quality Management
14
Reports
14
School-Based Health Center Services
15
Transportation
16

 
State of
Connecticut                                                             Page
2                                                           01/26/06

 

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

Introduction

The purpose of this document is to outline the policies according to which the
HUSKY MCOs and the Behavioral Health Partnership (BHP) will share responsibility
for providing covered services to HUSKY A and B enrollees after HUSKY behavioral
health benefits are carved out and administered under a contract with the BHP
Administrative Service Organization ("BHP ASO"). After the carve-out, the
Managed Care Organizations that participate in HUSKY A and B ("HUSKY MCOs") will
be responsible for providing services for medical conditions and BHP will be
responsible for providing services for behavioral health conditions. The BHP ASO
will provide member services, provider relations services, utilization
management, intensive care management, quality management and other management
services to facilitate the provision of timely, effective, and coordinated
services under the BHP. The BHP ASO will not be responsible for contracting with
providers or maintaining a provider network. Behavioral health providers will be
required to enroll in the Department of Social Services' Connecticut Medical
Assistance Program Network (CMAP). With the exception of DCF funded residential
services, claims will be processed by the Department of Social Services'
Medicaid vendor, Electronic Data Systems (EDS).
This document is intended to summarize the coverage responsibilities and
coordination responsibilities for each of the major service areas as established
by the HUSKY BH carve-out transition planning workgroup. In addition to this
document, which is intended for use as an amendment or attachment to the ASO and
MCO contracts, each of the HUSKY MCOs will develop a coordination agreement with
the BHP ASO. The coordination agreements will further elaborate the coordination
protocols with special attention to the areas noted below and to the key
contacts and workflows particular to each MCO.

Ancillary Services

HUSKY MCOs will retain responsibility for all ancillary services such as
laboratory, radiology, and medical equipment, devices and supplies regardless of
diagnosis. However, laboratory costs for methadone chemistry (quantitative
analysis) will be covered under the BHP when they are part of the bundled
reimbursement for methadone maintenance providers. The HUSKY MCOs may track and
trend laboratory utilization as part of coordination with the BHP ASO. In
addition, the MCOs will address any increases in the utilization trend with The
Department of Social Services.

State of
Connecticut                                                              Page
3                                                           01/26/06

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

Co-Occurring Medical and Behavioral Health Conditions - Screening, Referral, and
Coordination

The HUSKY MCOs currently have programs and procedures designed to support the
identification of untreated behavioral health disorders in medical patients at
risk for such disorders. Such procedures may be carried out by medical service
providers or by the MCO through the utilization management, case management and
quality management processes. The MCOs will be expected to continue such
activities in order to foster early and effective treatment of behavioral health
disorders, including those disorders that could affect compliance with and the
effectiveness of medical interventions.

Both the HUSKY MCOs and the BHP ASO will be required to communicate and
coordinate as necessary to ensure the effective coordination of medical and
behavioral health benefits. The HUSKY MCOs will contact the BHP ASO when
co-management is indicated (including BH hospital emergency department visits),
such as for persons with special physical health and behavioral health needs;
will respond to inquiries by the BHP ASO regarding the presence of medical
co-morbidities; and will coordinate with the BHP ASO when invited to do so.
Conversely, the BHP ASO will contact the HUSKY MCOs when co-management is
indicated; will respond to inquiries by the HUSKY MCOs regarding the presence of
behavioral co-morbidities; and will coordinate with the HUSKY MCOs when invited
to do so.

Both the BHP ASO and the MCOs will assign key contacts in order to facilitate
timely coordination. In addition, it is anticipated that the BHP ASO's intensive
care management department will be able to accept warm-line transfers as
necessary from the HUSKY MCO case management departments to facilitate timely
co-management.

The BHP ASO will convene Medical/Behavioral Co-Management meetings at least once
a month with each HUSKY MCO. The frequency of the meetings will be by agreement
between the BHP ASO and each HUSKY MCO. The purpose of the meeting will be to
ensure appropriate management of clients with co-occurring medical and
behavioral health conditions. Cases discussed between the BHP ASO and the MCO
will include all levels of behavioral health and medical care. Furthermore, the
BHP ASO and the HUSKY MCOs shall provide reports in advance of the meetings on
the cases to be reviewed.

The HUSKY MCOs and the BHP ASO will from time to time make a determination as to
whether a client's medical or behavioral health condition is primary. If there
is a conflicting determination as to whether medical or behavioral health is
primary, the respective medical directors will work together toward a timely and
mutually agreeable resolution. At the request of either party, the Department of
Social Services will make a determination as to the whether medical or
behavioral health is primary and that determination shall be binding.

State of
Connecticut                                                             Page
4                                                           01/26/06

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

Freestanding Medical/Primary Care Clinics

The HUSKY MCOs will be responsible for primary care and other medical services
provided by freestanding primary care/medical clinics regardless of diagnosis
except for behavioral health evaluation and treatment services billed under CPT
codes 90801-90806, 90853, 90846, 90847, and 90862 with a primary behavioral
health diagnosis and only when provided by a licensed behavioral health
professional.

Home Health Services

HUSKY MCOs and BHP will share responsibility for covering home health services.
The coordination agreements will include language that details procedures for
resolving coverage responsibility issues. Home health coordination will be based
on the following guidelines:

The HUSKY MCOs will be responsible for management and payment of claims when
home health services are required for the treatment of medical diagnoses alone
and when home health services are required to treat both medical and behavioral
diagnoses, but the medical diagnosis is primary. If the individual's behavioral
health treatment needs cannot be safely and effectively managed by the medical
nurse and/or aide, the home care agency will be required to provide psychiatric
nursing and/or aide services separately authorized and paid for under the BHP.

BHP will be responsible for management and payment of claims when home health
services are required for the treatment of behavioral diagnoses alone (ICD 9:
291-316) and when home health services are required to treat both medical and
behavioral diagnoses, but the behavioral diagnosis is primary. If the
individual's medical treatment needs cannot be safely and effectively managed by
the psychiatric nurse and/or aide, then the home care agency will be required to
provide medical nursing and/or aide services separately authorized and paid for
by the HUSKY MCOs.

The following table summarizes this policy:

HUSKY MCOs
BHP ASO
Medical diagnosis only
Behavioral diagnosis only
Medical and behavioral diagnoses, Med primary
Behavioral and medical diagnoses, Behavioral primary
Medical component only, when medical and behavioral diagnoses are present and
behavioral health needs cannot be effectively managed by the medical nurse
and/or aide.
Behavioral component only, when behavioral and medical diagnoses are present and
medical needs cannot be effectively managed by the medical nurse and/or aide.

In addition, HUSKY MCOs will manage and pay claims for home health physical
therapy, occupational therapy, and speech therapy services regardless of
diagnosis.

State of Connecticut                                           Page
5                                 01/26/06

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

When physical therapy, occupational therapy, and speech therapy services occur
alongside home health behavioral health services, the home health care agency
will be required to get authorization from and submit claims to the both the
HUSKY MCO and to Electronic Data Systems (EDS), the claims vendor for the BHP.

The above policy will require that providers and management entities make
decisions as to whether a medical or behavioral diagnosis is primary. This
determination will be made at the time the service is presented for
authorization. The determination will be based on the diagnosis that is the
principal focus of the services — typically the one that requires the most time
and/or expertise. A rebuttable presumption shall be made that the primary
diagnosis is psychiatric if a psychiatrist makes the referral. The following
examples should help in determining the issue of primary diagnosis:

• 
In general, if a recipient is receiving home health behavioral health services
and at some point requires home health services for a medical condition, the
behavioral health diagnosis remains primary if the medical treatment needs can
be safely and effectively managed by the nurse that is providing the behavioral
health services. If the medical condition requires treatment by a medical nurse,
and the medical nurse is able to safely assume responsibility for the behavioral
condition, then the medical diagnosis becomes primary.

•  
Similarly, if a recipient is receiving home health medical services and at some
point requires home health behavioral services for a behavioral condition, the
medical diagnosis remains primary if the behavioral health treatment needs can
be safely and effectively managed by the nurse that is providing the medical
services. If the behavioral condition requires treatment by a psychiatric nurse,
and the psychiatric nurse is able to safely assume responsibility for the
medical condition, then the behavioral diagnosis becomes primary.

If, at some point, separate nurses or aides are required to provide the
behavioral and medical services, then the nurse and/or aide treating the medical
condition must obtain authorization and payment from the HUSKY MCO and the nurse
and/or aide treating the behavioral health condition must obtain authorization
and payment under the BHP.

