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Back to Form 10-Q [form10-q.htm]
Exhibit 10.6
 
 
STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES

CONTRACT AMENDMENT

Amendment Number:
16
Contract #:
093-MED-WCC-1
Contract Period:
08/11/2001 - 06/30/2007
Contractor Name:
WELLCARE OF CONNECTICUT, INC.
Contractor Address:
116 Washington Avenue, 2nd Floor, North Haven, CT 06473

Contract number 093-MED-WCC-l 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 as amended by Amendments 1, 2,
3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15 is hereby further 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 115 dated 05/07 attached hereto.

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

 
A. HUSKY A Covered Services
B.  Provider Credentialing and Enrollment Requirements
C.  EPSDT Periodicity & Immunization Schedules
D.  DSS Marketing Guidelines
E.   Standards for Internal Quality Assurance Programs for Health Plans
F.   Claims Inventory, Aging and Unaudited Quarterly Financial Reports
G.   HUSKY A Medicaid Coverage Groups
H    BLANK - RESERVED FOR POSSIBLE FUTURE USE
I.     Capitation Payment Amounts
    1.           Table 1 - HUSKY A Capitation Rates effective 01/01/06 -
06/30/06
    2.           Table 2 - HUSKY A Capitation Rates effective 07/01/06 -
06/30/07 
J.     BLANK - RESERVED FOR POSSIBLE FUTURE USE
K.   Inpatient/Eligibility Recategorization Chart
L.    Pharmacy Reports M. Rate Certification
N.   HUSKY Behavioral Health Carve-Out Coverage and Coordination of Medical and
Behavioral Services
O.   CTBHP Master Covered Services Table

 
Page 1 of 2

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

 
4.
  Appendix I Capitation Payment Amounts -Table 1 - HUSKY A Capitation Rates
shall be effective for the period 01/01/06-06/30/06.

 
5.
  Appendix I Capitation Payment Amounts -Table 2 - HUSKY A Capitation Rates
shall be effective for the period 07/01/06-06/30/07.

 
6. 
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
  /s/  Todd S. Farha
5/30/2007
 /s/   Michael Starkowski
5/31/2007
Signature
Date
  Signature
Date
 
Todd S. Farha
President & CEO
Michael Starkowski
Commissioner
Typed Name
Title
Typed Name
Title

 
Attorney General (as id 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:

 
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 (Part II, 3.01-3.35)  07 HUSKY A 05/07

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
3.1         Provision of Services
3.2         Non-Discrimination
3.3         Member Rights
3.4         Gag Rules
3.5         Coordination and Continuation of Care
3.6         Emergency Services
3.7         Geographic Coverage
3.8         Choice of Health Professional
3.9         Provider Network
3.10       Network Adequacy and Maximum Enrollment Levels
3.11       Provider Contracts
3.12       Provider Credentialing and Enrollment
3.13       Second Opinions, Specialist Providers and the Referral Process
3.14       PCP and Specialist Selection, Scheduling and Capacity
3.15       Women's Health, Family Planning Access and Confidentiality
3.16       Pharmacy Access
3.17       Mental Health and Substance Abuse Access
3.18       Children's Issues and EPSDT Compliance
3.19       Specialized Outpatient Services for Children Under DCF Care
3.20       Prenatal Care
3.21       Dental Care
3.22       Other Access Features
3.23       Pre-Existing Conditions
3.24       Newborn Enrollment
3.25       Acute Care Hospitalization, Nursing Home or Long Term Chronic Disease
Hospital Stay 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       Marketing Requirements
3.32       Health Education
3.33       Internal and External Quality Assurance
3.34       Inspection of Facilities
3.35       Examination of Records
3.36       Medical Records
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(Part II, 3.01-3.35)  07 HUSKY A 05/07
 
3.37            Audit Liabilities
3.38            Clinical Data Reporting
3.39            Utilization Management
3.40            Financial Records
3.41            Insurance
3.42            Third Party Coverage
3.43            Coordination of Benefits and Delivery of Services
3.44            Passive Billing
3.45            Subcontracting for Services
3.46            Timely Payment of Claims
3.47            Member Charges for Noncovered Services
3.48            Insolvency Protection
3.49            Acceptance of DSS Rulings
3.50            Fraud and Abuse
3.51            Persons with Special Health Care Needs
3.52            Behavioral Health Payment Adjustment
 
4.          FUNCTIONS AND DUTIES OF THE DEPARTMENT
4.1            Eligibility Determinations
4.2            Populations Eligible to Enroll
4.3            Enrollment/Disenrollment
4.4            Default Enrollment
4.5            Capitation Payments to MCO
4.6            Retroactive Adjustments
4.7            Information
4.8            Ongoing MCO Monitoring
4.9            Utilization Review and Control
 
5.           DECLARATIONS AND MISCELLANEOUS PROVISIONS
5.1           Competition Not Restricted
5.2           Nonsegregated Facilities
5.3           Offer of Gratuities
5.4           Employment/Affirmative Action Clause
5.5           Confidentiality
5.6           Independent Capacity
5.7           Liaison
5.8           Freedom of Information
5.9           Waivers
5.10         Force Majeure
5.11         Financial Responsibilities of the MCO
5.12         Capitalization and Reserves
5.13         Provider Compensation
5.14         Members Held Harmless
5.15         Compliance with Applicable Laws, Rules and Policies
5.16         Advance Directives
5.17         Federal Requirements and Assurances
5.18         Civil Rights

