Exhibit 10.6.5

(SEAL) [w99373w9937300.gif]

State of New Jersey

DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

PO Box 712

          JAMES E. MCGREEVEY   TRENTON, NJ 08625-0712   JAMES M. DAVY Governor  
TELEPHONE 1-800-356-1561   Commissioner                 ANN CLEMENCY KOHLER    
  Director

June 1, 2004

Norine Yukon
President & CEO
AMERIGROUP New Jersey, Inc.
399 Thornall Street, 9th Floor
Edison, NJ 08837

Dear Ms. Yukon:

Enclosed is your copy of a recently processed contract amendment.

The amendment will extend the NJ Care 2000+ managed care contract through
June 30, 2005. This amendment has been approved by the Centers for Medicare and
Medicaid Services (CMS).

Thank you.

     

  Sincerely,
 
   

  Rita Hemingway

  Director, Contract Relations

  Office of Managed Health Care

RH:dv
Enclosure
c: Jill Simone, MD
    John Koehn

(PEOPLE FIRST LOGO) [w99373w9937301.gif]

 

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

 

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

AMERIGROUP NEW JERSEY, INC.

AGREEMENT TO PROVIDE HMO SERVICES

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date October 1, 2000, all parties agree that the contract shall be
amended, effective July 1, 2004 , as follows:

1.   Article 1, “Definitions”, the definition of Complaint shall be amended as
reflected in the relevant page of Article 1 attached hereto and incorporated
herein.

 

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

 

2.   Article 4, “Provision of Health Care Services” Sections 4.1.1.Q (new);
4.1.2(A)24; 4.1.4(A); 4.1.4(B); 4.1.5(A); 4.2.1(E); 4.2.6(B)7(d)ii;
4.2.6(B)7(f)ii.1; 4.4(B)1; 4.6.1(C)5; 4.6.2(P); 4.6.2(Q)1; 4.8.3(B) (new);
4.8.5; 4.8.8(H)7; 4.8.8(1); 4.8.8(M)3(c); 4.8.8(M)3(j); 4.8.8(M)3(n);
4.8.8(M)3(q); 4.8.8(M)3(s) and 4.9.2 shall be amended as reflected in Article 4,
Sections 4:1.1.Q, 4.1.2(A)24, 4.1.4(A), 4.1.4(B), 4.1.5(A), 4.2.1(E),
4.2.6(B)7(d)ii, 4.2.6(B)7(f)ii.1, 4.4(B)1, 4.6.1(C)5, 4.6.2(P), 4.6.2(0)1,
4.8.3(B), 4.8.5, 4.8.8(H)7, 4.8.8(1), 4.8.8(M)3(c), 4.8.8(M)3(j), 4.8.8(M)3(n),
4.8.8(M)3(q), 4.8.8(M)3(s) and 4.9.2 attached hereto and incorporated herein.  
3.   Article 5, “Enrollee Services” Sections 5.5(G); 5.8.2(S) and 5.15.1(A)
shall be amended as reflected in Article 5, Sections 5.5(G), 5.8.2(S) and
5.15.1(A) attached hereto and incorporated herein.   4.   Article 6, “Provider
Information” Section 6.2(D) shall be amended as reflected in Article 6,
Section 6.2(D) attached hereto and incorporated herein.   5.   Article 7, “Terms
and Conditions” Sections 7.16.7(A)1; 7.16.7(B)1; 7.20.2(C); 7.26(F) and 7.26(L)
(new) shall be amended as reflected in Article 7, Sections 7.16.7(A)1,
7.16.7(B)1, 7.20.2(C), 7.26(F) and 7.26(L) attached hereto and incorporated
herein.   6.   Article 8, “Financial Provisions” Sections 8.5.4; 8.8(0) and
8.10(B) shall be amended as reflected in Article 8, Sections 8.5.4, 8.8(0) and
8.10(B) attached hereto and incorporated herein.   7.   Appendix, Section A,
“Reports”

•   A.4.1 - Provider Network File: Attachment E (revised);   •   A.4.2 - Organ
Transplant Procedure (new);   •   A.4.4 - Certification of Provider Network
Report;

 

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

 

•   A.7.1 - Certifications: 1) Certification of Enrollment Information Relating
to Payment Under The Medicaid/NJ FamilyCare Programs; 2) Certification of
Encounter Information Relating to Payment Under the Medicaid/NJ FamilyCare
Programs; 3) Certification of .Any Information Required By the State and
Contained in Contracts Proposals and Related Documents Relating to Payments
Under the Medicaid/NJ FamilyCare Programs;   •   A. 7.8 - Table 6D: Revenue and
Expenses, Summary of MCSA Groups on. Claims Paid During Current Quarter (new); .
  •   A. 7.8 - Table 6E: Revenue and Expenses, Summary of MCSA Groups on Claims
Paid Year to Date (new);   •   A.7.20 - Table 18B: Federally Qualified Health
Center Encounters (new);   •   A.7.21 - Table 19: Income Statement By Rate Cell
Grouping, Table 19A thru V;   •   A.7.22 - Table 20: Lag Reports   •  
A.7.24 - Table 22: Plan H Invoice Form

shall be amended as reflected in Appendix, Section A, A.4.1, A.4.2, A.4.4,
A.7.1, A.7.8, A.7.20, A.7.21, A.7.22 and A.7.24 attached hereto and incorporated
herein.

8. Appendix, Section B, “Reference Materials”

•   B.5.2 - Cost-Sharing Requirements for NJ FamilyCare Plan C, Plan D and Plan
H Beneficiaries;   •   B.7.3 - Financial Guide for Reporting Medicaid/NJ
FamilyCare Rate Cell Grouping Costs; and   •   B.7.5 - EPSDT Codes;

   shall be amended as reflected in Appendix, Section B, B.5.2, B.7.3, and B.7.5
attached hereto and incorporated herein.

9.   Appendix, Section C, “Capitation Rates,” shall be revised as reflected in
SFY 2005 Capitation Rates attached hereto and incorporated herein

 

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

 

All other terms and conditions of the October 1, 2000 contract and subsequent
amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.

                  AMERIGROUP   State of New Jersey
 
                New Jersey, Inc.   Department of Human Services
 
           
BY:
/s/ Norine Yukon   BY:   (-s- Ann Clemency Kohler) [w99373w9937302.gif]

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

         

          Ann Clemency Kohler
 
            TITLE: President & CEO   TITLE: Director, DMAHS
 
            DATE: March 23, 2004   DATE: April 13, 2004
 
            APPROVED AS TO FORM ONLY        
 
            Attorney General        
 
            State of New Jersey        
 
            BY:   (-s- SIGNATURE) [w99373w9937303.gif]
 
               Deputy Attorney General        
 
            DATE: April 2, 2004        

 

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

 

with the contractor. Marketing by an employee of the contractor is considered
direct; marketing by an agent is considered indirect.

Commissioner—the Commissioner of the New Jersey Department of Human Services or
a duly authorized representative.

Complaint—a protest by an enrollee as to the conduct by the contractor or any
agent of the contractor, or an act or failure to act by the contractor or any
agent of the contractor, or any other matter in which an enrollee feels
aggrieved by the contractor, that is communicated to the contractor and that
could be resolved by the contractor within five (5) business days, except for
urgent situations, and as required by the exigencies of the situation.

Complaint Resolution-completed actions taken to fully settle a complaint to the
DMAHS’ satisfaction.

Comprehensive Risk Contract—a risk contract that covers comprehensive services,
that is, inpatient hospital services and any of the following services, or any
three or more of the following services:

1. Outpatient hospital services.

2. Rural health clinic services.

3. FQHC services.

4. Other laboratory and X-ray services.

5. Nursing facility (NF) services.

6. Early and periodic screening, diagnosis and treatment (EPSDT) services.

7. Family planning services.

8. Physician services.

9. Home health services.

Condition—a disease, illness, injury, disorder, or biological or psychological
condition or status for which treatment is indicated.

Contested Claim—a claim that is denied because the claim is an ineligible claim,
the claim submission is incomplete, the coding or other required information to
be submitted is incorrect, the amount claimed is in dispute, or the claim
requires special treatment.

Continuity of Care—the plan of care for a particular enrollee that should assure
progress without unreasonable interruption.

Contract—the written agreement between the State and the contractor, and
comprises the contract, any addenda, appendices, attachments, or amendments
thereto.

Contracting Officer—the individual empowered to act and respond for the State
throughout the life of any contract entered into with the State.

Contractor—the Health Maintenance Organization with a valid Certificate of
Authority in New Jersey that contracts hereunder with the State for the
provision of comprehensive

     
Amended as of July 1, 2004
  I-5

 

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

 

N.   Protection of Enrollee-Provider Communications. Health care professionals
may not be prohibited from advising their patients about their health status or
medical care or treatment, regardless of whether this care is covered as a
benefit under the contract.   O.   Medical or Dental Procedures. For procedures
that may be considered either medical or dental such as surgical procedures for
fractured jaw or removal of cysts, the contractor shall establish written
policies and procedures clearly and definitively delineated for all providers
and administrative staff, indicating that either a physician specialist or oral
surgeon may perform the procedure and, when, where, and how authorization, if
needed, shall be promptly obtained.   P.   Out-of-Network Services. If the
contractor is unable to provide in-network necessary services, covered under the
contract to a particular enrollee, the contractor must adequately and timely
cover those services out-of-network for the enrollee, for as long as the
contractor is unable to provide them in-network.   Q.   Termination of Benefits.
For benefits terminated at the direction of the State, the contractor shall be
responsible for previously authorized services for a period of sixty (60) days
after the effective date of termination.