In some cases, a recipient will not require treatment for both a medical and
behavioral condition at every visit. For example, a recipient may require two
visits per day for his or her medical condition, but only one visit per day for
the behavioral health condition, hi this case, the medical condition ought to be
billed as primary for both visits. Conversely, if a recipient requires two
visits per day for his or her behavioral condition, but only one visit per day
for the medical condition, the behavioral condition ought to be billed as
primary for both visits.

Finally, the primary reason for a visit may change from medical to behavioral or
visa versa in the course of home health treatment. If this change occurs at the
time of re-authorization, the home health care agency should pursue a new
authorization from the entity with responsibility for the new condition for
which home health care is required. If

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the change in primary diagnosis occurs during an authorized episode of care, the
home health care agency should discontinue services under the preceding
authorization and pursue a new authorization from the entity with responsibility
for the services going forward. If the HUSKY MCO reviews a request for
authorization and believes that the primary has changed from medical to
behavioral health, the MCO should direct the home care agency to pursue
authorization through the BHP ASO.   The converse is also true. If the primary
is not apparent, the clinical reviewers from the BHP ASO and the MCO should
confer and come to agreement.

Data provided by the HUSKY MCOs suggests that there are a modest number of
clients with diagnoses of autism or mental retardation receiving home health
services and that more than half of these clients have mixed diagnoses that
could complicate management and billing. BHP will be responsible for the
management and payment of claims when home health services are required for the
treatment of autism, whether on its own or co-morbid with mental retardation.
For those members with these dual diagnoses, providers will be directed to
obtain authorization from the BHP ASO and to bill EDS with autism primary. The
HUSKY MCOs will retain responsibility for mental retardation alone. BHP will
also be responsible for management and payment of claims when home health
services are required for the treatment of both autism and medical disorders,
when the medical disorder can be safely and effectively managed by the
psychiatric nurse and/or aide. If the individual's medical treatment needs are
so significant that they cannot be safely and effectively managed by the
psychiatric nurse and/or aide, then the home care agency will be required to
provide medical nursing and/or aide services separately authorized and paid for
by the HUSKY MCOs.

All home health care agencies operating in Connecticut are enrolled in the
Connecticut Medical Assistance Program (CMAP) network and may, at their
discretion, provide behavioral health home health services to HUSKY recipients.
In contrast, the HUSKY MCOs may contract with only a subset of the CMAP
providers. This means that there may be times when a client is in treatment for
a behavioral health condition with a CMAP provider that is not participating
with a HUSKY MCO. If this client develops a co-occurring medical disorder that
is secondary and can be managed by the psychiatric home care nurse, BHP will
continue to be responsible for management and payment of claims. If, however,
the patient's medical disorder becomes primary and thus the responsibility of
the HUSKY MCO, the HUSKY MCO can elect to continue to use the home care provider
as an out of network provider, or the HUSKY MCO can, at its discretion,
transition the care to a participating home care provider. The client's best
interest will be a factor in this determination. The MCOs and BHP ASO will be
expected to create coordination agreements to expedite the proper handling of
such cases.

Hospital Emergency Department

The HUSKY MCOs will assume responsibility for emergency department services,
including emergent and urgent visits and all associated charges billed by the
facility, regardless of diagnosis. Professional psychiatric services rendered in
an emergency department by a community psychiatrist will be reimbursed by the
BHP if the psychiatrist

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is enrolled in CMAP as an independent solo or group practitioner and bills under
the solo or group practice ID. The BHP will be responsible for observation stays
of 23 hours or less (RCC 762) with a primary behavioral health diagnosis. The
HUSKY MCOs and the Department will implement audit procedures to ensure that
hospitals do not bill HUSKY MCOs for emergency department services when patients
are admitted to the hospital and behavioral health is primary. The HUSKY MCOs
may track and trend Emergency Department utilization for behavioral health. The
MCOs will address any increase in the utilization trend with the Departments.

Hospital Inpatient Services

In order to assure appropriate coordination and communication, the coordination
agreements will include specific language detailing processes and procedures for
concurrent communication and the process for handling co-occurring medical and
behavioral health hospital inpatient conditions. In addition, the agreements
will include specific language on the procedures for resolving coverage related
issues when the ASO and MCOs disagree. Coordination will be based on the
following guidelines:

Psychiatric Hospitals

BHP will be responsible for all psychiatric hospital services and all associated
charges billed by a psychiatric hospital, regardless of diagnosis. The rate is
all-inclusive so there will be no reimbursement for professional services
rendered by community-based consulting physicians.

General Hospitals

HUSKY MCOs and BHP will share responsibility for covering inpatient general
hospital services. The HUSKY MCOs will be responsible for management and payment
of claims for inpatient general hospital services when the medical diagnosis is
primary. Medical would be considered primary when the billed RCC and the primary
diagnosis are both medical.

During a medical stay, BHP will be responsible for professional services
associated with behavioral health diagnoses. The admitting physician will be
responsible for coordinating medical orders for any necessary behavioral health
services with the BHP ASO. Other ancillary charges associated with non-primary
behavioral health diagnoses shall remain the responsibility of the HUSKY MCOs,
as described in the ancillary services section of this document.

BHP will be responsible for management and payment of claims for inpatient
general hospital services when the behavioral diagnosis is primary. The
behavioral diagnosis will be considered primary when the billed RCC and the
primary diagnosis are both behavioral or when the billed RCC is medical, but the
primary diagnosis on the claim form is behavioral. During a behavioral stay, the
HUSKY MCOs will be responsible for professional services and other charges
associated with primary medical diagnoses.

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o   When an admission to a general hospital is initially medical, but the reason
for continued admission becomes behavioral, responsibility for management and
payment of claims will transition to BHP. When the hospital admission is no
longer medically necessary for the medical diagnosis, the HUSKY MCO ceases to be
responsible for management and payment. The BHP ASO will monitor the timeliness
of transfer from a medical unit to a psychiatric unit when the primary diagnosis
changes from medical to behavioral health.

The following table summarizes this policy:

Inpatient Payment for Primary Diagnosis
 
Professional Services Paid for Secondary Diagnosis
Inpatient Type
Revenue Codes
Diagnosis
Assignment
 
HCPCS
Diagnosis
Assignment
General Hospital
BH
BH
BHP
 
BH
BH
BHP
General Hospital
BH
BH
BHP
 
Med
Med
MCO
General Hospital
Med
BH
BHP
 
BH
BH
BHP
General Hospital
Med
BH
BHP
 
Med
Med
MCO
General Hospital
Med
Med
MCO
 
Med
Med
MCO
General Hospital
Med
Med
MCO
 
BH
BH
BHP

Hospital Outpatient Clinic Services

BHP will be responsible for all outpatient psychiatric clinic, intensive
outpatient, extended day treatment, and partial hospitalization services
provided by general and psychiatric hospitals for the evaluation and treatment
of behavioral health disorders. BHP will also cover evaluation and treatment
services related to a non-behavioral health diagnosis if the billing code is
psychiatric as outlined in the covered services grid.

The HUSKY MCOs will be responsible for all primary care and other medical
services provided by hospital medical clinics regardless of diagnosis including
all medical specialty services and all ancillary services.

HUSKY Plus Behavioral

HUSKY Plus Behavioral services (intensive in-home psychiatric services) will be
included in the HUSKY B benefit package. The ASO will manage access to these
services under the carve-out.

Long Term Care

The HUSKY MCOs will be responsible for all long term care services (i.e.,
nursing homes, chronic disease hospitals) regardless of diagnosis. These
services are seldom

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required for the treatment of clients with primary behavioral health disorders
under the HUSKY program. The admission of a client with a primary behavioral
health disorder must be by mutual agreement of the BHP ASO and the HUSKY MCO in
which the client is enrolled.

DSS currently exempts any long-term care client from managed care the first of
the month in which the client's stay exceeds 90 days. DSS will consider early
exemption for clients with a primary behavioral health diagnosis if DSS were
provided with adequate notice when such clients are admitted to long-term care.

Member Services

The BHP ASO will have its own member services department with a dedicated toll
free phone number. The member services staff will provide non-clinical
information to recipients and when appropriate provide immediate access to
clinical staff for care related assistance. The member services staff will
respond to all calls directed to the member services line and it is expected
will have the ability to accept warm-line transfers from the HUSKY MCOs. The
HUSKY MCOs will replace references to existing BH subcontractors on member
materials with the new BHP ASO name and member services phone number, wherever
such references occur. Branch logic for the DSS' 1-877-CTHUSKY number will be
modified to incorporate the ASO member services line as an option for callers
that require BHP related assistance.

The MCOs will continue to conduct welcome calls to new members. At the time of
the welcome call, the HUSKY MCO member services representative will provide the
member with information on how to access the BHP ASO.