 
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(Part II, 3.01-3.35)    07 HUSKY A     05/07

 
5.19           Statutory Requirements
5.20           Disclosure of Interlocking Relationships
5.21           DEPARTMENT'S Data Files
5.22           Changes Due to a Section 1115 or 1915(b) Freedom of Choice
5.23           Hold Harmless
5.24           Executive Order Number 16
 
6.            GRIEVANCE SYSTEM AND PROVIDER DENIALS
6.1           Grievances
6.2           Notices of Action and Continuation of Services
6.3           Appeals and Administrative Hearing Processes
6.4           Expedited Appeals and Administrative Hearings
6.5           Provider Appeal Process
 
7.            CORRECTIVE ACTION AND CONTRACT TERMINATION
7.1           Performance Review
7.2           Settlement of Disputes
7.3           Administrative Errors
7.4           Suspension of New Enrollment
7.5           Monetary Sanctions
7.6           Temporary Management
7.7           Payment Withhold, Class C Sanctions or Termination for Clause
7.8           Emergency Services Denials
7.9           Termination for Default
7.10         Termination for Mutual Convenience
7.11         Termination for the MCO Bankruptcy
7.12         Termination for Unavailability of Funds
7.13         Termination for Collusion in Price Determination
7.14         Termination Obligations of Contracting Parties
7.15         Waiver of Default
 
8.            OTHER PROVISIONS
8.1           Severability
8.2           Effective Date
8.3           Order of Precedence
8.4           Correction of Deficiencies
8.5           This is not a Public Works Contract

 
9.            APPENDICES
Appendix A HUSKY A Covered Services
Appendix B Provider Credentialing and Enrollment Requirements
Appendix C EPSDT Periodicity & Immunization Schedules
Appendix D DSS Marketing Guidelines
Appendix E Standards for Internal Quality Assurance Programs for Health Plans
Appendix F Claims Inventory, Aging and Unaudited Quarterly Financial Reports

 
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(Part II, 3.01-3.35)   07 HUSKY A  05/07

Appendix G HUSKY A Medicaid Coverage Groups
Appendix I   Capitation Payment Amount - Tables
Appendix K Medical Acute Care Primary Inpatient/Eligibility Recategorization
Changes
Appendix L Pharmacy Reports
Appendix M Rate Certification
Appendix N HUSKY Behavioral Health Carve-Out Coverage and Coordination of
Medical and Behavioral Services Appendix O CTBHP Master Covered Services Table

 
Removed Appendices:
Appendix H   MMC Policy Transmittals
Appendix J    Physician Incentive Payments

 
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(Part II, 3.01-3.35)  07 HUSKY A  05/07

Part I: Standard Connecticut Contract Terms

 
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(Part II, 3.01-3.35)  07 HUSKY A   05/07

 
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:
Provider and/or MCO practices that are inconsistent with sound fiscal, business
or medical practices and that result in an unnecessary cost to the HUSKY A
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 A
program also constitute abuse.

 
Action:
The denial or limited authorization of a requested service, including the type
or level of service; the reduction, suspension, or termination of a previously
authorized service; the denial, in whole or in part, of payment for a service;
the failure to provide services in a timely manner, as defined by the
DEPARTMENT; the failure of an MCO to act within the timeframes for authorization
decisions set forth in this Contract.

 
Administrative Services Organization (ASO):
An organization providing utilization management, benefit information and
intensive care management services within a centralized information system
framework.
 
Advance Directive:
A written instruction, such as a living will or durable power of attorney for
health care, recognized under Connecticut law, relating to the provision of
health care when the individual is incapacitated.
 
Agent:
An entity with the authority to act on behalf of the DEPARTMENT.
 
Appeal:
A request to the MCO from a Member for a formal review of an MCO action.
 
Behavioral Health Partnership ("Partnership" or "BHP" or "CTBHP"):
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 Payment:
The individualized monthly payment made by the DEPARTMENT to the MCO on behalf
of Members.
 
Capitation Rate:
The amount paid per Member by the DEPARTMENT to each Managed Care Organization
(MCO) on a monthly basis.

 
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(Part II, 3.01-3.35)   07 HUSKY A  05/07

 
Chronic Disease Hospital
Conn. Agencies Reg. § 19-13-D1(b). A chronic disease hospital is defined as a
"long-term hospital having facilities, medical staff and all necessary personnel
for the diagnosis, care and treatment of a wide range of chronic diseases and
licensed as a chronic disease hospital.
 
CMS:
Centers for Medicare & Medicaid Services (CMS), a division within the United
States Department of Health and Human Services. This division was formerly known
as HCFA, the Health Care Financing Administration.
 
Clean Claim:
A bill for service(s) or good(s), a line item of services or all services and/or
goods for a recipient contained on one bill that 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.
 
Cold Call Marketing:
Any unsolicited personal contact by the MCO with a potential Member for the
purpose of marketing.
 
Commissioner:
The Commissioner of the Department of Social Services, as defined in Section
17b-3 of the Connecticut General Statutes.
 