4.1.2 BENEFIT PACKAGE

A.  
The following categories of services shall be provided by the contractor for all
Medicaid and NJ FamilyCare Plans A, B, and C enrollees, except where indicated.
See Section B.4.1 of the Appendices for complete definitions of the covered
services.

      1.   Primary and Specialty Care by physicians and, within the scope of
practice and in accordance with State certification/licensure requirements,
standards and practices, by Certified Nurse Midwives, Certified Nurse
Practitioners, Clinical Nurse Specialists, and Physician Assistants

      2.  
Preventive Health Care and Counseling and Health Promotion

      3.  
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program Services

     
For NJ FamilyCare Plans B and C participants, coverage includes early and
periodic screening and diagnosis medical examinations, dental, vision, hearing,
and lead screening services. It includes only those treatment services
identified through the examination that are available under the contractor’s
benefit package or specified services under the FFS program.
  4.  
Emergency Medical Care

     
Amended as of July 1, 2004
  IV-4

 

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

 

21.   Medical Supplies   22.   Prosthetics and Orthotics including certified
shoe provider.   23.   Dental Services   24.   Organ Transplants - includes
donor and recipient costs. Exception: The contractor will not be responsible for
transplant-related donor and recipient inpatient hospital costs for an
individual placed on a transplant list while in the Medicaid FFS program prior
to initial enrollment into the contractor’s plan.   25.   Transportation
Services for any contractor-covered service or non-contractor covered service
including ambulance, mobile intensive care units (MICUs) and invalid coach
(including lift equipped vehicles)   26.   Post-acute Care   27.   Mental
Health/Substance Abuse Services for enrollees who are clients of the Division of
Developmental Disabilities

B.  
Conditions Altering Mental Status. Those diagnoses which are categorized as
altering the mental status of an individual but are of organic origin shall be
part of the contractor’s medical, financial and care management responsibilities
for all categories of enrollees. These include the diagnoses in the following
ICD-9-CM Series:

1.   290.0 Senile dementia, simple type   2.   290.1 Presenile dementia   3.  
290.10 Presenile dementia, uncomplicated   4.   290.11 Presenile dementia with
delerium   5.   290.12 Presenile dementia with delusional features   6.   290.13
Presenile dementia with depressive features   7.   290.2 Senile dementia with
delusional or depressive features   8.   290.20 Senile dementia with delusional
features   9.   290.21 Senile dementia with depressive features   10.   290.3
Senile dementia with delerium   11.   290.4 Arteriosclerotic dementia   12.  
290.40 Arteriosclerotic dementia, uncomplicated   13.   290.41 Arteriosclerotic
dementia with delirium   14.   290.42 Arteriosclerotic dementia with delusional
features   15.   290.43 Arteriosclerotic dementia with depressive features   16.
  290.8 Other specific senile psychotic conditions   17.   290.9 Unspecified
senile psychotic condition   18.   291.1 Alcohol amnestic syndrome

     
Amended as of July 1, 2004
  IV-6

 

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

 

                 
02721
    02952       05120  
02722
    O254       05211  
02750
    03310       05211-52  
02751
    03320       05212  
02752
    03330       05212-52  
02790
    03410-22       05213  
02791
    03411       05214  

2.   Procedure Codes to be paid by Medicaid FFS up to 120 days from date of last
preliminary extractions after patient enrolls in New Jersey Care 2000+ (applies
to tooth codes 5 - 12 and 21 - 28 only):

05130
05130-22
05140
05140-22

3.   Extraction Procedure Codes to be paid by Medicaid FFS up to 120 days from
last date of preliminary extractions after first time New Jersey Care 2000+
enrollment in conjunction with the following codes (05130, 05130-22, 05140,
05140-22):

07110
07130
07210

4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR

A.  
Mental Health/Substance Abuse. The following mental health/substance abuse
services (except for the conditions listed in 4.1.2.B) will be managed by the
State or its agent for non-DDD enrollees, including all NJ FamilyCare enrollees.
(The contractor will retain responsibility for furnishing mental
health/substance abuse services, excluding the cost of the drugs listed below,
to Medicaid enrollees who are clients of the Division of Developmental
Disabilities).

•   Substance Abuse Services-diagnosis, treatment, and detoxification   •  
Costs for Methadone maintenance and its administration   •   Mental Health
Services

B.   Drugs. The following drugs will be paid fee-for-service by the Medicaid
program for all DMAHS enrollees:

•   Atypical antipsychotic drugs within the Specific Therapeutic Drug Classes
H7T and H7X

     
Amended as of July 1, 2004
  IV-9-

 

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

 

•   Methadone maintenance - cost and its administration. Except as provided in
Article 4.4, the contractor will remain responsible for the medical care of
enrollees requiring substance abuse treatment   •   Generically-equivalent drug
products of the drugs listed in this section.

C.   Up to twelve (12) inpatient hospital days required for social necessity in
accordance with Medicaid regulations.   D.   DDD/CCW waiver services: individual
supports (which includes personal care and training), habilitation, case
management, respite, and Personal Emergency Response Systems (PERS).

4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS - NO COORDINATION BY THE CONTRACTOR

    The following institutional services shall remain in the fee-for-service
program without requiring coordination by the contractor. In addition, Medicaid
beneficiaries participating in a waiver (except the Division of Developmental
Disabilities Community Care Waiver) or demonstration program or admitted for
long term care treatment in one of the following shall be disenrolled from the
contractor’s plan on the date of admission to institutionalized care.

A.   Nursing Facility care (Exception: if the admission is only for inpatient
rehabilitation/postacute care services and is 30 days or less, the enrollee will
not be disenrolled. The contractor remains financially responsible for
rehabilitation/postacute services in this setting for 30 days. Thereafter, if
the enrollee continues to receive rehabilitation/postacute services in this
setting, the enrollee will be disenrolled. The contractor will no longer be
financially responsible.) Not covered for NJ FamilyCare Plans B and C.   B.  
Inpatient psychiatric services (except for RTCs) for individuals under age 21
and 65 and over - Services that are provided:

1.   Under the direction of a physician;   2.   In a facility or program
accredited by the Joint Commission on Accreditation of Health Care
Organizations; and   3.   Meet the federal and State requirements.

C.  
Intermediate Care Facility/Mental Retardation Services - Items and services
furnished in an intermediate care facility for the mentally retarded. Covered
for NJ FamilyCare Plan A only.
  D.   Waiver (except Division of Developmental Disabilities Community Care
Waiver) and demonstration program services. Covered for NJ FamilyCare Plan A
only.

     
Amended as of July 1, 2004
  1V-10

 

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

 

C.   Access Standards. The contractor shall ensure that all covered services,
that are required oh an emergency basis are available to all its enrollees,
twenty-four (24) hours per day, seven (7) days per week, either in the
contractor’s own provider network or through arrangements approved by DMAHS. The
contractor shall maintain twenty-four (24) hours per day, seven (7) days per
week on-call telephone coverage, including Telecommunication Device for the Deaf
(TDD)/Tech Telephone (TT) systems, to advise enrollees of procedures for
emergency and urgent care and explain procedures for obtaining
non-emergent/non-urgent care during regular business hours within the enrollment
area as well as outside the enrollment area.   D.   Non-Participating Providers.

1.   The contractor shall be responsible for developing and advising its
enrollees and where applicable, authorized persons of procedures for obtaining
emergency services, including emergency dental services, when it is not
medically feasible for enrollees to receive emergency services from or through a
participating provider, or when the time required to reach the participating
provider would mean risk of permanent damage to the enrollee’s health. The
contractor shall bear the cost of providing emergency service through
non-participating providers.   2.   Non-contracted hospitals providing emergency
services to Medicaid or NJ FamilyCare members enrolled in the managed care
program shall accept, as payment in full, the amounts that the non-contracted
hospitals would receive from Medicaid for the emergency services and/or any
related hospitalization as if the beneficiary were enrolled in fee-for-service
Medicaid.