HUSKY MCO member services departments will occasionally receive calls from
members who are requesting BH services. In addition, BH issues may emerge in the
course of a welcoming call. The member may screen positive for behavioral health
issues and express an interest in discussing further or have clear behavioral
health issues and need a referral. In either case, the member service
representative can affect a warm-line transfer to the ASO member services
department, take the member's information and fax this information to the ASO
for follow-up, or provide the member with the telephone number for the BHP ASO.

If the client is in crisis, the MCO member services representative should follow
the MCO's protocols for handling crisis calls. The BHP ASO will have the
capacity to accept warm-line transfer of such crisis calls when, at the
discretion of the MCO, such transfer is appropriate.

Mental Health Clinics

BHP will be responsible for all Mental Health Clinic Services regardless of
diagnosis including routine outpatient services and all diagnostic and treatment
services billed as intensive outpatient treatment, extended day treatment, and
partial hospitalization

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treatment. BHP will also cover evaluation and treatment services related to a
medical diagnosis such as psychological testing for a client with traumatic
brain injury.

Methadone Maintenance

BHP will be responsible for reimbursing methadone clinics for methadone
maintenance services provided to HUSKY enrollees. All methadone maintenance
services for which the source of service is the methadone maintenance clinic are
included in the Department's bundled rate with methadone maintenance
clinics.   The MCOs will cover all methadone maintenance laboratory services
when billed by an independent laboratory

Multi-Disciplinary Examinations

The MCOs will be responsible for contracting with DCF certified
Multi-Disciplinary Examination providers and for covering all components of the
DCF Multi-Disciplinary Examinations including behavioral health evaluation
services (e.g., 90801, 96110). .

Notice of Action

The HUSKY MCOs will be responsible for issuing notices of action for medical
review decisions and the BHP ASO will be responsible for issuing notices of
action for behavioral health review decisions. The HUSKY MCOs will issue notices
of action to the client and the provider, but will not issue a notice to the BHP
ASO. Similarly, the BHP ASO will issue notices of action to the client and the
provider, but will not issue a notice to the HUSKY MCO.

In preparation for a fair hearing, the Department of Social Services will work
with the Department's contractor that issued the notice to prepare the
Department's case. Typically, the ASO will not be involved in an MCO related
fair hearing and the MCO will not be involved in an ASO related fair hearing.
However, when a client has co-morbid medical and behavioral health conditions
and the action affects both conditions, then both the MCO and the ASO may be
involved in preparation for the fair hearing.

If a HUSKY MCO or one of its providers disagrees with a clinical management
decision made by the BHP ASO, the HUSKY MCO is encouraged to raise the issue
with the ASO on behalf of the client and to resolve the issue informally prior
to the scheduled fair hearing. The converse is also true. If the issue remains
unresolved, DSS will review the issue with the HUSKY MCO and the ASO and make a
determination as to whether DSS supports the decision of the contractor that
issued the notice. If DSS supports the contractor that issued the notice, the
matter will proceed to fair hearing.

The HUSKY MCOs may at times refer a client or provider to the BHP ASO because
the primary presenting condition is behavioral health rather than medical. The
HUSKY MCO's determination that a condition is behavioral health rather than
medical shall not constitute grounds for issuing a notice of action. The
converse is true for the BHP ASO.

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The HUSKY MCO may at times issue a notice of action for a prescription written
by a CMAP enrolled behavioral health prescribing provider. In such instances,
the HUSKY MCO will be expected to send notice of action to the client and to the
prescribing provider.

Operations

In order to support coordination and communication regarding operational issues
such as claims payment, the Departments will host a monthly meeting with the BHP
ASO and the HUSKY MCOs.

Outreach

The HUSKY MCOs currently provide outreach to members to assist them with
accessing necessary services. The MCOs will continue to provide outreach to
members to assist them with accessing medical services. For example, they may
reach out to members to connect them to a primary care provider or to ensure
necessary follow-up after a medical hospitalization. If an MCO's outreach worker
identifies a member with a behavioral health issue, the worker may, at the MCO's
discretion, provide information to the member on how to access behavioral health
services via the ASO or facilitate a direct referral.

The BHP ASO will conduct extensive outreach focused on connecting clients to
behavioral health care when clients are experiencing barriers to care. They will
also make efforts to ensure a connection to care after discharge from a hospital
or residential treatment center. If in the course of outreach the BHP ASO
identifies a member with a significant medical issue, the ASO may provide
information to the member on how to access necessary medical services through
the MCO or the member's primary care provider or facilitate a direct referral.

Pharmacy

The HUSKY MCOs will assume responsibility for all pharmacy services and all
associated charges, regardless of diagnosis. However, methadone costs that are
part of the bundled reimbursement for methadone maintenance and ambulatory detox
providers will be covered under BHP. Methadone maintenance providers and
ambulatory detox providers are responsible for supplying and dispensing
methadone and these costs are covered by the BHP as part of an all-inclusive
rate.

Each HUSKY MCO maintains its own pharmacy program with distinct formularies,
drug utilization review requirements, and prior authorization requirements.
Under BHP, the Departments will have contracts with prescribing behavioral
health providers and these providers will be required to follow the pharmacy
program requirements of the HUSKY MCO in which the member is enrolled as well as
other applicable Medicaid program

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requirements. BHP prescribing providers include psychiatrists, psychiatric
nurses, freestanding behavioral health clinics, and hospitals.

DSS disseminates all policy transmittals and provider bulletins for CMAP
providers through EDS. The ASO will not have a role in communications of this
type. DSS will issue a provider bulletin to all enrolled prescribing providers
prior to the carve-out date in order to apprise the providers of the pharmacy
program requirements of each MCO and remind providers of the HUSKY program's
temporary supply rules. DSS will require that providers adhere to each MCOs
pharmacy program requirements and provide MCOs with any clinical information
necessary to support requests for authorization or the preparation of clinical
summaries for the purpose of fair hearings.

Subsequently, the MCOs must notify DSS of changes to its pharmacy program
requirements. DSS will in turn use the provider bulletin process to notify CMAP
providers of such changes within 30 days of the effective date. The Departments
prefer that DSS manage such pharmacy program communications since it will have a
complete and up-to-date file of enrolled prescribing providers. This new
communication process should resolve some of the pharmacy program communication
issues that currently exist in the HUSKY program. Specifically, among some HUSKY
MCOs, certain providers such as freestanding behavioral health clinics are not
included in routine pharmacy program communications issued by the MCO. Under the
carve-out, all providers will be apprised of the requirements of all HUSKY MCOs.
The initial provider bulletin pertaining to pharmacy will provide each MCO's web
address where pharmacy program requirements are available.
The BHP ASO will fully cooperate with the MCOs and work closely with the MCOs to
ensure compliance with the pharmacy programs of the individual MCOs. The BHP ASO
will work closely with the MCOs to monitor pharmacy utilization and, if
necessary, cooperate with the MCOs in conducting targeted provider education or
training related to prescribing. DSS will require that its prescribing providers
participate in quality initiatives and targeted pharmacy education and training
conducted by the HUSKY MCOs for the purpose of improving prescribing practices
and/or adherence to pharmacy program requirements. If the HUSKY MCOs encounter a
behavioral health provider who engages in persistent misconduct related to
psychiatric prescribing, the matter should be referred to DSS for investigation.

The HUSKY MCOs may track and trend behavioral health pharmacy utilization and
address any increase in the utilization trend with the Departments. DSS will
continue to review each MCO's compliance with pharmacy contract provisions and
new DSS staff will meet with each MCO to familiarize themselves with each MCO
formulary/pharmacy process and available data in order to be prepared to work
with the MCOs on reporting specs.

Primary Care Behavioral Health Services

The HUSKY MCOs will retain responsibility for all primary care services and all
associated charges, regardless of diagnosis. These responsibilities include:

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1.      behavioral health related prevention and anticipatory guidance;
2.      screening for behavioral health disorders;
3.
treatment of behavioral health disorders that the primary care
physician concludes can be safely and appropriately treated in a primary care
setting;

4.
management of psychotropic medications, when the primary care
physician concludes it is safe and appropriate to do so, in conjunction with
treatment by a BHP non-medical behavioral health specialist when necessary; and

5.
referral to a behavioral health specialist when the primary care
physician concludes that it is safe and appropriate to do so.

The BHP ASO will develop education and guidance for primary care physicians
related to the provision of behavioral health services in primary care settings.
At their discretion, the HUSKY MCOs can collaborate with the ASO in the
development of education and guidance or they will be provided the opportunity
to review and comment. The education and guidance will address PCP prescribing
with support and guidance from the ASO or referring clinic, in circumstances
when the PCP is comfortable with this responsibility. The BHP ASO will make
telephonic psychiatric consultation services available to primary care
providers. Consultation may be initiated by any primary care provider that is
seeking guidance on psychotropic prescribing for a HUSKY A, HUSKY B, or
Voluntary Services enrollee.