Consultant:
A corporation, company, organization or person or their affiliates retained by
the DEPARTMENT to provide assistance in this project or any other project, 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 services that the MCO is required to provide to Members under this
contract.
 
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 a completed application for the HUSKY A program is received by
the DEPARTMENT or its agent, containing the applicant's signature.
 
Day:
Except where the term business day is expressly used, all references in this
contract will be construed as calendar days.
 
DEPARTMENT or DSS:
The Department of Social Services, State of Connecticut

 
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(Part II, 3.01-3.35) 07 HUSKY A 05/07

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 provider
that is qualified to furnish Medicaid services; 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.
 
Enhanced Care Clinics:
Clinics that qualify for fees that are higher than the standard Medicaid fee
schedule for outpatient mental health and substance abuse clinics. In order to
qualify for such higher fees, clinics must meet special service requirements as
determined by the CT BMP.
 
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services:
Comprehensive child health care services to Members under twenty-one (21) years
of age, including all medically necessary prevention, screening, diagnosis and
treatment services listed in Section 1905 (r) of the Social Security Act.

 
1.
EPSDT Case Management Services: Services such as making and facilitating
referrals and development and coordination of a plan of services that will
assist Members under twenty-one (21) years of age in gaining access to needed
medical, social, educational, and other services.

 
2.
EPSDT Diagnostic and Treatment Services: All health care, diagnostic services,
and treatment necessary to correct or ameliorate defects and physical and mental
illnesses and conditions discovered by an interperiodic or periodic EPSDT
screening examination.

 
3.
EPSDT Screening Services: Comprehensive, periodic health examinations for
Members under the age of twenty-one (21) provided in accordance with the
requirements of the federal Medicaid statute at 42 U.S.C. §1396d(r)(1).

 
Enrollment Broker: The organization contracted by the DEPARTMENT to perform the
following administrative and operational functions for the HUSKY A and B
programs: HUSKY application processing, HUSKY B eligibility determinations,
passive billing and enrollment brokering.
 
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.
 
Formulary:
A list of selected Pharmaceuticals determined to be the most useful and cost
effective for patient care, developed by a pharmacy and therapeutics committee
at the MCO.

 
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(Part II, 3.01-3.35) 07 HUSKY A 05/07

 
FQHC-Sponsored MCO:
An MCO that is more than fifty (50) percent owned by Connecticut Federally
Qualified Health Centers, certified by the DEPARTMENT to enroll Medicaid
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.
 
Grievance:
An expression of dissatisfaction about the MCO on any matter other than an
"action" as defined herein. Possible subjects for grievances include, but are
not limited to, the quality of care or services provided by the MCO and aspects
of interpersonal relationships such as rudeness of a provider or an MCO
employee, or failure to respect a Member's rights.
 
Health Employer Data 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.
 
HHS:
The United States Department of Health and Human Services.
 
HUSKY, Part A or HUSKY A:
For purposes of this contract, HUSKY 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.
 
Institution for Mental Disease (IMD)
Means a hospital, nursing facility, or other institution of more than sixteen
beds, primarily for the diagnosis, treatment or care of persons with mental
diseases, not including mental retardation.
 
In-Network Providers or Network Providers:
Providers who have contracted with the MCO to provide services to Members.
 
Lock-in:
Limitations on Member changes of managed care plans for a period of time, not to
exceed twelve (12) months.
 
Managed Care Organization (MCO):
The organization signing this agreement with the DEPARTMENT.
 
Marketing:
Any communication from an MCO to a Medicaid recipient who is not enrolled in
that entity, 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.
 
Marketing Materials:
Any materials produced in any medium, by or on behalf of an MCO that can
reasonably be interpreted as intended to market to potential Members.

 
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(Part II, 3.01-3.35)  07 HUSKY A 05/07
 
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.
 
Medicaid Program Provider Manuals:
Service-specific documents created by Connecticut Medicaid to describe policies
and procedures applicable to the Medicaid program generally and that service
specifically.
 
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/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.
 
Member:
For the purposes of HUSKY A, a Medicaid client who has been certified by the
State as eligible to enroll under this contract, and whose name appears on the
MCO enrollment information that the DEPARTMENT will transmit to the MCO every
month in accordance with an established notification schedule.
 
National Committee for Quality Assurance (NCQA):
NCQA is a not-for-profit organization that develops and defines quality and
performance measures for managed care, thereby providing an external standard of
accountability.
 
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.
 
Peer Review Organization (PRO):
A professional medical organization that conducts peer review of medical care
certified by HCFA or CMS.
 
Pharmacy Benefits Manager (PBM):
An entity that, through an arrangement with the MCO, is responsible for managing
or arranging for one or more of the Medicaid pharmacy services provided by the
MCO pursuant to this contract.
 
Pharmacy or Provider Lock-In:
An optional MCO program, subject to approval by the DEPARTMENT, to restrict
certain Members to a specific pharmacy or provider in order to monitor services
and reduce unnecessary or inappropriate utilization.
 
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.

 
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(Part H, 3.01-3.35) 07 HUSKY A 05/07

 
Potential Member:
A Medicaid recipient who is subject to enrollment in a managed care organization
but is not yet a Member of a specific MCO.
 
Primary Care Provider (PCP):
A licensed health care 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.
 