E.   Emergency Care Prior Authorization. Prior authorization shall not be
required for emergency services through stabilization. This applies to
out-of-network as well as to in-network providers.   F.   Medical
Screenings/Urgent Care. Prior authorization shall not be required for medical
screenings or for providing services in urgent care situations at the hospital
emergency room. The hospital emergency room physician may determine the
necessity for contacting the PCP or the contractor for information about an
enrollee. who presents with an urgent condition.   G.   The contractor shall pay
for all medical screening services rendered to its enrollees by hospitals and
emergency room physicians regardless of the admitting symptoms or discharge
diagnosis. The amount and method of reimbursement for medical screenings shall
be subject to negotiation between the contractor and the hospital and directly
with non-hospital salaried emergency room physicians and shall include
reimbursement for urgent care and non-urgent care rates. Non-participating
hospitals may be reimbursed for hospital costs at Medicaid rates or other
mutually agreeable rates for medical screening services. Additional fees for

     
Amended .as of July 1, 2004
  N-21

 

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

 

i.   The contractor shall provide to DMAHS documentation as to the efforts made
to educate providers with low screening rates.   ii.   The contractor shall
implement plans for corrective action with those identified PCPs that describe
interventions to be taken to identify and correct deficiencies and impediments
to the screening and how the effectiveness of its interventions will be
measured.

e.   On a quarterly basis, the contractor shall submit to DMAHS a report of all
lead-burdened children who are receiving treatment and case management services.
  f.   Lead Case Management Program. The contractor shall establish a Lead Case
Management Program (LCMP) and have written policies and procedures for the
enrollment of children with blood lead levels ³ 10 µg/dl and members of the same
household who are between six months and six years of age, into the contractor’s
LCMP.

i.   Lead Case Management shall consist of, at a minimum:

1)   Follow-up of a child in need of lead screening, or who has been identified
with an elevated blood lead level ³ 10 µg/dl. At minimum, follow-up shall
include:

A)   For a child with an elevated blood lead level ³ 10 µg/dl, the Plan’s LCM
shall ascertain if the blood lead level has been confirmed by a venous blood
determination. In the absence of confirmatory test results, the LCM will arrange
for a test.   B)   For a child with a confirmed blood (venous) lead level of ³
10 µg/dl the contractor’s LCM shall notify and provide to the local health
department the child’s name, primary health care provider’s name, the confirmed
blood lead level, and any other pertinent information.

2)   Education of the family about all aspects of lead hazard and toxicity.
Materials shall explain the sources of lead exposure, the consequences of

     
Amended as of July 1, 2004
  IV-35

 

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

 

    elevated blood levels, preventive measures. including housekeeping, hygiene,
and appropriate nutrition. The reasons why it is necessary to follow a
prescribed medical regimen shall also be explained.   3)   Communication among
all interested parties.   4)   Development of a written case management plan
with the PCP and the child’s family and other interested parties. The case
management plan shall be reviewed and updated on an ongoing basis.   5)  
Coordination of the various aspects of the affected child’s care, e.g., WIC,
support groups, and community resources, and   6)   Aggressively pursuing
non-compliance with follow-up tests and appointments, and document these
activities in the LCMP.

ii.   Active case management may be discontinued if one of the following
criteria has been met:

1)   The child has one confirmed blood lead levels < 10 µg/dl drawn and all
other children under the age of six years living in the household who have been
tested and their blood levels are < 10 µg/dl, and the sources of lead have been
identified and reduced, or   2)   The family has been permanently relocated to a
lead-safe house, or   3)   The parent/guardian has given a written refusal of
service, or   4)   The LCM is unable to locate the child after a minimum of
three documented attempts, using the assistance of County Board of Social
Services, and the LHD. The child’s PCP will be notified in writing.

4.2.7 IMMUNIZATIONS

     
Amended as of July 1, 2004
  IV-36

 

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

 

    with the administration of Methadone, which will .remain FFS), neurological
evaluations, laboratory testing and radiologic examinations, and any other
diagnostic procedures that are necessary to make the diagnostic determination
between a primary MH/SA disorder and an underlying physical disorder, as well as
for medical work-ups required for medical clearances prior to the provision of
psychiatric medication or electroconvulsive therapy (ECT), or for transfer to a
psychiatric/SA facility. Routine laboratory procedures ordered by treating MH/SA
providers in conjunction with MH/SA treatment, for routine blood testing
performed in conjunction with the administration of atypical antipsychotics (see
Article 4.1.4B for non-DDD enrollees, are not the responsibility of the
contractor.   2.   The contractor shall develop a referral process to be used by
its providers which shall include providing a copy of the medical consultation
and diagnostic results to the MH/SA provider. The contractor shall develop
procedures to allow for notification of an enrollee’s MHH/SA provider of the
findings of his/her physical examination and laboratory/radiological tests
within twenty-four (24) hours of receipt for urgent cases and within five
business days in non-urgent cases. This notification shall be made by phone with
follow-up in writing when feasible.

C.   Pharmacy Services. Except for the drugs specified in Article 4.1.4
(Clozapine, Risperidone, Olanzapine, etc.), all pharmacy services are covered by
the contractor. This includes drugs prescribed by the contractor or MH/SA
providers. The contractor shall only restrict or require a prior authorization
for prescriptions or pharmacy services prescribed by MH/SA providers if one of
the following exceptions is demonstrated:

1.   The drug prescribed is not related to the treatment of substance
abuse/dependency/addiction or mental illness or to any side effects of the
psychopharmacological agents. These drugs are to be prescribed by the
contractor’s PCP or specialists in the contractor’s network.   2.   The
prescribed drug does not conform to standard rules of the contractor’s pharmacy
plan.   3)   The contractor, at its option, may require a prior authorization
(PA) process if the number of prescriptions written by the MH-1/SA provider for
MH/SA-related conditions exceed four (4) per month per enrollee. For drugs that
require weekly prescriptions, these prescriptions shall be counted as one per
month and not as four separate prescriptions. The contractor’s PA process for
the purposes of this section shall require review and prior approval by DMAHS.

     
Amended as of July 1, 2004
  IV-45

 

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

 

g.   Serving as Chairperson of Quality Management Committee; [Note: the medical
director may designate another physician to serve as chairperson with prior
approval from DMAHS.]   h.   Oversight of provider education, in-service
training and orientation;   i.   Assuring that adequate staff and resources are
available for the provision of proper medical care to enrollees; and   j.   The
review and approval of studies and responses to DMAHS concerning QM matters.

3.   Enrollee Rights and Responsibilities. Shall include the right to the
Medicaid Fair Hearing Process for Medicaid enrollees.   4.   Medical Record
standards shall address both Medical and Dental records. Records shall also
contain notation of any cultural/linguistic needs of the enrollee.   5.  
Provider Credentialing. Before any provider may become part of the contractor’s
network, that provider shall be credentialed by the contractor. The contractor
must comply with N.J.A.C. 8:38C-1 et seq. and Standard IX of NJ modified
QARI/QISMC (Section B.4.14 of the Appendices). Additionally, the contractor’s
credentialing procedures shall include verification that providers and
subcontractors have not been suspended, debarred, disqualified, terminated or
otherwise excluded from Medicaid, Medicare, or any other federal or state health
care program. The contractor shall obtain federal and State lists of
suspended/debarred providers from the appropriate agencies.   6.   Institutional
and Agency Provider Credentialing. The contractor shall have written policies
and procedures for the initial quality assessment of institutional and agency
providers with which it intends to contract. At a minimum, such procedures shall
include confirmation that a provider has been reviewed and approved by a
recognized accrediting body and is in good standing with State and federal
regulatory bodies. If a provider has not been approved by a recognized
accrediting body, the contractor shall develop and implement standards of
participation. For home health agency and hospice agency providers, the
contractor shall verify that the providers are licensed and meet Medicare
certification participation requirements.   7.   Delegation/subcontracting of
QAPI activities shall not relieve the contractor of its obligation to perform
all QAPI functions. The contractor shall submit a written request and a plan for
active oversight of the QAPI

     
Amended as of July 1, 2004
  IV-61

 

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

 

its aggregate, enrolled commercial and Medicare population in the State or
region (if these data are collected and 1..ported to DHSS, a copy of the report
should be submitted also to DMAHS) the following clinical indicator measures:

          HEDIS   Report Period Reporting Set Measures   by Contract Year
Childhood Immunization Status
  annually
Adolescent Immunization Status
  annually
Well-Child Visits in first 15 months of life
  annually
Well-Child Visits in the 3rd, 4th, 5th and 6th year of life
  annually
Adolescent Well-Care Visits
  annually
Prenatal and Postpartum Care
  annually
Breast Cancer Screening
  annually
Cervical Cancer Screening
  annually
Medical Assistance with Smoking Cessation
  annually

Childhood & Adolescent Immunization HEDIS data for NJ FamilyCare enrollees up to
the age of 19 years must be reported separately.

     
Q.
  Quality Improvement Projects (QIPs). The contractor shall participate in QIPs
defined annually by the State with input from the contractor. The State will,
with input from the contractor and possibly other MCEs, define measurable
improvement goals and QIP-specific measures which shall serve as the focus for
each QIP. The contractor shall be responsible for designing and implementing
strategies for achieving each QIP’s objectives. At the beginning of each
contract year the contractor shall present a plan for designing and implementing
such strategies, which shall receive approval from the State prior to
implementation. The contractor shall then submit semiannual progress reports
summarizing performance relative to each of the objectives of each contract
year.           The QIPs shall be completed annually and shall include the areas
identified below. The external review organization (ERO) under contract with DHS
shall prepare a final report for year one that will contain data, using
State-approved sampling and measurement methodologies, for each of the measures
below. Changes in required QIPs shall be defined by the DHS and incorporated
into the contract by amendment.           For each measure the DHS will identify
a baseline and a compliance standard. Baseline data, target standards, and
compliance standards shall be established or updated by the State.           If
DHS determines that the contractor is not in compliance with the requirements of
the annual QIP objectives, either based on the contractor’s progress report or

    Amended as July 1, 2004
IV-64

 

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

 

the ERO’s report, the contractor shall prepare and submit a corrective action
plan for DHS approval.