To promote effective coordination and collaboration, the BHP ASO will work with
interested HUSKY MCOs and provider organizations to sponsor opportunities for
joint training. HUSKY MCO policies and provider contracts must permit the
provision of behavioral health services by primary care providers; however, the
MCOs will not be expected to provide education and training to improve ability
of primary care providers to provide these services.

The HUSKY MCOs may track and trend primary care behavioral health utilization.
The MCOs will address any increase in the utilization trend with the
Departments.

Quality Management

The BHP ASO will be required to conduct at least three quality improvement
initiatives each year. For the second year of the contract, the ASO will invite
the HUSKY MCOs to participate in a joint quality improvement initiative focused
on an area of mutual concern. Each MCO may participate at its discretion. The
Departments will determine during the second year of the project whether to ask
the BHP ASO to propose an additional joint quality improvement initiative with
the MCOs during the third year of its contract.

Reports

The BHP ASO will provide a weekly census report on all behavioral health
inpatient stays identifying those with co-occurring medical and behavioral
health conditions. In

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addition, the reports in Exhibit E of the BHP ASO contract will also be made
available to the MCOs upon request.

The MCOs will provide daily and monthly reports and/or data as mutually agreed
upon to the BHP ASO regarding i) behavioral health emergency department visits,
ii) behavioral health emergency room recidivism, iii) substance abuse & neonatal
withdrawal, iv) child/adolescent obesity and/or type II diabetes, v) sickle cell
report, vi) eating disorders report, and vii) medical detox.

The Departments will also make MCO specific behavioral health encounter data
available to the MCOs upon request to support quality management activities and
coordination. The format of the data extract will be consistent with the
encounter data reporting format, or other format mutually agreed upon by the
Departments and the MCO.

The HUSKY MCOs will identify BH NEMT data versus medical NEMT data in their NEMT
reporting to DSS. In addition, the HUSKY MCOs will track and trend NEMT
complaints related to BH visits separately from NEMT complaints related to
medical visits. The BHP ASO will also compile NEMT related complaints, although
these complaints will be forwarded to the HUSKY MCOs for resolution.

The MCOs will continue to include behavioral health access in their CAHPS survey
and report this information to the Departments.

School-Based Health Center Services

In general, BHP will be responsible for reimbursing school-based health centers
for behavioral health diagnostic and treatment services (CPT 90801-90807, 90853,
90846, and 90847) provided to students with a behavioral health diagnosis. The
HUSKY MCOs will be responsible for primary care services provided by
school-based health centers, regardless of diagnosis, but they will not be
responsible for behavioral health assessment and treatment services billed under
CPT codes 90801-90807, 90853, 90846, and 90847. The following narrative provides
additional background and a rationale for this arrangement.

School-based health centers currently provide a range of general health and
behavioral health services that are reimbursable under the HUSKY program. All of
these school-based health centers are licensed by the Department of Public
Health, either as freestanding outpatient clinics or as satellites under a
hospital license. Under these licenses, clinics can provide general medical
services as well as behavioral health services.

School-based health centers vary in their degree of expertise in the provision
of behavioral health services. Some school-based health centers provide
prevention and counseling for students with emotional or behavioral issues and
bill for those services using general primary care prevention and counseling
codes, often without a behavioral

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health diagnosis. Those primary care and preventive counseling services that are
currently covered under the MCO contracts with individual School-Based Health
Centers will continue to be the responsibility of the HUSKY MCOs.

Other school-based health centers have taken steps to develop their behavioral
health services including relying on licensed behavioral health practitioners
and/or affiliation agreements with local outpatient child psychiatric clinic
that provide clinical staff, consultation, or oversight. If the school-based
health center provides behavioral health diagnostic and treatment services,
these services will be the responsibility of the BHP ASO. The school-based
health center must enroll as a CMAP provider in order to be reimbursed for those
services under BHP.

In some cases, the behavioral health component of the school-based health
center's services is provided under the license of an outpatient child
psychiatric clinic. In this case, the outpatient child psychiatric clinic will
be enrolled as a CMAP provider and the services provided will be reimbursable as
behavioral health clinic services under BHP.

Transportation

All of the HUSKY MCOs will continue to provide transportation for HUSKY A
enrollees with behavioral health disorders for behavioral health services that
are covered under Medicaid. Specifically, the MCOs will continue to be
responsible for transportation to hospitals, clinics, and independent
professionals for routine outpatient, extended day treatment, intensive
outpatient, partial hospitalization, detoxification, methadone maintenance, and
inpatient psychiatric services. The MCOs will also be responsible for services
that might be covered under EPSDT. For example, case management services are not
included in the Connecticut Medicaid state plan, but they are covered under
EPSDT when medically necessary. Although case management does not necessarily
require transportation to a facility, if transportation to a facility were
necessary for a case management encounter, the MCOs would be responsible for
providing it. These policies under BHP are simply a continuation of current
HUSKY A program policies.

The MCOs will not be responsible for transportation for non-Medicaid services
such as respite, or DCF funded services that are designed to come to the client
including care coordination, emergency mobile psychiatric services, home-based
services, and therapeutic mentoring.

The transportation benefit for behavioral health visits will continue to be
subject to the same policies and procedures applicable to other HUSKY A covered
services. The Departments will issue a member services handbook that indicates
that transportation services are covered for HUSKY A enrollees and that such
services will be covered by the HUSKY MCO with which the member is enrolled. The
handbook will indicate that the MCO specific transportation policies apply, that
HUSKY MCO recipients should refer to their HUSKY member handbook for details,
and arrange for transportation directly with their HUSKY MCO transportation
broker.

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The ASO will make referrals to the closest appropriate providers (typically 3
names will be given upon request) and avoid referrals to facilities and offices
outside of a 25-30 mile radius unless circumstances require otherwise. The ASO
is not required to review provider distance from the member when responding to
requests for authorization. The transportation brokers will assess all requests
for transportation when contacted by the member and it will be up to the
transportation broker and the MCO to apply coverage limitations as appropriate
when contacted by the member. In most cases, the transportation broker and/or
the MCO will be able to make decisions about whether to authorize transportation
to the non-closest provider or to a provider that is outside of the 25-30 mile
radius by working directly with the member.   However, the ASO will be required
to respond to inquiries from the MCO or transportation broker if additional
information is needed to support authorization of a transportation request.

The HUSKY MCOs will also retain responsibility for all Emergency Medical
Transportation and associated charges, regardless of diagnosis, and
hospital-to-hospital ambulance transportation of members with a behavioral
health condition.

The BHP ASO is expected to work closely with the MCOs to monitor transportation
utilization and, if necessary, cooperate with the MCOs in conducting targeted
provider education or training related to the appropriate use of transportation
services. The HUSKY MCOs may track and trend utilization of transportation to
behavioral health facilities. Any increases in the utilization trend will be
addressed with the Departments.

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APPENDIX O

CTBHP Master Covered Services Table

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

 
 
CTBHP Covered Services Table Revised July 31,2006

0507

HUSKY A and B Appendix O - CT BHP Master Covered Services Table - September 2006
Coverage
1 = HUSKY MCO - All diagnoses
Responsibility
2= BHP -All diagnoses
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
 