Revenue Center Code:
A revenue code identifies a specific Medicaid billable service type. Facilities
must choose the code that most appropriately describes the service to be billed
to Medicaid.
 
Risk:
The possibility of monetary loss or gain by the MCO resulting from service costs
exceeding or being less than payments made to it 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 emergent nor urgent
nature.
 
Subcontract:
Any written agreement between the MCO and another party to fulfill any
requirements of this contract, except a written agreement between the MCO and a
vendor.
 
Subcontractor:
The party contracting with the MCO to manage or arrange for one or more of the
Medicaid services provided by the MCO pursuant to this contract, but excluding
services provided by a vendor.
 
Third-Party:
Any individual, entity or program that is or may be liable to pay all or part of
the expenditures for Medicaid furnished under a State plan.
 
Title XIX:
The provisions of 42 United States Code Section 1396 et seq.. including any
amendments thereto. (See Medicaid)
 
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 for which treatment cannot be delayed
without imposing undue risk on the Members' 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.
 
Well-care Visits:
Routine physical examinations, immunizations and other preventive services that
are not prompted by the presence of any adverse medical symptoms.

 
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(Part H, 3.01-3.35) 07 HUSKY A 05/07

 
2.   DELEGATIONS OF AUTHORITY
 
The State of Connecticut Department of Social Services is the single state
agency responsible for administering the Medicaid program. No delegation by
either party in administering this contract shall relieve either party of
responsibility for carrying out the terms of this 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 individuals enrolled under this contract, directly or
through arrangements with others, all of the covered services described in
Appendix A of this contract.

 
b.
The MCO shall ensure that the services provided to Members are sufficient in
amount, duration and scope to reasonably be expected to achieve the purpose for
which the service is provided. The services provided under this contract shall
be in an amount, duration and scope that is no less than the amount, duration
and scope of services for fee-for- service Medicaid clients. The MCO shall not
arbitrarily deny or reduce the amount, duration or scope of a required service
solely because of the Member's diagnosis, type of illness or medical condition.

 
c.
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 and Medically Necessary or Medical
Necessity at Part II Section 1, General Contract Terms for MCOs. As required by
42 CFR 438.236 and as more fully described in Appendix E, the MCO shall adopt
practice guidelines as part of its quality improvement program. The MCO shall
disseminate the guidelines to affected providers and to Members, upon request.
The MCO's utilization management decisions must be consistent with
any applicable practice guidelines adopted by the MCO. In order
to operationalize the medical necessity definition, the MCO may use utilization
management criteria or guidelines developed by the MCO or a by a subcontractor
or a third party. The MCO shall only use such criteria or guidelines in
conjunction with the DEPARTMENT'S medical necessity and medical appropriateness
definitions. The DEPARTMENT'S definitions take precedence over any guidelines or
criteria and are mandatory and binding on all MCO utilization management
decisions. The MCO shall also ensure that its subcontracts and contracts with
network providers require that the decisions of subcontractors and network
providers affecting the delivery of acute or chronic care services to Members
are made on an individualized basis and in accordance with the contractual
definitions for Medical Appropriateness or Medically Appropriate and Medically
Necessary and Medical Necessity.

 
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(Part II, 3.01-3.35) 07 HUSKY A 05/07
 
d.
The MCO shall provide twenty-four (24) hour, seven (7) day a week accessibility
to qualified medical personnel for 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.

 
e.
Changes to Medicaid covered services mandated by Federal or State law, or
adopted by amendment to the State Plan for Medicaid, 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 Medicaid
coverage were expanded to include new services, such services would be paid for
via the traditional Medicaid fee- for-service system unless covered by mutual
consent between the DEPARTMENT and the MCO (in which case an appropriate
adjustment to the capitation rates would be made). If Medicaid covered services
are changed to exclude services, the DEPARTMENT may determine that such services
will no longer be covered under HUSKY A 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 concerning the change to Medicaid covered services, 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.

 
f.
Any change regarding the provision of covered services that will
become effective during the term of this Contract shall be implemented by
the MCO within sixty (60) days of receiving notice of the change from
the DEPARTMENT, unless law requires earlier compliance.

 
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

 
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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 Part 60-1 et seg., Obligations of Contractors and
Subcontractors). The MCO shall also comply with Sections 4a-60, 4a-61, 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 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 HCFA 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 available 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 by the contract, the MCO shall provide covered
services to HUSKY A Members under this contract in the same manner as those
services are provided to other Members of the MCO, although

 
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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 A and other Members of the MCO. The MCO
shall ensure that its network providers offer hours of operation that are no
less than those offered to the MCO's commercial members or comparable to
Medicaid fee-for-service, if the provider serves only Medicaid Members.

c. 
Nothing in this section shall preclude the implementation of a pharmacy or
provider lock-in program by the MCO, based on the DEPARTMENT'S approval of such
program.