1.   Well-Child Care (EPSDT)

The QIP for Well-Child Care shall focus upon achieving compliance with the EPSDT
periodicity schedule (See Article 4.2.6) in the following priority areas:

                                      Minimum         Performance   Compliance  
Discretionary Clinical Area   Standard   Standard   Sanction
Age-appropriate Comprehensive exams
(CMS-specified age groups)
                       
 
    80 %     60 %     60 - 70 %
< 1 year old
    80 %     60 %     60 - 70 %
1 - 2 years old
    80 %     65 %     60 - 70 %
3 - 5 years old (at least 1 visit)
    80 %     60 %     60 - 70 %
6 - 9 years old (at least 1 visit)
    80 %     60 %     60 - 70 %
10 - 14 years old (at least 1 visit)
    80 %     60 %     60 - 70 %
15 - 18 years old (at least 1 visit)
    80 %     60 %     60 - 70 %
19 - 20 years old (at least 1 visit)
Immunizations 2 year olds
(HEDIS combined rate)
    80 %     60 %     60 - 70 %
Annual Dental Visit - 3 - 12 yr olds
    80 %     60 %     60 - 70 %
13 - 21 yr olds
    80 %     60 %     60 - 70 %
Lead screen (under age 3)
    80 %     60 %     60 - 70 %

2.   Prenatal Care and Pregnancy Outcome

The QIP for Prenatal Care and Pregnancy Outcome shall focus upon achieving
improvements in compliance with prenatal care protocols and in obtaining
positive pregnancy outcomes

                              Compliance Clinical Area   Target Standard  
Standard
Initial visit in first trimester or within 6 wks of enrollment
    85 %     75 %
Adequate frequency of prenatal care
    85 %     75 %
Low birth weight babies
               

Amended as of July 1, 2004 IV-65

 

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

 

A.   The contractor shall provide the DMAHS a full network, monthly, on computer
diskette in accordance with the specifications provided in Section A.4:1 of the
Appendices. The network file shall include an indicator for new additions and
deletions and shall include:

1.   Any and all changes in participating primary care providers, including, for
example, additions, deletions, or closed panels, must be reported monthly to
DMAHS.   2.   Any and all changes in participating physician specialists, health
care providers, CNPs/CNSs, ancillary providers, and other subcontractors must be
reported to DMAHS on a monthly basis.

B.   DMAHS review of provider network deficiencies will be conducted on a
quarterly basis or more frequently as may be required.   C.   The contractor
shall provide the HBC with a full network on a monthly basis in accordance with
the specifications found in Section A.4.1 of the Appendices. The electronic
files shall be sent to DMAHS, and a copy to the DMAHS’ designee for
distribution.

4.8.4 PROVIDER DIRECTORY REQUIREMENTS

The contractor shall prepare a provider directory which shall be presented in
the following manner. Fifty (50) copies of the provider directory, and any
updates, shall be provided to the HBC, and ten (10) copies shall be provided to
DMAHS at least every six months or within 30 days of an update.

A.   Primary care providers who will serve enrollees listed by

•   County, by city, by specialty   •   Provider name and degree; specialty
board eligibility/certification status; office address(es) (actual street
address); telephone number; fax number if available; office hours at each
location; indicate if a provider serves enrollees with disabilities and how to
receive additional information such as type of disability; hospital
affiliations; transportation availability; special appointment instructions if
any; languages spoken; disability access; and any other pertinent information
that would assist the enrollee in choosing a PCP.

B.   Contracted specialists and ancillary services providers who will serve
enrollees

•   Listed by county, by city, by physician specialty, by non-physician
specialty, and by adult specialist and by pediatric specialist for those
specialties indicated in Section 4.8.8.C.

     
Amended as of July 1, 2004
  IV-98

 

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

 

C.   Subcontractors

Provide, at a minimum, a list of all other health care providers by county, by
service specialty, and by name. The contractor shall demonstrate its ability to
provide all of the services included under this contract.

4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES

The contractor shall develop and enforce credentialing and recredentialing
criteria for all provider types which should follow the CMS’ credentialing
criteria, as delineated in the NJ modified QARI/QISMC standards found in
Article 4.6.1 and Section B.4.14 of the Appendices, and comply with N.J.A.C.
8:38C-1 et seq.

4.8.6 LABORATORY SERVICE PROVIDERS

A.   The contractor shall ensure that all laboratory testing sites providing
services under this contract, including those provided by primary care
physicians, specialists, other health care practitioners, hospital labs, and
independent laboratories have either a Clinical Laboratory Improvement Amendment
(CLIA) certificate of waiver or a certificate of registration along with a CLIA
identification number, and comply with New Jersey DHSS disease reporting
requirements. Those laboratory service providers with a certificate of waiver
shall provide only those tests permitted under the terms of their waiver.
Laboratories with certificates of registration may perform a full range of
laboratory tests.

The contractor shall provide to DMAHS, on request, copies of certificates that
its own laboratory or any other laboratory it conducts business with, has a CLIA
certificate for the services it is performing as fulfillment of requirements in
42 C.F.R. § 493.1809.

If the contractor has its own laboratory, the contractor shall submit at the
time of initial contracting a written list of all diagnostic tests performed in
its own laboratory if applicable and those tests which are referred to other
laboratories annually and within fifteen (15) working days of any changes.

3.   The contractor shall inform DMAHS and provide a geographic access analysis
in accordance with the specifications found in the Appendix, Section A.4.3 if it
contracts with a new laboratory subcontractor 45 days prior to the effective
date of the subcontractor’s contract and shall notify DMAHS of a termination of
a laboratory subcontractor 90 days prior to the effective date of the
subcontractor’s termination. The contractor shall provide a copy of a new
subcontractor’s certificate of waiver or certificate of registration within ten
(10) days of operation.

         
Amended as of July 1, 2004
      IV-99

 

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

 

3.   - Other:

a.   Genetic Testing and Counseling Centers b. Hemophilia Treatment Centers

H.   Other Specialty Centers/Providers [Institutional File]

Contractor should establish relationships with the following providers/centers
on a consultant or referral basis.

.   1.Spina Bifida Centers/providers
2. Adult Scoliosis
3. Autism and Attention Deficits
4. Spinal Cord Injury
5. Lead Poisoning Treatment Centers
6. Child Abuse Regional Diagnostic Centers
7. County Case Management Units
8. Psychologists (for clients of DDD)
9. Physical Medicine (for inpatient rehabilitation services)
10. Maternal & Fetal Medicine
11. Medical Toxicology

     
Amended as of July 1, 2004
  IV-107

 

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

 

i.   Provider Network Access Standards and Ratios

             
Specialty
 
A — Miles per 2

  B — Miles per 1
  Min. No. Per County            Capacity Limit

 
Urban Non-Urban
  Urban Non-urban   Except Where Noted            Per Provider

         
Amended as of July 1, 2004
      IV-108

 

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

 

                                                                 
PCP Children GP
            6       15       2       10       2       1:       1.500  
 
 
FP
    6       15       2       10       2       1:       1.500  
 
 
Peds
    6       15       2       10       2       1:       1.500  
Adults
 
GP
    6       15       2       10       2       l:       1.500  
 
 
FP
    6       15       2       10       2       1:       1.500  
 
  1M         6       15       2       10       2       1:       1.500  
CNPICNS
            6       15       2       10       2       1:       1.000  
CNM
            12       25       6       15       2       1:       1.500  
Dentist, Primary Care
            6       15       2       10       2       1:       1.500  
Allergy
            15       25       10       15       2       1:       75.000  
Anesthesiology
            15       25       10       15       2       1:       17.250  
Cardiology
            15       25       10       15       2       1:       100,000  
CardiovascularsurgeryDisease
        15       25       10       15       2       1:       166.000  
Chiropractor
            15       25       10       15       1       1:       20.000  
Colorectal surgery
            15       25       10       15       2       1:       30.000  
Dermatology
            15       25       10       15       2       1:       75.000  
Emergency Medicine
            15       25       10       15       2       1:       19.000  
Endocrinology
            15       25       10       15       2       1:       143,000  
Endodontia
            15       25       10       15     1 (where available)     1:      
30.000  
Gastroenterology
            15       25       10       15       2       1:       100.000  
General Surgery
            15       25       10       15       2       1:       30.000  
Geriatric Medicine
            15       25       10       15       1       1:       10.000  
Hematology
            15       25       10       15       2       1:       100.000  
Infectious Disease
            15       25       10       15       2       1:       125.000  
Neonatology
            15       25       10       15       2       1:       100,000  
Nephrology
            15       25       10       15       2       I:       125,000  
Neurology
            15       25       10       15       2       1:       100.000  
Neurological Surgery
            15       25       10       15       2       1:       166,000  
Obstetrics/Gynecology
            15       25       10       15       2       1:       7.100  
Oncology
            15       25       10       15       2       1:       100,000.  
Ophthalmology
            15       25       10       15       2       1:       60.00  
 