4= Not covered
     
Code
General Hospital Inpatient
Coverage
110
Room & Board- Private
3
111
Room & Board- Private -Med/Surg/Gyn
3
112
Room & Board- Private -OB
3
113
Room & Board- Private -Pediatric
3
114
Room & Board - Private - Psychiatric
2
115
Room & Board- Private -Hospice
3
116
Room & Board - Private - Detox
2
117
Room & Board- Private -Oncology
3
118
Room & Board- Private -Rehab
3
119
Room & Board- Private -Other
3
120
Room & Board-Semi-Private/2 Bed
3
121
Room & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn
3
122
Room & Board-Semi-Private/ 2 Bed -OB
3
123
Room & Board-Semi-Private/ 2 Bed-Pediatric
3
124
Room & Board - Semi-Private/2 Bed - Psychiatric
2
125
Room & Board-Semi-Private/ 2 Bed-Hospice
3
126
Room & Board - Semi-Private/2 Bed - Detox
2
127
Room & Board-Semi-Private/ 2 Bed-Oncology
3
128
Room & Board-Semi-Private/ 2 Bed-Rehab
3
129
Room & Board-Semi-Private/ 2 Bed-Other
3
130
Room & Board-Semi-Private/3-4 Bed
3
131
Room & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn
3
132
Room & Board-Semi-Private/3-4 Bed-OB
3
133
Room & Board-Semi-Private/3-4 Bed-Pediatric
3
134
Room & Board - Semi-Private/3-4 Bed - Psychiatric
2
135
Room & Board-Semi-Private/3-4 Bed-Hospice
3
136
Room & Board - Semi-Private/3-4 Bed - Detox
2
137
Room & Board-Semi-Private/3-4 Bed-Oncology
3
138
Room & Board-Semi-Private/3-4 Bed-Rehab
3
139
Room & Board-Semi-Private/3-4 Bed-Other
3
140
Room & Board-Private-Deluxe
3
141
Room & Board-Private-Deluxe- Med/Surg/Gyn
3
142
Room & Board-Private - Deluxe-OB
3
143
Room & Board-Private - Deluxe-Pediatric
3
144
Room & Board - Private - Deluxe - Psychiatric
2
145
Room & Board-Private - Deluxe-Hospice
3
146
Room & Board - Private - Deluxe - Detox
2
147
Room & Board-Private - Deluxe-Oncology
3
148
Room & Board-Private - Deluxe-Rehab
3
149
Room & Board-Private - Deluxe-Other
3
150
Room & Board - Ward
3
151
Room & Board - Ward - Med/Surg/ Gyn
3
152
Room & Board - Ward - OB
3
153
Room & Board - Ward - Pediatric
3
154
Room & Board - Ward - Psychiatric
2
155
Room & Board - Ward - Hospice
3
156
Room & Board - Ward - Detox
2
157
Room & Board - Ward - Oncology
3
158
Room & Board - Ward - Rehab
3
159
Room & Board - Ward - Other
3
160
Other Room & Board
3
164
Other Room & Board - Sterile Environment
3
167
Other Room & Board - Self Care
3
169
Other Room & Board - Other
3
170
Room & Board- Nursery
3
171
Room & Board- Nursery - Newborn
3
172
Room & Board- Nursery - Premature
3
175
Room & Board- Nursery - Neonatal ICU
3
179
Room & Board- Nursery - Other
3

 
5/1/2007

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CTBHP Covered Services Table Revised July 31, 2006

0507

 
HUSKY A and B Appendix 0 - CT BHP Master Covered Services Table - September 2006
 
Coverage
1= HUSKY MCO - All diagnoses
 
Responsibility
2= BHP - All diagnoses
 
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
190
Subacute Care
3
200
Intensive Care
3
201
Intensive Care - Surgical
3
202
Intensive Care - Medical
3
203
Intensive Care - Pediatric
3
204
Intensive Care - Psychiatric
2
205
Intensive Care - Post ICU
3
207
Intensive Care - Burn Treatment
3
208
Intensive Care - Trauma
3
209
Intensive Care - Other
3
210
Coronary Care
3
211
Coronary Care - Myocardial Infarction
3
212
Coronary Care - Pulmonary
3
213
Coronary Care - Heart Transplant
3
214
Coronary Care - Post CCU
3
219
Coronary Care - Other
3
224
Late discharge/Medically necessary
4
 
Note: MCOs cover alcohol detoxification on a medical floor.
 
Code
General Hospital Emergency Department
Coverage
450
Emergency Room General Classification
1
451
EMTALA Emergency Medical Screening Services
1
452
Emergency Room Beyond EMTALA Screening
1
456
Urgent Care
1
459
Other Emergency Room
1
762
Observation room
3
981
Professional Fee - Emergency Department
1
     
Code
General Hospital Outpatient
Coverage
490
Ambulatory Surgery**
3
762
Observation room
3
900
Psychiatric Services General (Evaluation)
2
901
Electroconvulsive Therapy**
2
905
Intensive Outpatient Services - Psychiatric
2
906
Intensive Outpatient Services - Chemical Dependency
2
907
Community Behavioral Health Program (Day Treatment)
2
913
Partial Hospital
2
914
Individual Therapy
2
915
Group Therapy
2
916
Family Therapy
2
918
Psychiatric Service - Testing
3
919
Other - Med Admin
2
961
Professional Fees-Psychiatric
4
All others
 
1
 
Note: Includes outpatient provided by special care hospitals (e.g., Gaylord)
   
"MCOs pay for all professional services charges (e.g., anesthesiologist)
regardless of diagnosis, except psychiatrist charges.
 
Code
Psychiatric Hospital Inpatient (includes Riverview, CVH)
Coverage
100
All inclusive room and board plus ancillary
4
124
Room and Board-Psychiatric
2
126
Room & Board - Semi-Private/2 Bed - Detox
2
128
Room & Board-Semi-Private/ 2 Bed-Rehab
4
190
Subacute Care
2
224
Late discharge/Medically necessary
4
     
Code
Psychiatric Hospital Outpatient
Coverage
490
Ambulatory Surgery**
3
762
Observation room
2
900
Psychiatric Services General (Evaluation)
2
901
Electroconvulsive Therapy
2
905
Intensive Outpatient Services ^psychiatric
2
906
Intensive Outpatient Services - Chemical Dependency
2

 
5/1/2007
2 of 11 HUSKY A B Appendix 0 - BHP Master Covered Services Table 05/01/07]

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CTBHP Covered Services Table Revised July 31, 2006

0507

HUSKY A and B Appendix O - CT BHP Master Covered Services Table - September 2006
Coverage
1= HUSKY MCO -All diagnoses
Responsibility
2= BHP -All diagnoses
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
 
4= Not covered
907
Community Behavioral Health Program (Day Treatment)
2
913
Partial Hospital-More Intensive
2
914
Psychiatric Service-Individual Therapy
2
915
Psychiatric Service-Group Therapy
2
916
Psychiatric Service-Family Therapy
2
918
Psychiatric Service-Testing
2
919
Other- Med Admin
2
 
"MCOs pay for all professional services charges (e.g., anesthesiologist)
regardless of diagnosis, except psychiatrist charges.
 
Code
Alcohol and Drug Abuse Center (Non-hospital Inpatient Detox)
Coverage
H0011
Acute Detoxification (residential program inpatient)
2
     
Code
Alcohol and Drug Abuse Center (Ambulatory Detoxification)
Coverage
H0014
Ambulatory Detoxification
2
     
Code
PRTF
Coverage
T2048
Psychiatric health facility service, per diem
2
     
Code
DCF Residential
Coverage
N/A
DCF Funded residential facility
2
     
Code
Long Term Care Facility
Coverage
100
Per diem rate
1
183
Home reserve
1
185
Inpatient hospital reserve
1
189
Non-covered reserve
4
 
Note: Includes inpatient at special care hospitals.
 
Code
MH Clinic
Coverage
90801
Psychiatric Diagnostic Interview
2
90802
Interactive Psychiatric Diagnostic Interview
2
90804
Individual Psychotherapy- Office or other Outpatient (20-30 min)
2
90805
Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical
evaluation and management services
2
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90807
Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical
evaluation and management services
2
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90809
Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical
evaluation and management services
2
90810
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90811
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with
medical evaluation and management services
2
90812
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90813
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with
medical evaluation and management services
2
90814
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90815
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with
medical evaluation and management services
2
90846
Family Psychotherapy (without the patient present)
2
90847
Family Psychotherapy (conjoint psychotherapy) (with the patient present)
2
90849
Multi-group family psychotherapy
2
90853
Group psychotherapy
2
90857
Interactive group psychotherapy
2
90862
Pharmacologic management
2
90887
Interpretation or explanation of results of psychiatric or other medical
examinations and procedures or other accumulated data to family or other
responsible persons.
2
96101
Psychological testing, per hour
2
96110
Developmental testing and report, limited
2
96111
Developmental testing and report, extended
2
96118
Neuropsychological testing battery, per hour
2
H0015
Intensive Outpatient-Substance Dependence*
2
H0035
Mental health partial hospitalization, treatment, less than 24 hours (CMHC)*
2
H2012
Extended Day Treatment
p*ft**
H2013
Partial Hospitalization (non-CMHC)*
2*

 
5/1/2007

3 of 11 HUSKY A B Appendix O - BHP Master Covered Services Table 05/01/07]

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CTBHP Covered Services Table Revised July 31,2006

0507

HUSKY A and B Appendix O - CT BMP Master Covered Services Table - September 2006
Coverage
1= HUSKY MCO - All diagnoses
Responsibility
2= BMP -All diagnoses
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
 
4= Not covered
H2019
Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST,
HVS) (Clients under 21 only)
2***
T1017
Targeted case management, each 15 minutes (part of home-based services only -
IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only)
2
J1630
Jnjection, Haloperidol, up to 5 mg
2
J1631
Injection, Haloperidol decanoate, per 50 mg^
2
J2680
Injection, Fluphenazine decanoate, up to 25 mg
2
M0064
Brief office visit for the sole purpose of monitoring or changing drug
prescriptions used in the treatment of mental psychoneurotic and personality
disorders
2
S9480
Intensive Outpatient-Mental Health
2
S9484
Emergency mobile mental health service, follow-up (Clients under 21 only)
o***
S9485
Emergency mobile mental health service, initial evaluation (Clients under 21
only)
Oft**
T1016
Case Management - Coordination of health care services - each 15 min.
2
H0037
Community_psychiatric supportive treatment program, per diem
4
S9475
Ambulatory setting, substance abuse treatment or detoxification services
4
 