3.03            Member Rights

a.
The MCO shall have written policies regarding member rights. The MCO must comply
with all applicable state and federal laws pertaining to member rights and
privacy. The MCO shall further ensure that the MCO's employees, subcontractors
and network providers consider and respect those rights when providing services
to Members.

b.           Member rights include, but are not limited to, the following:

1.
The right to be treated with respect and due consideration for the Member's
dignity and privacy;

2.
The right to receive information on treatment options and alternatives in a
manner appropriate to the Member's condition and ability to understand;

3.
The right to participate in treatment decisions, including the right to refuse
treatment;

4.
The right to be free from any form of restraint or seclusion as a means of
coercion, discipline, retaliation or convenience;

5.
The right to receive a copy of his or her medical records, including, if the
HIPAA privacy rule applies, the right to request that the records be amended or
corrected as allowed in 45 CFR part 164; and

6.
Freedom to exercise the rights described herein without any adverse affect on
the Member's treatment by the DEPARTMENT, the MCO or the MCO's subcontractors or
network providers.

3.04            Gag Rules

a. 
Subject to the limitations described in 42 U.S.C. Section 1396u-2(b)(3)(B) and
(C), the MCO shall not prohibit or otherwise restrict a health care provider
acting within his or her lawful scope of practice from advising or

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advocating on behalf of a Member, who is a patient of the provider, for the
following:

1.
The Member's health status, medical care, or treatment options, including any
alternative treatment that may be self-administered;

2.
Any information the Member needs in order to decide among relevant treatment
options;

3.
The risks, benefits and consequences of treatment or nontreatment;

4.
The Member's right to participate in decisions regarding his or her health care,
including, the right to refuse treatment, and to express preferences about
future treatment decisions

b. 
This prohibition applies regardless of whether benefits for such care or
treatment are provided under this contract.

3.05   Coordination and Continuation of Care

a.
The MCO shall have systems in place to provide well-managed patient care that
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.

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 EPSDT screening services in accordance with the
schedules for immunizations and periodicity of well-child services as
established by the DEPARTMENT and federal regulations.

6.
Provide or arrange for the provision of EPSDT case management services for
Members under twenty-one (21) years of age when the Member has a physical or
mental health condition that makes the coordination of medical, social, and
educational services medically necessary. As necessary, case management services
shall include but not be limited to:

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a)
Assessment of the need for case management and development of a plan for
services;

b)
Periodic reassessment of the need for case management and review of the plan for
services;

c)
Making referrals for related medical, social, and educational services;

d)
Facilitating referrals by providing assistance in scheduling appointments for
health and health-related services, and arranging transportation and interpreter
services;

e)
Coordinating and integrating the plan of services through direct or collateral
contacts with the family and those agencies and providers providing services to
the child;

f)
Monitoring the quality and quantity of services being provided;

               g) Providing health education as needed; and

 
h)
Advocacy necessary to minimize conflict between service providers and to
mobilize resources to obtain needed services.

7.
Provide necessary coordination and case management services for children with
special health care needs.

8.
If notified, PCPs will 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.

9.
The MCO shall coordinate Members' care with the CT BMP, as outlined in this
Contract, including but not limited to section 3.17, and Appendix N.

3.06    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.
The MCO shall cover and pay for emergency services without regard to prior
authorization and regardless of whether the provider that furnishes the services
has a contract with the MCO.

c.
The MCO shall be responsible for payment for emergency department visits,
including emergent and urgent visits 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.

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The CT BHP 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
DEPARTMENT 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.

e.
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 medical condition.

f.
The MCO shall 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.

g.
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.

h.
 
The MCO shall not base its determinations on what constitutes an emergency
medical condition on a list of diagnoses or symptoms. The determination of
whether the prudent layperson standard is met shall be made on a case-by-case
basis. However, the MCO may determine that the emergency medical condition
definition is met, based on a list such as ICD-9 codes.

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

j. 
The MCO shall cover post-stabilization services obtained either within or
outside the MCO's provider network, under the following circumstances;

 
1. 
The services were pre-approved by the MCO;

2.
The services were not pre-approved by the MCO, but administered to maintain the
Member's stabilized condition within one hour of a request to the MCO for
pre-approval of further post-stabilization care services.

k.  
 The MCO shall cover post stabilization services that were obtained either
within or outside the MCO's provider network and not pre-approved, but
administered to maintain, improve or resolve the Member's stabilized condition
in the following circumstances:

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1.
The MCO does not respond to a request for pre-approval of such services within
one hour;

2.
The MCO cannot be contacted; or

3.
The MCO and the treating physician cannot reach an agreement concerning the
Member's care and an MCO physician is not available for consultation. In this
circumstance, the MCO must give the treating physician the opportunity to
consult with an MCO physician and the treating physician may continue with care
of the patient until an MCO physician is reached or one of the
following criteria are met:

b)
An MCO physician with privileges at the treating hospital assumes responsibility
for the Member's care;

c)
An MCO physician assumes responsibility for the member's care through transfer;

c) 
The MCO and the treating physician reach an agreement concerning the Member's
care.

I.        
 If there is a disagreement between a hospital or other treating facility and an
MCO concerning whether the Member is stable enough for discharge or transfer
from the emergency room, the judgment of the attending physician(s) or the
provider actually treating the Member 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
Member.

m.
 
When a Member's PCP or another MCO 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 medically necessary emergency
services, without regard to whether the Member's condition meets the emergency
medical condition definition.

n.        
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 appeal and the DEPARTMENT'S administrative hearing processes.

o.        
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.

p.
The MCO may not make payment for emergency services contingent upon the Member
providing the MCO with notification either before or after receiving emergency
services. The MCO may, however, enter into

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contracts with providers or facilities that require, as a condition of payment,
the provider or facility to provide notification to the MCO after Members are
present at the emergency room, assuming adequate provision is given for such
notification.

q.        
The MCO shall retain responsibility for payment for emergency medical
transportation, 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, less any payments for indirect costs of
medical education and direct costs of graduate medical education.