                                                               
Optometrist
            15       25       10       15       2       1:       8.000  
Oral Surgery
            15       25       10       15       2.       1:       20,000  
Orthodontia
            15       25       10       15       1       1:       20.000  
Orthopedic Surgery
            15       25       10       15       2       l:       28.000  
Otolaryngology (ENT)
            15       25       10       15       2       1:       53.000  
Periodontia
            15       25       10       15     1 (where available)     1:      
30,000  
Physical Medicine
            15       25       10       15     (where applicable)     1:      
75,000  
Plastic Surgery
            15       25       10       15       2       1:       250.000  
Podiatrist
            15       25       10       15       2       1:       20,000  
Prosthodontia
            15       25       10       15     1 (where available)     I:      
30.000  
Psychiatrist
            15       25       10       15       2       1:       30,000  
Psychologist
            15.       25       10       15       —       I:       30.000  
Pulmonary Disease
            15       25       10       15       2       1:       100,000  
Radiation Oncology
            15       25       10       15       2       1:       100,000  
Radiology
            15       25       10       15       2       1:       25,000  
Rheumatology
            15       25       10       15       2       1:       150,000  
Audiology
            12       25       6       15       2       I:       100,000  
Thoracic Surgery
            15       25       10       15       2       1:       150,000  
Urology
            15       25       10       15       2       1:       60.000  
Fed Qua! Health Ctr
                                            1             I/county if
 
                                                          available
Hospital
            20       35       10       15       2             2 per county
 
                                                          (where applicable)
Pharmacies
            10       15       5       12               1:       1,000  
Laboratory
            N/A       N/A       7       12                          
DME/Med Supplies
            12       25       6       15       1       1:       50.000  
Hearing Aid
            12       25       6       15       1       1:       50,000  
Optical Appliance
            12       25       6       15       2       1:       50,000  
 
                                                               
 
                                                               

 

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

 

of medicine in the following counties: Cape May, Cumberland, Gloucester,
Hunterdon, Salem, Sussex.

b.   Cardiology, pediatric — In-county alternative: adult cardiovascular
disease; out of county pediatric referral applies to: Cumberland. Hunterdon,
Somerset, Sussex, Warren.   c.   Endocrinology, adult — In-county alternative:
none, refer out of county for Cape May, Gloucester, Sussex, Warren.   d.  
Endocrinology, pediatric — In-county alternative: adult endocrinologist; out of
county referral for pediatric endocrinology applies to: Atlantic, Cape May,
Cumberland, Gloucester, Hunterdon, Mercer, Ocean, Salem, Somerset, Sussex,
Warren.   e.   Gastroenterology, pediatric — In-county alternative: adult
gastroenterologists; out of county referral for pediatric gastroenterology
applies to: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon,
Mercer, Ocean, Salem, Sussex, Warren.   f.   General Surgery, pediatric —
In-county alternative: adult general surgery; out of county referral for
pediatrics applies to: Burlington, Cape May, Cumberland, Gloucester, Hunterdon,
Mercer, Morris, Salem, Somerset, Sussex, Warren.   g.   Geriatrics — In-county
alternative: Family Practitioner or Internist; applies to: Cape May, Cumberland,
Gloucester, Mercer, Morris, Salem, Somerset, Sussex, Warren.   h.  
Hematology/Oncology, pediatric - In-county alternative: none; out of county
pediatrics referral applies to: Burlington, Cape May, Cumberland, Gloucester,
Salem, Somerset, Warren.   i.   Infectious Disease, pediatric — In-county
alternative: Adult infectious disease; out of county pediatric referral applies
to: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Ocean,
Salem, Somerset, Sussex, Warren.   j.   Nephrology, adult — In-county
alternative: none; refer out of county for Cape May, Sussex, Warren.   k.  
Nephrology, pediatric — In-county alternative: adult nephrologist; out of county
pediatric referral applies to: Atlantic, Burlington, Cape May, Cumberland,
Gloucester, Hunterdon, Mercer, Monmouth, Ocean, Salem, Somerset, Sussex, Warren.

         
Amended as of
  July 1, 2004   IV-1’14

 

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

 

1.   Neonatal/Perinatal medicine — Alternative: none, refer out of county.   m.
  Neurology, pediatric — In-county alternative: adult neurology; out of county
pediatric referral applies to: Burlington, Cape May, Cumberland, Gloucester,
Hunterdon, Sussex, Warren.   n.   Neurological Surgery — In-county alternative:
none; out of county referral applies to: Cape May, Cumberland, Gloucester,
Hudson, Salem, Warren.   o.   Plastic Surgery — In-county alternative: none; out
of county referral applies to: Cape May, Salem, Sussex, Warren.       Pulmonary
Disease, pediatric — In-county alternative: Adult pulmonary disease; out of
county pediatric referral applies to: Burlington, Cape May, Cumberland,
Gloucester, Ocean, Warren.   q.   Radiation Oncology — In-county alternative:
none; out of county referral applies to: Cape May, Salem, Sussex, Warren.   r.  
Rheumatology, pediatric — In-county alternative: adult rheumatology; out of
county pediatric referral applies to: all counties except Bergen and Essex.   s.
  Thoracic surgery — In-county alternative: none, refer out of county for Cape
May, Hunterdon, Morris, Sussex, Warren.

4.   Hospitals. For the following counties, the contractor may limit its
hospital provider network to one (1) hospital, which must be a full service,
acute care hospital including at least licensed medical-surgical, pediatric,
obstetrical, and critical care services: Cape May, Cumberland, Gloucester,
Hunterdon, Salem, Somerset, Sussex, and Warren.

4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS

     

     A. The contractor shall establish and maintain a dental provider network,
including primary and specialty care dentists, which is adequate to provide the
full scope of benefits. The contractor shall include general dentists and
pediatric dentists as primary care dentists (PCDs). A system whereby the PCD
initiates and coordinates any consultations or referrals for specialty care
deemed necessary for the treatment and care of the enrollee is preferred.

     B. The dental provider network shall include sufficient providers able to
meet the dental treatment requirements of patients with developmental
disabilities. (See Article 4.5.2E for details.)

         
Amended as of
  July 1, 2004   IV-115

 

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

 

5.   The contractor shall submit to DMAHS for review and approval prior to
implementation any changes required to comply with HIPAA.

G.   The contractor shall submit at least annually or 30 days prior to any
changes, lists of names, addresses, ownership/control information of
participating providers and subcontractors, and individuals or entities, which
shall be incorporated in this contract.

1.   The contractor shall obtain prior DMAHS review and written approval of any
proposed plan for merger, reorganization or change in ownership of the
contractor and approval by the appropriate State regulatory agencies.   2.   The
contractor shall comply with Article 4.9.1 G. l to ensure uninterrupted and
undiminished services to enrollees, to evaluate the ability of the modified
entity to support the provider network, and to ensure that any such change has
no adverse effects on DMAHS’ managed care program and shall comply with the
Departments of Banking and Insurance, and Health and Senior Services statutes
and regulations.

H.   The contractor shall demonstrate its ability to provide all of the services
included under this contract through the approved network composition and
accessibility.   I.   The contractor shall not oblige providers to violate their
state licensure regulations.   J.   The contractor shall provide its providers
and subcontractors with a schedule of fees and relevant policies and procedures
at least 30 days prior to implementation.   K.   The contractor shall arrange
for the distribution of informational materials to all its providers and
subcontractors providing services to enrollees, outlining the nature, scope, and
requirements of this contract.   L.   Subcontractor Delegation. The contractor
shall monitor any functions and responsibilities it delegates to any
subcontractor. The contractor shall be accountable for any and all functions and
responsibilities it delegates to a subcontractor. The contractor shall obtain
the prior approval of DMAHS for any such delegation and shall meet the
requirements of 42 C.F.R. § 438.

4.9.2 CONTRACT SUBMISSION

The contractor shall submit to DMAHS one complete, fully executed contract for
each type of provider, i.e., primary care physician, physician specialist,
non-physician practitioner, hospital and other health care providers/services
covered under the benefits package, subcontract and the form contract of any
subcontractor’s provider contracts. The use of a signature stamp is not
permitted and shall not be considered a fully executed contract. Contracts shall
be submitted with all attachments, appendices, referenced

     
Amended as of July 1, 2004
  IV-118

 

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

 

documents, and with rate schedules, etc., upon request. A copy of the
appropriate completed contract checklist fog DHS, DHSS, and DOBI shall be
attached to each contract form. Regulatory approval and approval by the
Department is required for each provider contract form and subcontract prior to
use. Submission of all other contracts shall follow the format and procedures
described below:

A.   Copies of the complete fully executed contract with every FQHC.
Certification of the continued in force contracts previously submitted will be
permitted.   B.   Hospital contracts shall list each specific service to be
covered including but not limited to:

    1. Inpatient services;
2. Anesthesia and whether professional services of anesthesiologists and nurse
anesthetists are included;
3. Emergency room services

 

a. Triage fee — whether facility and professional fees are included;
b. Medical screening fee — whether facility and professional fees are included;
c. Specific treatment rates for:

     

(1) Emergent services
(2) Urgent services
(3) Non-urgent services
(4) Other

d.   Other — must specify

    4. Neonatology — facility and professional fees
5. Radiology

.   a. Diagnostic
b. Therapeutic
c. Facility fee
d. Professional services

    6. Laboratory — facility and professional services
7. Outpatient/clinic services must be specific and address

    a. School-based health service programs
b. Audiology therapy and therapists

    8. AIDS Centers
9. Any other specialized service or center of excellence
10. Hospice services if the hospital has an approved hospice agency that is
Medicare certified.
11. Home Health agency services if hospital has an approved home health agency
license from the Department of Health and Senior Services that meets licensing
and Medicare certification participation requirements.
12. Any other service.