'Coverage restricted to providers approved by DSS to provide this service
   
*** Coverage restricted to providers certified by DCF to provide this service
   
""Coverage restricted to providers licensed by DCF to provide this service
       
Code
FQHC Mental Health Clinic
Coverage
90801
Psychiatric Diagnostic Interview
2
90802
Interactive Psychiatric Diagnostic Interview
2
90804
Individual Psychotherapy- Office or other Outpatient (20-30 min)
2
90805
Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical
evaluation and management services
2
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90807
Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical
evaluation and management services
2
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90809
Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical
evaluation and management services
2
90810
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90811
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with
medical evaluation and management services
2
90812
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90813
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with
medical evaluation and management services
2
90814
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90815
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with
medical evaluation and management services
2
90846
Family Psychotherapy (without the patient present)
2
90847
Family Psychotherapy (conjoint psychotherapy) (with the patient present)
2
90849
Multi-group family psychotherapy
2
90853
Group psychotherapy
2
90857
Interactive group psychotherapy
2
90862
Pharmacologic management
2
90887
Interpretation or explanation of results of psychiatric or other medical
examinations and procedures or other accumulated data to family or other
responsible persons.
2
96101
Psychological testing, per hour
2
96110
Developmental testing and report, limited
2
96111
Developmental testing and report, extended
2
96118
Neuropsychological testing battery, per hour
2
H0015
Intensive Outpatient-Substance Dependence*
2
H2012
Extended Day Treatment
n****
H2013
Partial Hospitalization (non-CMHC)*
2*
J1630
Injection, Haloperidol, up to 5 mg
2
J1631
Injection, Haloperidol decanoate, per 50 mg
2
J2680
Injection, Fluphenazine decanoate, up to 25 mg
2
M0064
Brief office visit for the sole purpose of monitoring or changing drug
prescriptions used in the treatment of mental psychoneurotic and personality
disorders
2
S9480
Intensive Outpatient-Mental Health
2
S9484
Emergency mobile mental health service, follow-up (Clients under 21 only)
2***
S9485
Emergency mobile mental health service, initial evaluation (Clients under 21
only)
o***
T1015
Clinic visit/encounter all-inclusive (For use by FQHC MH Clinics)
2

 
5/1/2007
4 of 11 HUSKY A B Appendix O - BHP Master Covered Services Table 05/01/07]

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CTBHP Covered Services Table Revised July 31, 2006

0507

 
HUSKY A and B Appendix O - CT BHP Master Covered Services Table - September 2006
 
Coverage
1= HUSKY MCO - All diagnoses
 
Responsibility
2= BHP - All diagnoses
 
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
H0037
Community psychiatric supportive treatment program, per diem
4
S9475
Ambulatory setting, substance abuse treatment or detoxification services
4
 
'Coverage restricted to providers approved by DSS to provide this service
       
Code
Rehabilitation Clinic
Coverage
90801
Psychiatric Diagnostic Interview
3
90804
Individual Psychotherapy- Office or other Outpatient (20-30 min)
3
90805
Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical
evaluation and management services
3
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
3
90807
Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical
evaluation and management services
3
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
3
90809
Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical
evaluation and management services
3
90846
Family psychotherapy (without the patient present)
3
90847
Family psychotherapy (conjoint)
3
90853
Group psychotherapy
3
90857
Interactive Group therapy
3
96118
Neuropsychological testing battery, per hour
3
All others
 
1
     
Code
School-Based Health Centers (Freestanding Medical Clinic)
Coverage
90782
Therapeutic or diagnostic injection; subcutaneous or intramuscular
1
90783
Therapeutic or diagnostic injection; intra-arterial
1
90784
Therapeutic or diagnostic injection; intravenous
1
90801
Psychiatric Diagnostic Interview
3
90804
Individual psychotherapy (20-30 min)
3
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90846
Family psychotherapy (without the patient present)
3
90847
Family psychotherapy (conjoint psychotherapy w/patient present)
3
90853
Group psychotherapy (other than of a multiple-family group)
3
99211
Office or other outpatient visit for the evaluation and management of an
established patient, that may not require the presence of a physician.
(Typically 5 minutes)
1
99212
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
problem focused history; problem focused examination; straightforward medical
decision-making. (Typically 10 minutes face-to-face)
1
99213
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
expanded problem focused history; expanded problem focused examination; medical
decision making of low complexity. (Typically 15 minutes face-to-face)
1
99214
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
detailed history; detailed examination; medical decision making of moderate
complexity (Typically 25 minutes face-to-face)
1
99215
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
comprehensive history; comprehensive examination; medical decision making of
high complexity (Typically 40 minutes face-to-face)
1
All others
 
1
     
Code
School-Based Health Centers (FQHC Medical Clinic)
Coverage
90782
Therapeutic or diagnostic injection; subcutaneous or intramuscular
1
90783
Therapeutic or diagnostic injection; intra-arterial
1
90784
Therapeutic or diagnostic injection; intravenous
1
90801
Psychiatric Diagnostic Interview
3
90804
Individual psychotherapy (20-30 min)
3
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90846
Family psychotherapy (without the patient present)
3
90847
Family psychotherapy (conjoint psychotherapy w/patient present)
3
90853
Group psychotherapy (other than of a multiple-family group)
3
T1015
Clinic visit/encounter all-inclusive (For use by FQHC Clinics)
2
99211
Office or other outpatient visit for the evaluation and management of an
established patient, that may not require the presence of a physician.
(Typically 5 minutes)
1

5/1/2007

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CTBHP Covered Services Table Revised July 31, 2006

0507

HUSKY A and B Appendix O - CT BHP Master Covered Services Table - September 2006
Coverage
1 = HUSKY MCO - All diagnoses
Responsibility
2= BHP - All diagnoses
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
 
4= Not covered
99212
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
problem focused history; problem focused examination; straightforward medical
decision-making. (Typically 10 minutes face-to-face)
1
99213
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
expanded problem focused history; expanded problem focused examination; medical
decision making of low complexity. (Typically 15 minutes face-to-face)
1
99214
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
detailed history; detailed examination; medical decision making of moderate
complexity (Typically 25 minutes face-to-face)
1
99215
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
comprehensive history; comprehensive examination; medical decision making of
high complexity (Typically 40 minutes face-to-face)
1
All others
 
1
     
Code
Methadone Clinic
Coverage
H0020
Methadone service; rate includes all services for which the source of service is
the methadone maintenance clinic.
2
     
Code
MD, DO and APRN other than Psychiatrist or Psychiatric APRN
Coverage
00104
Anesthesia for electroconvulsive therapy
1
80100
Drug screen, qualitative, chromatographic method, each procedure
1
81000
Urinalysis, by dip stick or tablet reagent, non-automated, with microscopy
1
83840
Methadone chemistry (quantitative analysis)
1
90782
Therapeutic or diagnostic injection; subcutaneous or intramuscular
1
90783
Therapeutic or diagnostic injection; intra-arterial
1
90784
Therapeutic or diagnostic injection; intravenous
1
908XX
Psychotherapy codes
4
99211
Office or other outpatient visit for the evaluation and management of an
established patient, that may not require the presence of a physician.
(Typically 5 minutes)
1
99212
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
problem focused history; problem focused examination; straightforward medical
decision making (Typically 10 minutes face-to-face)
1
99213
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
expanded problem focused history; expanded problem focused examination; medical
decision making of low complexity. (Typically 15 minutes face-to-face)
1
99214
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
detailed history; detailed examination; medical decision making of moderate
complexity (Typically 25 minutes face-to-face)
1
99215
Office or other outpatient visit for the evaluation and management of an
established patient, which requires at least two of these three components:
comprehensive history; comprehensive examination; medical decision making of
high complexity (Typically 40 minutes face-to-face)
1
All others
 
1
     
Code
Psychiatrist (MD or DO)
Coverage
90801
Diagnostic Interview
2
90802
Interactive Diagnostic Interview
2
90804
Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90805
Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical
evaluation and management services
2
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90807
Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical
evaluation and management services
2
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90809
Individual PsychotherapyjOffice or other Outpatient (75-80 min) with medical
evaluation and management services
2
90810
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90811
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with
medical evaluation and management services
2
90812
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90813
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with
medical evaluation and management services
2
90814
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90815
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with
medical evaluation and management services
2