3.07           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 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 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 the Medicaid fee-for-service program.

b.
On a monthly basis, the MCO shall 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.

Sanction: In any sampling, if more than two (2) percent of Members reside in
towns beyond fifteen (15) miles of a town containing a PCP the DEPARTMENT may
impose a strike towards a Class A sanction pursuant to Section 7.05.

3.08           Choice of Health Professional

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

3.09           Provider Network

a.       The MCO shall maintain a provider network capable of delivering or
arranging for the delivery of all covered health goods and services to all

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Members. In addition, the MCO's provider network shall have the capacity to
deliver or arrange for the delivery of all the goods and services reimbursable
under this contract regardless of whether all of the goods and services are
provided through direct provider contracts. The MCO shall submit a file of their
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.
In establishing and maintaining its provider network, the MCO shall consider the
following:

1.
Anticipated enrollment;

2.
Expected utilization of services, taking into consideration the characteristics
and health care needs of the specific Medicaid populations in the MCO;

3.
The number and types (in terms of training, experience, and specialization) of
providers required to furnish the contracted Medicaid services;

4.
The numbers of network providers who are not accepting new Medicaid patients;

5.
The geographic location of providers and Medicaid Members, considering distance,
travel time, the means of transportation ordinarily used by Medicaid members,
and whether the location provider physical access for Members with disabilities.

c.
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 shall 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, if the provider network
file fails to meet these requirements.

d.
If the MCO declines to include a provider or group of providers in its network,
the MCO shall give the affected provider(s) written notice of the reason for its
decision.

e.
The MCO shall not discriminate against providers with respect to participation,
reimbursement, or indemnification for any provider who is acting within the
scope of that provider's license or certification under applicable State law,
solely on the basis of the provider's license or certification. This shall not
be construed to prohibit the MCO from including providers only to the extent
necessary to meet the needs of the MCO's Members or from establishing measures
designed to maintain the quality of services and control costs, consistent with
its responsibilities. This shall not preclude the MCO from using different
reimbursement amounts for different specialties or for different practitioners
in the same specialty.

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f.
The MCO's provider selection policies and procedures shall not discriminate
against particular providers that serve high-risk populations or specialize in
conditions that require costly treatment.

g.
The MCO shall not employ or contract with any provider excluded
from participation in a Federal health care program under either Section 1128 or
1128A of the Social Security Act.

3.10   
Network Adequacy and Maximum Enrollment Levels Primary Care Providers and
Dentists

a.
On a quarterly basis, except as otherwise specified by 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
Medicaid fee-for-service experience in order to ensure that access in the MCO is
at least equal to access experienced in the Medicaid fee-for-service 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;

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.
In the event that the number of Members in a given county equals or exceeds
ninety percent (90%) of the capacity determined in accordance with section a
noted above, the DEPARTMENT shall evaluate the adequacy of the MCO's network on
a monthly basis.

c.
Maximum Enrollment Levels: Based on the adequacy of the MCO's provider network,
the DEPARTMENT may establish a maximum HUSKY A enrollment level for Members in
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.

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d.
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 that would allow the MCO to serve additional 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.

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.

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 MCO's HUSKY A membership factored by the
ratio of one complaint per 10,000 members.

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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;

6)
Whether both the Member and the MCO have reasonably attempted to obtain an
appointment that will meet the Member's 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 may request 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

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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.

3.11    Provider Contracts

All contracts between the MCO and its in-network providers shall, at a minimum,
include each of the following provisions:

a.
MCO network providers serving the Medicaid population must meet the minimum
requirements for participation in the Medicaid program as set forth in the
Regulations of Connecticut State Agencies, Section 17b-262- 522 to Section
17b-262-533, as applicable;

b.
MCO Members shall be held harmless for the costs of all Medicaid- 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 3.46 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 the Medicare or
Medicaid program in any state;

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

i.
That the MCOs and subcontractors require in-network Primary Care Providers to
participate in the DEPARTMENT'S efforts to study access, quality and outcome.

 
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j.  
The MCO shall not reduce its reimbursements to federally qualified health
centers from the rate in effect as of the effective date of this contract.

k.
The MCO shall increase the reimbursement rate to general hospitals for hospital
outpatient visits for Clinic (Revenue Cost Center Codes 510 series as listed
below or CRT Evaluation and Management Codes 99200 series as listed below) and
for Emergency Room visits (RCC 450) by adding the following amounts to the rates
the Contractor has had in effect for dates of service 7/1/06 forward. The
increase will be added once per episode of care as indicated by the presence of
one of the listed RCC or CPT codes.