C.   FQHC contracts:

     
Amended as of July 1, 2004
  IV-119

 

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

 

The contractor shall accept enrollment of Medicaid/NJ FamilyCare eligible
persons within the defined enrollment areas in the order in which they apply or
are auto-assigned to the contractor (on a random basis with equal distribution
among all participating contractors) without restrictions, within contract
limits. Enrollment shall be open at all times except when the contract limits
have been met. A contractor shall not deny enrollment of a person with an SSI
disability or New Jersey Care Disabled category who resides outside of the
enrollment area. However, such enrollee with a disability shall be required to
utilize the contractor’s established provider network. The contractor shall
accept enrollees for enrollment throughout the duration of this contract.

D.   Enrollment timeframe. As of the effective date of enrollment, and until the
enrollee is disenrolled from the contractor’s plan, the contractor shall be
responsible for the provision and cost of all care and services covered by the
benefits package listed in Article 4.1. Enrollees who become eligible to receive
services between the 1st through the end of the month shall be eligible for
Managed Care services in that month. When an enrollee is shown on the enrollment
roster as covered by a contractor’s plan, the contractor shall be responsible
for providing services to that person from the first day of coverage shown to
the last day of the calendar month of the effective date-of disenrollment. DMAHS
will pay the contractor a capitation rate during this period of time.   E.  
Hospitalizations. For-any eligible person who applies for participation in the
contractor’s plan, but who is hospitalized prior to the time coverage under the
plan becomes effective, such coverage shall not commence until the date after
such person is discharged from the hospital and DMAHS shall be liable for
payment for the hospitalization, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. If an enrollee’s
disenrollment or termination becomes effective during a hospitalization, the
contractor shall be liable for hospitalization until the date such person is
discharged from the hospital, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. The contractor shall
notify DMAHS within 180 days of initial hospital admission.   F.   Unless
otherwise required by statute or regulation, the contractor shall not condition
any Medicaid/NJ FamilyCare eligible person’s enrollment upon the performance of
any act or suggest in any way that failure to enroll may result in a loss of
Medicaid/NJ FamilyCare benefits.   G.   There shall be no retroactive enrollment
in Managed Care. Services for those beneficiaries during any retroactive period
will remain fee-for-service, except for individuals eligible under NJ FamilyCare
Plans B, C, and H who are not eligible until enrolled in an MCE. Coverage shall
continue indefinitely unless this contract expires or is terminated, or the
enrollee is no longer eligible or is deleted from the contractor’s list of
eligible enrollees.

     
Amended as of July 1, 2004
V - 7  

 

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

 

R.   Complaints and Grievances/Appeals

1.   Procedures for resolving complaints, as approved by the DMAHS;   2.   A
description of the grievance/appeal procedures to be used to resolve disputes
between a contractor and an enrollee, including: the name, title, or department,
address, and telephone number of the person(s) responsible for assisting
enrollees in grievance/appeal resolutions; the time frames and circumstances for
expedited and standard grievances; the right to appeal a grievance determination
and the procedures for filing such an appeal; the time frames and circumstances
for expedited and standard appeals; the right to designate a representative; a
notice that, all disputes involving clinical decisions will be made by qualified
clinical personnel; and that all notices of determination will include
information about the basis of the decision and further appeal rights, if any;  
3.   The contractor shall notify all enrollees in their primary language of
their rights to file grievances and appeal grievance decisions by the
contractor;

S.   An explanation that Medicaid/NJ FamilyCare Plan A enrollees, and Plans D
and H enrollees with a program status code of 380, have the right to a Medicaid
Fair Hearing with DMAHS and the appeal process through the DHSS for Medicaid and
NJ FamilyCare enrollees, including instructions on the procedures involved in
making such a request;   T.   Title, addresses, phone numbers and a brief
description of the contractor’s plan for contractor management/service
personnel;   U.   The interpretive, linguistic, and cultural services available
through the contractor’s plan;   V.   An explanation of the terms of enrollment
in the contractor’s plan, continued enrollment, automatic re-enrollment,
disenrollment procedures, time frames for each procedure, default procedures,
enrollee’s rights and responsibilities and causes for which an enrollee shall
lose entitlement to receive services under this contract, and what should be
done if this occurs;   W.   A statement strongly encouraging the enrollee to
obtain a baseline physical and dental examination, and to attend scheduled
orientation sessions and other educational and outreach activities;   X.   A
description of the EPSDT program, and language encouraging enrollees to make
regular use of preventive medical and dental services;   Y.   Provision of
information to enrollees or, where applicable, an authorized person, to assist
them in the selection of a PCP;

 

Amended as of July 1, 2004

 
V-15

 

 

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

 

    The contractor’s system and procedure shall be available to both Medicaid
beneficiaries and NJ FamilyCare beneficiaries. All enrollees have available the
complaint and grievance/appeal process under the contractor’s plan, the
Department of Health and Senior Services and, for Medicaid and certain NJ
FamilyCare beneficiaries (i.e., Plan A enrollees and beneficiaries with a PSC of
380 under Plan D), the Medicaid Fair Hearing process. Individuals eligible
solely through NJ FamilyCare Plans B, C, D, and H (except for Plan D and H
individuals with a program status code of 380),do not have the right to a
Medicaid Fair Hearing.   B.   Complaints. The contractor shall have procedures
for receiving, responding to, and documenting resolution of enrollee complaints
that are received orally and are of a less serious or formal nature. Complaints
that are resolved to the enrollee’s satisfaction within three (3) business days
of receipt do not require a formal written response or notification. The
contractor shall call back an enrollee within twenty-four hours of the initial
contact if the contractor is unavailable for any reason or the matter cannot be
readily resolved during the initial contact. Any complaint that is not resolved
within three business days shall be treated as a grievance/appeal, in accordance
with requirements defined in Article 5.15.3.   C.   HBC Coordination. The
contractor shall coordinate its efforts with the health benefits coordinator
including referring the enrollee to the HBC for assistance as needed in the
management of the complaint/grievance/appeal procedures.   D.   DMAHS
Intervention. DMAHS shall have the right to intercede on an enrollee’s behalf at
any time during the contractor’s complaint/grievance/appeal process whenever
there is an indication from the enrollee, or, where applicable, authorized
person, or the HBC that a serious quality of care issue is not being addressed
timely or appropriately. Additionally, the enrollee may be accompanied by a
representative of the enrollee’s choice to any proceedings and
grievances/appeals.   E.   Legal Rights. Nothing in this Article shall be
construed as removing any legal rights of enrollees under State or federal law,
including the right to file judicial actions to enforce rights.

5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE

A.   The contractor shall provide all enrollees or, where applicable, an
authorized person, upon enrollment in the contractor’s plan, and annually
thereafter, pursuant to this contract, with. a concise statement of the
contractor’s grievance/appeal procedure and the enrollees’ rights to a hearing
by the Independent Utilization Review Organization (IURO) per NJAC 8:38-8.7 as
well as their right to pursue the Medicaid Fair Hearing process described
in-N.J.A.C. 10:49-10.1 et seq. The information shall be provided through an
annual mailing, a member handbook, or any other method approved by DMAHS. The
contractor shall prepare the

 

Amended as of July 1, 2004

 
V-36

 

 

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

 

    provider performance. Practice guidelines may be included in a separate
document.   9.   The contractor’s policies and procedures   10.   PCP
responsibilities   11.   Other provider/subcontractors’ responsibilities   12.  
Prior authorization and referral procedures   13.   Description of the mechanism
by which a provider can appeal a contractor’s service decision through the DHSS’
Independent Utilization Review Organization process   14.   Protocol for
encounter data element reporting/records   15.   Procedures for screening and
referrals for the MH/SA services   16.   Medical records standards   17.  
Payment policies   18.   Enrollee rights and responsibilities

B.   Bulletins. The contractor shall develop and disseminate bulletins as needed
to incorporate any and all changes to the Provider Manual. All bulletins shall
be mailed to the State at least three (3) calendar days prior to publication or
mailing to the providers or as soon as feasible. The Department shall have the
right to issue and/or modify the bulletins at any time. If the DHS determines
that there are factual errors or misleading information, the contractor shall be
required to issue corrected information in the manner determined by the DHS.    
  Timeframes. Within twenty (20) calendar days after the contractor places a
newly enrolled provider in an active status, the contractor shall furnish the
provider with a current Provider Manual, all related bulletins and the
contractor’s methodology for supplying encounter data.       The contractor
shall provide a current Provider Manual to the Department annually. All updates
of the manual shall also be provided to the Department within 30 days of the
revision.   E.   The Provider Manual and all policies and procedures shall be
reviewed at least annually to ensure that the contractor’s current practices and
contract requirements are reflected in the written policies and procedures.