5/1/2007

6 of 11 HUSKY A B Appendix O - BHP Master Covered Services Table 05/01/07]

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CTBHP Covered Services Table Revised July 31, 2006

0507

 
HUSKY A and B Apjoejrdixjg^CT BMP Master Covered Services Table - September 2006
 
Coverage
1 = HUSKY MCO - All diagnoses
 
Responsibility
2= BHP- All diagnoses
 
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
90816
Individual Psychotherapy-Facility Based (20-30 min)
2
90817
90816 with medical evaluation and management
2
90818
Individual psychotherapy, insight oriented 45-50 minutes
2
90819
90818 with medical evaluation and management
2
90821
Individual Psychotherapy-Facility Based (75-80 min)
2
90822
Individual Psychotherapy-Facility Based (75-80 min) with med management
2
90823
Interactive Individual Psychotherapy-Facility Based (20-30 min)
2
90824
Interactive Individual Psychotherapy-Facility Based (20-30 min) med management
2
90826
Interactive Individual Psychotherapy-Facility Based (45-50 min)
2
90827
Interactive Individual Psychotherapy-Facility Based (45-50 min) med management
2
90828
Interactive Individual Psychotherapy-Facility Based (75-80 min)
2
90829
Interactive Individual Psychotherapy-Facility Based (75-80 min) med management
2
90846
Family Psychotherapy (without the patient present)
2
90847
Family Psychotherapy (conjoint)
2
90849
Multi-group family psychotherapy
2
90853
Group Psychotherapy
2
90857
Interactive Group psychotherapy
2
90862
Pharmacological management, including prescription, use, and review of
medication with no more than minimal medical psychotherapy
2
90865
Narcosynthesis for Psychiatric Diagnostic and Therapeutic purposes
2
90870
Electroconvulsive therapy (including necessary monitoring); single seizure
2
90875
Individual psychophysiological therapy incorporating biofeedback training (20-30
min)
2
90876
Individual psychophysiological therapy incorporating biofeedback training (45-50
min)
2
90880
Hypnotherapy
2
90887
Interpretation or explanation of results of psychiatric or other medical
examinations and procedures or other accumulated data to family or other
responsible persons.
2
96101
Psychological testing, per hour
2
96110
Developmental testing with report
2
96111
Developmental testing, extended
2
96118
Neuropsychological testing battery, per hour
2
99201
Office or other outpatient visit, 10 minutes, new patient
2
99202
Office or other outpatient visit, 20 minutes, new patient
2
99203
Office or other outpatient visit, 30 minutes, new patient
2
99204
Office or other outpatient visit, 45 minutes, new patient
2
99205
Office or other outpatient visit, 60 minutes, new patient
2
99211
Office or other outpatient visit, 5 minutes, established patient
2
99212
Office or other outpatient visit, 10 minutes, established patient
2
99213
Office or other outpatient visit, 15 minutes, established patient
2
99214
Office or other outpatient visit, 25 minutes, established patient
2
99215
Office or other outpatient visit, 40 minutes, established patient
2
99217
Observation care discharge
2
99218
Initial observation care, low severity
2
99219
Initial observation care, moderate severity
2
99220
Initial observation care, high severity
2
99221
Inpatient hospital care, 30 minutes
2
99222
Inpatient hospital care, 50 minutes
2
99223
Inpatient hospital care, 70 minutes
2
99231
Subsequent hospital care, 15 minutes
2
99232
Subsequent hospital care, 25 minutes
2
99233
Subsequent hospital care, 35 minutes
2
99234
Observation of inpatient hospital care, low severity
2
99235
Observation of inpatient hospital care, moderate severity
2
99236
Observation of inpatient hospital care, high severity
2
99238
Hospital discharge day management 30 minutes or less
2
99239
Hospital discharge day management more than 30 minutes
2
99241
Office consultation for a new or established patient, approximately 15 minutes
2
99242
Office consultation for a new or established patient, approximately 30 minutes
2
99243
Office consultation for a new or established patient, approximately 40 minutes
2
99244
Office consultation for a new or established patient, approximately 60 minutes
2
99245
Office consultation for a new or established patient, approximately 80 minutes
2
99251
Initial inpatient consultation, 20 minutes
2

5/1/2007

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CTBHP Covered Services Table Revised July 31, 2006

0507

 
HUSKY A and B Appendix 0 - CT BHP Master Covered Services Table - September 2006
 
Coverage
1= HUSKY MCO - All diagnoses
 
Responsibility
2= BHP - All diagnoses
 
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
99252
Initial inpatient consultation, 40 minutes
2
99253
Initial inpatient consultation, 55 minutes
2
99254
Initial inpatient consultation, 80 minutes
2
99255
Initial inpatient consultation, 110 minutes
2
99271
Confirmatory consultation, limited or minor
2
99272
Confirmatory consultation, low severity
2
99273
Confirmatory consultation, moderate severity
2
99274
Confirmatoryjjonsultation, moderate to high severity
2
99275
Confirmatory consultation, high severity
2
99281
Emergency department visit, minor severity
2
99282
Emergency department visit, low to moderate severity
2
99283
Emergency department visit, moderate severity
2
99284
Emergency department visit, high severity
2
99285
Emergency department visit, high severity with significant threat
2
J1630
Injection, Haloperidol, up to 5 mg
2
J1631
Injection, Haloperidol decanoate, per 50 mg
2
J2680
Injection, Fluphenazine decanoate, up to 25 mg
2
M0064
Brief office visit for the sole purpose of monitoring or changing prescriptions
used in the treatment of mental psychoneurotic or personality disorders
2
T1016
Case Management - Coordination of health care services - each 15 min.
2
All others
 
4
     
Code
Psychiatric APRN
Coverage
90801
Diagnostic Interview
2
90802
Interactive Diagnostic Interview
2
90804
Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90805
Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical
evaluation and management services
2
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90807
Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical
evaluation and management services
2
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90809
Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical
evaluation and management services
2
90810
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90811
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with
medical evaluation and management services
2
90812
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90813
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with
medical evaluation and management services
2
90814
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90815
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with
medical evaluation and management services
2
90816
Individual Psychotherapy-Facility Based (20-30 min)
2
90817
90816 with medical evaluation and management
2
90818
Individual psychotherapy, insight oriented 45-50 minutes
2
90819
90818 with medical evaluation and management
2
90821
Individual Psychotherapy-Facility Based (75-80 min)
2
90822
Individual Psychotherapy-Facility Based (75-80 min) with med management
2
90823
Interactive Individual Psychotherapy-Facility Based (20-30 min)
2
90824
Interactive Individual Psychotherapy-Facility Based (20-30 min) med management
2
90826
Interactive Individual Psychotherapy-Facility Based (45-50 min)
2
90827
Interactive Individual Psychotherapy-Facility Based (45-50 min) med management
2
90828
Interactive Individual Psychotherapy-Facility Based (75-80 min)
2
90829
Interactive Individual Psychotherapy-Facility Based (75-80 min) med management
2
90846
Family Psychotherapy (without the patient present)
2
90847
Family Psychotherapy (conjoint)
2
90849
Multi-group family psychotherapy
2
90853
Group Psychotherapy
2
90857
Interactive Group psychotherapy
2
90862
Pharmacological management, including prescription, use, and review of
medication with no more than minimal medical psychotherapy
2
90865
Narcosynthesis for Psychiatric Diagnostic and Therapeutic purposes
2

5/1/2007

8 of 11 HUSKY A B Appendix 0 - BHP Master Covered Services Table 05/01/07]

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CTBHP Covered Services Table Revised July 31,2006