1.
An increase of $15.20 per visit for hospital outpatient visits for the following
Revenue Center Codes (RCC) or CPT Evaluation and Management Codes (CPT E&M) for
hospital outpatient clinic visits:

 
a) RCC 510 Clinic
b) RCC 514 OB-GYN Clinic
c) RCC 515 Pediatric Clinic
d) RCC 519 Other
e) RCC 456 Urgent

f) CPT E&M 99201 - New Patient Office or other OP visit -10 minutes

g) CPT E&M 99202 - New Patient Office or other OP visit - 20 minutes

h) CPT E&M 99203 - New Patient Office or other OP visit - 30 minutes

i)  CPT E&M 99204 - New Patient Office or other OP visit - 45 minutes

j)  CPT E&M 99205 - New Patient Office or other OP visit - 60 minutes

k) CPT E&M 99211 - Established Patient Office or other OP visit -5 minutes

I)  CPT E&M 99212 -Established Patient Office or other OP visit -10 minutes

m) CPT E&M 99213 - Established Patient Office or other OP visit -15 minutes

n) CPT E&M 99214 - Established Patient Office or other OP visit -25 minutes

o) CPT E&M 99215 - Established Patient Office or other OP visit -40 minutes
 
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2.
An increase of $12.13 per visit for Emergency Room visits (RCC 450).

I. 
The additional payment amounts shall be made retroactive to July 1, 2006.

m. 
No later than September 30, 2007, the MCO shall submit a report to the
DEPARTMENT that describes in detail and by individual hospital how the MCO
reimbursed the general hospitals to meet the increased hospital outpatient
payment requirements as stated in subsection (k) above.

n. 
The MCO's failure to pay the increased hospital outpatient reimbursements to the
satisfaction of the DEPARTMENT and/or the failure to fully report such payments
could result in the withhold from future capitation payments by the DEPARTMENT.

3.12   Provider Credentialing and Enrollment

a.
The MCO shall have written policies and procedures for the selection
and retention of providers. 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 documentation to support that credentialing
criteria have been met, 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.
MCO credentialing and recredentialing 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;

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;

 
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d)
Revocation and suspension of hospital privileges;

e)
A history of malpractice claims; and

7.    
Evidence of compliance with Clinical Laboratory Improvement Amendments of 1988
(CLIA), Public Law 100-578, 42 DSC § 1395aa et seg. and 42 CFR Part 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 Nurses (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 in its network.

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 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 in-network provider as set forth above.

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

Sanction: The DEPARTMENT may impose a Class B sanction pursuant to Section 7.05
if, upon completion of a performance review, it is established that a provider
in the MCO's network fails to meet the minimum credentialing criteria for
participation set forth in (a) and (b) above or a PCP in the MCO's network fails
to meet the criteria set forth in (d).

3.13           Second Opinions, Specialist Providers and the Referral Process

a.
The MCO shall provide for a second opinion from a qualified health
care professional within its provider network, or arrange for the ability of
the Member to obtain one outside the network, at no cost to the Member.

b.
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 be in-network or out-of-network. The MCO shall ensure that the
Member does not incur any costs for such referrals whether the referral is to an
in-network or out- of network provider. 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.

3.14           PCP and Specialist Selection, Scheduling and Capacity

a.
The MCO shall implement procedures to ensure that each Member has an ongoing
source of primary care appropriate to his or her needs and a person formally
designated as primarily responsible for coordinating the health care services
furnished to the Member.

b.
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 notified to do so. The
assignment must be appropriate to the Member's age, gender and residence.

c.
The MCO shall ensure that providers in its network adhere to the
following 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;

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

5.
Dental screening and preventative visits shall be scheduled within six (6) weeks
from the date of the request;

6.
Specialists shall provide treatment within the scope of their practice and
within professionally accepted promptness standards for providing such
treatment;

7.
EPSDT comprehensive health screens and immunizations shall be scheduled in
accordance with the DEPARTMENT'S EPSDT periodicity and immunization schedules;

8.
New Members shall receive an initial PCP appointment in a timely manner; (for
those Members who do not access goods and services within the first six (6)
months of enrollment, the MCO shall identify and remedy any access problems);
and

9.
Waiting times at PCPs are kept to a minimum.

d.
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 PCP is assured.

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

f.
The MCO shall track each Member's use of primary medical care services. In the
event that a Member does not regularly receive primary medical care services
from the PCP or the PCP's group other than visits to school based health
clinics, the MCO shall contact the Member and offer to assist the Member in
selecting a PCP.

g.
If the Member has not received any primary care services, the MCO shall contact
the Member and offer to assist the Member in scheduling a well- care visit if
the Member's last well-care visit was not within the appropriate guidelines for
his or her age and gender.

Performance Measure: Appointment Availability. The DEPARTMENT or its agent will
routinely monitor appointment availability as measured by (c)(1) through (c)(9)
above:

a. 
Using test cases to arrange appointments of various kinds with selected
providers. The DEPARTMENT shall require the MCO to submit a corrective action
plan within thirty (30) days, outlining the steps that the MCO will take to
rectify the problem, when less than ninety (90) percent of the sample make
appointments available within the required time, or

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b.
Tracking complaints received by the MCO, the DEPARTMENT and HUSKY Infoline. If
the DEPARTMENT deems that the MCO's provider network is not capable of accepting
additional enrollments, the DEPARTMENT shall require the MCO to submit a
corrective action plan within thirty (30) days, outlining the steps that the MCO
will take to rectify the problem

c.
If the DEPARTMENT determines that appointment availability is insufficient, 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.