Amended as of July 1, 2004  
VI-2

 

 

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

 

    measured by procedure codes specified in Appendix Section B.7.5 using
encounter data. If the contractor has not achieved the eighty (80) percent
participation rate by the end of the twelve-month period, it shall submit a
corrective action plan to DMAHS within thirty (30) days of notification by DMAHS
of its actual participation rate. DMAHS shall have the right to conduct a
follow-up onsite review and/or impose financial damages for non-compliance.

a.   Mandatory Sanction. Failure of the contractor to achieve the minimum
screening rate shall require the following refund of capitation paid:

i.   Achievement of a 50 percent to less than 60 percent EPSDT screening, dental
visit and immunization rate (the lowest measured rate of each of the components
of EPSDT screening, i.e., periodic exam, immunization rate, and dental screening
rate, shall be considered to be the rate for EPSDT participation and the basis
for the sanction): refund of $1 per enrollee for all enrollees under age 21 not
screened.   ii.   Achievement of a 40 percent to less than 50 percent EPSDT
screening, dental visit, and immunization rate: refund of $2 per enrollee for
all enrollees under age 21 not screened.   iii.   Achievement of a 30 percent to
less than 40 percent EPSDT screening, dental visit and immunization rate: refund
of $3 per enrollee for all enrollees under age 21 not screened.   iv.  
Achievement of less than 30 percent: refund of $4 per enrollee for all enrollees
under age 21 not screened.

b.   Discretionary Sanction. The DMAHS shall have the right to impose a
financial or administrative sanction if the contractor’s performance screening
rate is between sixty (60) — seventy (70) percent. The DMAHS, in its sole
discretion, may impose a sanction after review of the contractor’s corrective
action plan and ability to demonstrate good faith efforts to improve compliance.

2.   Failure to achieve and maintain the required screening rate shall result in
the Local Health Departments being permitted to screen the contractor’s
pediatric members. The cost of these screenings shall be paid by the DMAHS to
the LHD, and the screening cost shall be deducted from the contractor’s
capitation rate in addition to the damages imposed as a result of failure to
achieve EPSDT performance standards.   3.   Mandatory sanctions may be offset
when the contractor demonstrates improved compliance. The Division, in its sole
discretion, may reduce the sanction amount by $1 for each twelve (12) point
improvement over prior reporting period

Amended as of July 1, 2004  
VII-29

 

 

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

 

    performance rate. Offsets shall not reduce the financial sanction amount to
below $1 per enrollee not screened.

B.   Blood Lead Screening

1.   The contractor shall ensure that it has achieved an eighty (80) percent
blood lead screening rate of its enrollees under three years of age during a
twelve (12)-month contract period. Blood lead screening is described in
Article 4 and shall be measured using encounter data and the DHSS database. If
the contractor has not achieved the eighty (80) percent blood lead screening
rate by the end of the twelve (12)-month period, it shall submit a corrective
action plan to DMAHS within thirty (30) days of notification by DMAHS of its
actual blood lead level screening rate. DMAHS shall have the right to conduct a
follow-up onsite review and/or impose financial damages for non-compliance.

a.   Mandatory sanction. Failure of the contractor to achieve sixty (60) percent
screening rate shall require the following refund of capitation paid:

i.   Achievement of a 50 percent to less than 60 percent lead screening rate:
refund of $2 per enrollee for all enrollees under age 3 not screened.   ii.  
Achievement of a 40 percent to less than 50 percent lead screening rate: refund
of $3 per enrollee for all enrollees under age 3 not screened.   iii.  
Achievement of a 30 percent to less than 40 percent lead screening rate: refund
of $4 per enrollee for all enrollees under age 3 not screened.   iv.  
Achievement of less than 30 percent lead screening rate: refund of $5 per
enrollee for all enrollees under age 3 not screened.

b.   Discretionary sanction. The DMAHS shall have the right to impose a
financial or administrative sanction if the contractor’s performance screening
rate is between sixty (60) - seventy (70) percent. The DMAHS, in its sole
discretion, may impose a sanction after review of the contractor’s corrective
action plan and ability to demonstrate good faith efforts to improve compliance.

C.   The contractor must demonstrate continuous quality improvement in achieving
the performance standards for EPSDT and lead screenings as stated in Article 4.
The Division shall, in its sole discretion, determine the appropriateness of
contractor proposed corrective action and the imposition of any other financial
or administrative sanctions in addition to those set out above.

Amended as of July 1, 2004  
VII-30

 

 

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

 

7.20 CONTRACTOR CERTIFICATIONS

7.20.1 GENERAL PROVISIONS

A.   With respect to any report, invoice, record, papers, documents, books of
account, or other contract-required data submitted to the Department in support
of an invoice or documents submitted to meet contract requirements, including,
but not limited to, proofs of insurance and bonding, Lobbying Certifications and
Disclosures, Conflict of Interest Disclosure Statements and/or Conflict of
Interest Avoidance Plans, pursuant to the requirements of this contract, the
Contractor’s Representative or his/her designee shall certify that the report,
invoice, record, papers, documents, books of account or other contract required
data is current, accurate, complete and in full compliance with legal and
contractual requirements to the best of that individual’s knowledge and belief.
  B.   The contractor shall attest, based on best knowledge, information, and
belief, as to the accuracy, completeness and truthfulness of enrollment
information, encounter data, provider networks, marketing materials, provider
and beneficiary notifications and educational materials and any other
information/documents specified in this contract.

7.20.2 CERTIFICATION SUBMISSIONS

A.   Where in this contract there is a requirement that the contractor “certify”
or submit a “certification,” such certification shall be in the form of an
affidavit or declaration under penalty of perjury dated and signed by the
Contractor’s Representative or his/her designee.   B.   The data must be
certified by one of the following:

1.   Chief Executive Officer (CEO)   2.   Chief Financial Office (CFO)   3.   An
individual who has delegated authority to sign for, and who reports directly to
the contractor’s CEO or CFO.

C.   The contractor shall submit the certification concurrently with the
certified data. (See Appendix, Section A.7.1 for certification forms.)

7.20.3 ENVIRONMENTAL COMPLIANCE

    The contractor shall comply with all applicable environmental laws, rules,
directives, standards, orders, or requirements, including but not limited to,
Section 306 of the Clean Air Act (42 U.S.C. § 1857(h)), Section 508 of the Clean
Water Act (33 U.S.C. § 1368), Executive Order 11738, and the Environmental
Protection Agency (EPA) regulations (40 C.F.R., Part 15) that prohibit the use
of the facilities included on the EPA List of Violating Facilities.

Amended as of July 1, 2004  
VII-34

 

 

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

 

    shall include, but not be limited to, utilization information on enrollee
encounters with PCPs, children who have not received an EPSDT examination or a
blood lead screening, specialty claims, prescriptions, inpatient stays, and
emergency room use.   E.   The contractor shall collect and analyze data to
implement effective quality assurance, utilization review, and peer review
programs in which physicians and other health care practitioners participate.
The contractor shall review and assess data using statistically valid sampling
techniques including, but not limited to, the following:       Primary care
practitioner audits; specialty audits; inpatient mortality audits; quality of
care and provider performance assessments; quality assurance referrals;
credentialing and recredentialing; verification of encounter reporting rates;
quality assurance committee and subcommittee meeting agendas and minutes;
enrollee complaints, grievances, and follow-up actions; providers identified for
trending and sanctioning, including providers with low blood lead screening
rates; special quality assurance studies or projects; prospective, concurrent,
and retrospective utilization reviews of inpatient hospital stays; and denials
of off-formulary drug requests.   F.   The contractor shall prepare and submit
to DMAHS quarterly reports to be reported by hard copy and diskette in a format
and software application system determined by DMAHS, containing summary
information on the contractor’s operations for each quarter of the program (See
Section A.7 of the Appendices, Tables 1 through 21. Exception - Tables 3A and 3B
shall be submitted monthly by the fifteenth (15`h) of every month.). These
reports shall be received by DMAHS no later than forty-five (45) calendar days
after the end of the quarter. After a grace period of five (5) calendar days,
for each calendar day after a due date that DMAHS has not yet received at a
prescribed location a report that fulfills the requirements of any one item,
assessment for damages equal to one half month’s negotiated blended capitation
rate that would normally be owed by DMAHS to the contractor for one recipient
shall be applied. The damages shall be applied as an offset to subsequent
payments to the contractor.       The contractor shall be responsible for
continued reporting beyond the term of the contract because of lag time in
submitting source documents by providers.   G.   The contractor may submit
encounter reports daily but must submit encounter reports at least quarterly.
However, encounter reports will be processed by DMAHS’ fiscal agent no, more
frequently than monthly. All encounters shall be reported to DMAHS within
seventy-five (75) days of the end of the quarter in which they are received by
the contractor and within one year plus seventy-five (75) days from the date of
service.