0507

 
HUSKY A and B Appendix O - CT BHP Master Covered Services Table - September 2006
 
Coverage
1= HUSKY MCO - All diagnoses
 
Responsibility
2= BHP - All diagnoses
 
Legend:
3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
90870
Electroconvulsive therapy (including necessary monitoring); single seizure
2
90875
Individual psychophysiological therapy incorporating biofeedback training (20-30
min)
2
90876
Individual psychophysiological therapy incorporating biofeedback training (45-50
min)
2
90880
Hypnotherapy
2
90887
Interpretation or explanation of results of psychiatric or other medical
examinations and procedures or other accumulated data to family or other
responsible persons.
2
96101
Psychological testing, per hour
2
96110
Developmental testing with report
2
96111
Developmental testing, extended
2
96118
Neuropsychological testing battery, per hour
2
99201
Office or other outpatient visit, 10 minutes, new patient
2
99202
Office or other outpatient visit, 20 minutes, new patient
2
99203
Office or other outpatient visit, 30 minutes, new patient
2
99204
Office or other outpatient visit, 45 minutes, new patient
2
99205
Office or other outpatient visit, 60 minutes, new patient
2
99211
Office or other outpatient visit, 5 minutes, established patient
2
99212
Office or other outpatient visit, 10 minutes, established patient
2
99213
Office or other outpatient visit, 15 minutes, established patient
2
99214
Office or other outpatient visit, 25 minutes, established patient
2
99215
Office or other outpatient visit, 40 minutes, established patient
2
99217
Observation care discharge
2
99218
Initial observation care, low severity
2
99219
Initial observation care, moderate severity
2
99220
Initial observation care, high severity
2
99221
Inpatient hospital care, 30 minutes
2
99222
Inpatient hospital care, 50 minutes
2
99223
Inpatient hospital care, 70 minutes
2
99231
Subsequent hospital care, 15 minutes
2
99232
Subsequent hospital care, 25 minutes
2
99233
Subsequent hospital care, 35 minutes
2
99234
Observation of inpatient hospital care, low severity
2
99235
Observation of inpatient hospital care, moderate severity
2
99236
Observation of inpatient hospital care, high severity
2
99238
Hospital discharge day management 30 minutes or less
2
99239
Hospital discharge day management more than 30 minutes
2
99241
Office consultation for a new or established patient, approximately 15 minutes
2
99242
Office consultation for a new or established patient, approximately 30 minutes
2
99243
Office consultation for a new or established patient, approximately 40 minutes
2
99244
Office consultation for a new or established patient, approximately 60 minutes
2
99245
Office consultation for a new or established patient, approximately 80 minutes
2
99251
Initial inpatient consultation, 20 minutes
2
99252
Initial inpatient consultation, 40 minutes
2
99253
Initial inpatient consultation, 55 minutes
2
99254
Initial inpatient consultation, 80 minutes
2
99255
Initial inpatient consultation, 110 minutes
2
99271
Confirmatory consultation, limited or minor
2
99272
Confirmatory consultation, low severity
2
99273
Confirmatory consultation, moderate severity
2
99274
Confirmatory consultation, moderate to high severity
2
99275
Confirmatory consultation, high severity
2
99281
Emergency department visit, minor severity
2
99282
Emergency department visit, low to moderate severity
2
99283
Emergency department visit, moderate severity
2
99284
Emergency department visit, high severity
2
99285
Emergency department visit, high severity with significant threat
2
J1630
Injection, Haloperidol, up to 5 mg
2
J1631
Injection, Haloperidol decanoate, per 50 mg
2
J2680
Injection, Fluphenazine decanoate, up to 25 mg
2
M0064
Brief office visit for the sole purpose of monitoring or changing prescriptions
used in the treatment of mental psychoneurotic or personality disorders
2
T1016
Case Management - Coordination of health care services - each 15 min.
2

5/1/2007

9 of 11 HUSKY A B Appendix O - BHP Master Covered Services Table 05/01/07]

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CTBHP Covered Services Table Revised July 31, 2006

0507

HUSKY A and B Appendix O;- CT BMP Master Covered Services Table
- September 2006
Coverage
1= HUSKY MCO - All diagnoses
Responsibility
2= BMP - All diagnoses
Legend:
3= BMP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
All others
 
4
     
Code
Psychologist and Psychologist Group
Coverage
90801
Diagnostic Interview
2
90802
Interactive Diagnostic Interview
2
90804
Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90810
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90812
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90814
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90816
Individual Psychotherapy-Facility Based (20-30 min)
2
90818
Individual psychotherapy, insight oriented 45-50 minutes
2
90821
Individual Psychotherapy-Facility Based (75-80 min)
2
90823
Interactive Individual Psychotherapy-Facility Based (20-30 min)
2
90826
Interactive Individual Psychotherapy-Facility Based (45-50 min)
2
90828
Interactive Individual Psychotherapy-Facility Based (75-80 min)
2
90846
Family Psychotherapy (without the patient present)
2
90847
Family Psychotherapy (conjoint)
2
90849
Multi-group family psychotherapy
2
90853
Group Psychotherapy
2
90857
Interactive Group psychotherapy
 
2
90875
Individual psychophysiological therapy incorporating biofeedback training (20-30
min)
2
90876
Individual psychophysiological therapy incorporating biofeedback training (45-50
min)
2
90880
Hypnotherapy
 
2
90887
Interpretation or explanation of results of psychiatric or other medical
examinations and procedures or other accumulated data to family or other
responsible persons. .
2
96101
Psychological testing, per hour
2
96110
Developmental testing with report
2
96111
Developmental testing, extended
2
96118
Neuropsychological testing battery, per hour
2
T1016
Case Management - Coordination of health care services - each 15 min.
2
           
Code
Independent Practice Behavioral Health Professional (LCSW, LMFT, LPC, LADC)
Coverage
90801
Diagnostic Interview
2
90802
Interactive Diagnostic Interview
2
90804
Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90806
Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90808
Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90810
Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)
2
90812
Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)
2
90814
Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)
2
90816
Individual Psychotherapy-Facility Based (20-30 min)
2
90818
Individual psychotherapy, insight oriented 45-50 minutes
2
90821
Individual Psychotherapy-Facility Based (75-80 min)
2
90823
Interactive Individual Psychotherapy-Facility Based (20-30 min)
2
90826
Interactive Individual Psychotherapy-Facility Based (45-50 min)
2
90828
Interactive Individual Psychotherapy-Facility Based (75-80 min)
2
90846
Family Psychotherapy (without the patient present)
2
90847
Family Psychotherapy (conjoint)
2
90849
Multi-group family psychotherapy
 
2
90853
Group Psychotherapy
 
2
90857
Interactive Group psychotherapy
2
90875
Individual psychophysiological therapy incorporating biofeedback training (20-30
min)
2
90876
Individual psychophysiological therapy incorporating biofeedback training (45-50
min)
2
90880
Hypnotherapy
2
90887
Interpretation or explanation of results of psychiatric or other medical
examinations and procedures or other accumulated data to family or other
responsible persons.
2
96110
Developmental testing with report
2

5/1/2007

10 of 11 HUSKY A B Appendix O - BMP Master Covered Services Table 05/01/07]

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

 
CTBHP Covered Services Table Revised July 31, 2006

0507

 
HUSKY A and B Appendix O - CT BMP Master Covered Services Table - September 2006
 
Coverage
1= HUSKY MCO - All diagnoses
 
Responsibility
2= BMP - All diagnoses
 
Legend:
3= BMP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
   
4= Not covered
 
96111
Developmental testing, extended
2
T1016
Case Management - Coordination of health care services - each 15 min.
2
     
Code
Home Health Care Agencies
Coverage
RCC/HCPC
   
421
Physical Therapy
1
424
Physical Therapy Evaluation
1
431
Occupational Therapy
1
434
Occupational Therapy Evaluation
1
441
Speech Therapy
1
444
Speech Therapy Evaluation
1
570/T1004
Services of a qualified nursing aide, up to 15 minutes
3
580/S9123
Nursing care, in the home by an RN, per hour
3
580/S9124
Nursing Care, in the home by an LPN, per hour
3
580/T1001
Nursing Assessment/Evaluation
3
580/T1002
RN Services, up to 15 minutes
3
580/T1003
LPN/LVN services, up to 15 minutes
3
580/T1502
Administration of oral, intramuscular and/or subcutaneous medication by health
care agency/professional, per visit
3
 
*BHP covers home health services for children with autism including when autism
is co-morbid with mental retardation.
 
Code
Independent Occupational Therapist
Coverage
All codes
 
1
     
Code
Independent Physical Therapist
Coverage
All codes
 
1
     
Code
Medical Transportation
Coverage
All codes
 
1
     
Code
Emergency Medical Transportation
Coverage
All codes
 
1
     
Code
Independent Laboratory Services
Coverage
80100
Drug screen, qualitative, chromatographic method, each procedure
1
81000
Urinalysis, by dip stick or tablet reagent, non-automated, with microscopy
1
83840
Methadone chemistry (quantitative analysis)
1
All other codes
 
1
     
Code
Pharmacy
Coverage
All codes
 
1
     
Code
Other Community Services
Coverage
H2017
Psychosocial Rehabilitation services, per 15 minutes
 
H2019
Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST,
HBV) (Clients under 21 only)
2
T1017
Targeted case management, each 15 minutes (part of home-based services only -
IICAPS, MST, MDFT, FFT, FST, HBV) (Clients under 21 only)
2***
H2032
Activity Therapy, per 15 minutes (Therapeutic Mentoring/Behavioral Management
Service) (Clients under 21 only)
2***
 
"'Coverage restricted to providers certified by DCF to provide this service
   
""Coverage restricted to providers licensed by DCF to provide this service
 

5/1/2007

11 of 11 HUSKY A B Appendix 0 - BHP Master Covered Services Table 05/01/07]