      Amended as of July 1, 2004  
VI-38

 

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

 

H.   The contractor shall, annually and at the time changes are made report its
staffing positions including the names of supervisory personnel (Director level
and above and the QM/UR personnel), organizational chart, and any position
vacancies in these major areas.   I.   DMAHS shall have the right to create
additional reporting requirements at any time as required by applicable federal
or State laws and regulations, as they exist or may hereafter be amended and
incorporated into this contract.   J.   Reports that shall be submitted on an
annual or semi-annual basis, as specified in this contract, shall be due within
sixty (60) days of the close of the reporting period, unless specified
otherwise.   K.   MCSA Paid Claims Reconciliation. On a quarterly basis, the
contractor shall provide paid claims data, via an encounter data file or
separate paid claims file, that meet the HIPAA format requirements for audit and
reconciliation purposes. The contractor shall provide documentation that
demonstrates a 100% reconciliation of the amounts paid to the amounts billed to
the DMAHS. The paid claims data shall include at a minimum, claim type, provider
type, category of service, diagnosis code (5 digits), procedure/revenue code,
Internal Control Number or Patient Account Number under HIPAA, provider. ID,
dates of services, that will allow the DMAHS to price claims in comparison to
Medicaid fee schedules for evaluation purposes.   L.   Encounter Data
Submissions. The contractor shall cooperate with the DMAHS in its review of the
status of encounter data submissions to determine needed improvements for
accuracy and completeness of encounter data submissions. With the contract
period beginning July 2005, the contractor will be subject to additional
sanctions if not in full compliance with encounter data submission standards.

7.27 FINANCIAL STATEMENTS

7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)

A.   Annual Audit. The contractor shall submit its audited annual financial
statements prepared in accordance with Statutory Accounting Principles
(SAP) certified by an independent public accountant no later than June 1 of each
year, for the immediately preceding calendar year as well as for any company
that. is a financial guarantor for the contractor in accordance with N.J.S.A.
8:38-11.6.   B.   Audit of Rate Cell Grouping Costs       The contractor shall
submit, quarterly, reports found in Appendix, Section A in accordance with the
“HMO Financial Guide for Reporting Medicaid/NJ Family Care Rate Cell Grouping
Costs” (Appendix, Section B7.3). These reports shall be

Amended as of July 1, 2004

 

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

 

8.5.3 NEWBORN INFANTS

    The contractor shall be reimbursed for newborns from the date of birth
through the first 60 days after the birth through the period ending at the end
of the month in which the 60th day falls by a supplemental payment as part of
the supplemental maternity payment. Thereafter, capitation payments will be made
prospectively, i.e., only when the baby’s name and ID number are accreted to the
Medicaid eligibility file and formally enrolled in the contractor’s plan.

8.5.4 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME

    Because costs for pregnancy outcomes were not included in the capitation
rates, the contractor shall be paid supplemental payments for pregnancy outcomes
for all eligibility categories.
Payment for pregnancy outcome shall be a single, predetermined lump sum payment.
This amount shall supplement the existing capitation rate paid. The Department
will make a supplemental payment to contractors following pregnancy outcome. For
purposes of this Article, pregnancy outcome shall mean each live birth, still
birth or miscarriage occurring at- the thirteenth (13th) or greater week of
gestation. This supplemental payment shall reimburse the contractor for its
inpatient hospital, antepartum, and postpartum costs incurred in connection with
delivery. Costs for care of the baby for the first 60 days after the birth plus
through the end of the month in which the 60th day falls are included (See
Section 8.5.3). Regional payment shall be made by the State to the contractor
based on submission of a financial summary report of hospital and/or birthing
center claims paid for final pregnancy outcomes. No other services, inpatient
hospital or otherwise, rendered prior to final pregnancy outcome shall qualify
or be payable for a maternity supplement.       The report shall be accompanied
by a signed certification form and an electronic file to include:

1.   Paid inpatient hospital/birthing center claims;   2.   Name of mother;   3.
  Mother’s Medicaid identification number;   4.   Newborn’s name, if known;   5.
  Diagnosis and five-digit ICD-9 codes, including V-codes, specified by DMAHS;
and   6.   Place of service.

    The contractor shall continue to submit encounter data that will document
each paid claim reported on the financial summary report. The DMAHS will conduct
a reconciliation of these paid claims utilizing encounter data.

8.5.5 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS

Amended as of July 1, 2004  
VIII-8

 

 

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

 

K.   Hospitalizations. For any eligible person who applies for participation in
the contractor’s plan, but who is hospitalized prior to the time coverage under
the plan becomes effective, such coverage shall not commence until the date
after such person is discharged from the hospital and DMAHS shall be liable for
payment for the hospitalization, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. If an enrollee’s
disenrollment or termination becomes effective during a hospitalization, the
contractor shall be liable for hospitalization until the date such person is
discharged from the hospital, including any charges for readmission within
forty-eight (48) hours of discharge for the same diagnosis. The contractor must
notify DMAHS of these occurrences to facilitate payment to appropriate
providers.   L.   Continuation of Benefits. The contractor shall continue
benefits for all enrollees for the duration of the contract period for which
capitation payments have been made, including enrollees in an inpatient facility
until discharge. The contractor shall notify DMAHS of these occurrences.   M.  
Drug Carve-Out Report. The DMAHS will provide the contractor with a monthly
electronic file of paid drug claims data for non-dually eligible, ABD enrollees.
  N.   MCSA Administrative Fee. The Contractor shall receive a monthly
administrative fee, PMPM, for its MCSA enrollees, by the fifteenth (15th) day of
any month during which health care services will be available to an enrollee.  
O.   Reimbursement for MCSA Enrollee Paid Claims. The DMAHS shall reimburse the
contractor for all claims paid on behalf of MCSA enrollees. The contractor shall
submit to DMAHS a financial summary report of claims paid on behalf of MCSA
enrollees on a weekly basis. The report shall be summarized by category of
service corresponding to the MCSA benefits and payment dates, accompanied by an
electronic file of all individual claim numbers for which the State is being
billed.   P.   MCSA Claims Payment Audits. The contractor shall monitor and
audit claims payments to providers to identify payment errors, including
duplicate payments, overpayments, underpayments, and excessive payments. For
such payment errors (excluding underpayments), the contractor shall refund DMAHS
the overpaid amounts. The contractor shall report the dollar amount of claims
with payment errors on a monthly basis, which is subject to verification by the
State. The contractor is responsible for collecting funds due to the State from
providers, either through cash payments or through offsets to payments due the
providers.

8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS

A.   The contractor shall make advance payments to its providers, capitation,
FFS, or other financial reimbursement arrangement, based on a provider’s
historical billing or utilization of services if the contractor’s claims
processing systems      

Amended as of July 1, 2004  
VIII-19

 

 

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

 

    against the next PIP made to the hospital. An example of how this
methodology shall work is as follows:

EXAMPLE:

                                              PIP   Claims   Reconciliation  
Net         Payment   Adjudicated   Adjustment   Payment   Balance .
Aug 1
    300,000 (A)                                
Aug 1
    300,000 (B)                             600,000  
Aug 1-31
            180,000                       420,000  
Sept 1
    300,000 (C)             (120,000 ) (A)     180,000       600,000  
Sept 1-30
            270,000                       330,000  
Oct 1
    300,000 (D)             (30,000 ) (B)     270,000       600,000  
Oct 1-31
            320,000                       280,000  
Nov 1
    300,000 (E)             20,000 (C)     320,000       600,000  

8.10 FEDERALLY QUALIFIED HEALTH CENTERS

A.   Standards for Contractor FQHC Rates. The contractor shall not reimburse
FQHCs less than the level and amount of payment that the contractor would make
for a similar set of services if the services were furnished by a non-FQHC. The
contractor may pay the FQHCs on a fee-for-service or capitated basis. The
contractor shall make payments for primary care equal to, or greater than, the.
average amounts paid to other primary care providers. Non-primary care services
may be included if mutually agreeable between the contractor and FQHC. For
non-primary care services, payments shall be equal to, or greater than, the
average amounts paid to other non-primary care providers for equivalent
services.   B.   DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall be
paid under a Prospective Payment System (PPS) by DMAHS. At the end of each
calendar quarter, the contractor and the FQHC will complete certain reporting
requirements specified that will enable DMAHS to determine PPS reimbursement and
compare that to what was actually paid by the contractor to the FQHC. DMAHS will
reimburse the FQHC the difference (between the PPS rate per encounter and the
payments to the FQHC made by the contractor) if the payments by the contractor
to the FQHC are less than the PPS rate. In the event of an overpayment, the FQHC
shall reimburse DMAHS for payments received from the contractor that are in
excess of PPS rate. FQHC providers must meet the contractor’s credentialing and
program requirements.   C.   Contractor Participation in Reconciliation Process.
The contractor shall participate in the reconciliation processes if there is a
dispute between what the