3.15   Women's Health, Family Planning Access and Confidentiality

a.
The MCO shall provide female Members with direct access to a women's health
specialist in network for covered care necessary to provide women's routine and
preventive health care services. This access shall be in addition to the
Member's PCP if that provider is not a women's health specialist.

b.
The MCO shall notify and give each Member, including adolescents,
the opportunity to use his or her own PCP or utilize any family planning service
provider for 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, and shall reimburse providers for all family
planning services regardless of whether that provider is a participating
provider. The MCO shall reimburse out-of-network providers of family planning
services at least the Medicaid fee-for-service rate for the service. The MCO may
require family planning providers to submit claims or reports in specified
formats before reimbursing services.

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

d.
Family planning services that must be covered include:

1.
Reproductive health exams;

2.
Patient counseling;

3.
Patient education;

4.
Lab tests to detect the presence of conditions affecting reproductive health;

5.
Sterilizations;

6.
Screening, testing, and treatment of and pre and post- test counseling for
sexually transmitted diseases and HIV; and

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7.       
Abortions, if the pregnancy is the result of an act of rape or incest or in the
case where a woman suffers from a physical disorder, physical injury, or
physical illness, including a life-endangering physical condition caused by or
arising from the pregnancy itself, that would, as certified by a physician,
place the woman in danger of death unless an abortion is performed.

e.
Pursuant to federal law ("the Hyde Amendment," as reflected in the
federal appropriations for Title XIX) and 42 CFR Part 441, Subpart E,
the DEPARTMENT may only seek federal funding for those abortions described in
(d)(7) above. The MCO shall cover all abortions that fall within these
circumstances. The MCO shall submit a Form W-484 for any such abortions and
comply with the DEPARTMENT'S Medical Services Policy concerning abortions.

f.
The DEPARTMENT and the MCO shall enter into a separate contract for all
medically necessary abortions that do not qualify for federal matching funds, as
described in subsection (d) and (e) above.

g.
The MCO shall ensure that the provisions of 42 CFR 441.250 - 259 and Section 173
G of the DEPARTMENT'S Medical Services Policy and Provider Bulletin 2004-77 are
strictly followed by the MCO in payment for sterilization and Hysterectomies.
These requirements include, but are not limited to, the submission of a
completed W-612 informed consent form (sterilization) or a W-613 information
form (hysterectomy) prior to payment for either of these procedures.

Sanction: If the MCO fails to comply with the provisions in subsection (e), and
fails to accurately maintain and submit accurate records of those abortions,
that meet the federal definition for funding, the DEPARTMENT may impose a Class
A sanction, pursuant to Section 7.05.

3.16    Pharmacy Access

For purposes of this section, "prescription" shall include authorization for
legend and over-the-counter drugs covered by Medicaid policy.

a.
The MCO shall be responsible for payment for pharmacy services regardless of a
Member's diagnosis. The only exception is that the CT BHP 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 CT BHP 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:

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

2.
The MCO may establish a pharmacy lock-in program for Members suspected of abuse
or excessive utilization. Any MCO pharmacy lock-in program will be subject to
DEPARTMENT approval;

3.
Have established protocols to respond to urgent requests for medications;

4.
Monitor and take steps to correct excessive utilization of regulated substances,
including but not limited to, restricting pharmacy access pursuant to a pharmacy
lock-in program approved by the DEPARTMENT; and

5.
Require pharmacists to utilize the Automated Eligibility Verification System
(AEVS) to determine client eligibility and MCO affiliation 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.

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

d.
The MCO may have a drug management program that includes a prescription drug
formulary.

1.
The MCO drug formulary must include only Food and Drug Administration approved
drug products and must be broad enough in scope to meet the needs of all
Members.

2.
For each specific therapeutic drug class the MCO drug formulary shall consist of
a reasonable selection of drugs that do not require prior approval.

e.
The MCO shall obtain the DEPARTMENT'S written approval prior to deleting any
drugs from its formulary or issuing any communication regarding its proposed
formulary changes. In addition the MCO shall:

1.
Submit any deletions to its formulary and any new prior authorization
requirements for formulary drugs to the DEPARTMENT at least thirty (30) days
prior to making any such change.

2.
Submit all physician, pharmacist and Member letters, notices, e- mail alerts or
other electronic or written communications related to the proposed formulary
change to the DEPARTMENT thirty (30) days prior to issuing or sending any such
communication.

3.
If, however, the DEPARTMENT does not respond to proposed formulary changes or
communications submitted for approval within

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thirty (30) days of receipt from the MCO, the MCO may proceed with the change or
issue the communication, as applicable.

4.
Submit subsequent additions to the formulary at the time the addition is made
without seeking prior approval by the DEPARTMENT and regardless of whether the
drug(s) to be added requires prior authorization. If the MCO's formulary
includes a legend drug that requires prior authorization and the FDA
approves the drug for over-the-counter use, the MCO is not required to seek the
DEPARTMENT'S approval to substitute the over-the-counter version with a prior
authorization requirement.

5.
Notify prescribing providers thirty (30) days in advance of any changes to the
MCO's formulary.

The DEPARTMENT reserves the right to identify clinical deficiencies in the
content of or operational deficiencies of the MCO's 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 submission of the written response. If the DEPARTMENT is
not satisfied with the MCO's response, the DEPARTMENT may require the MCO to add
specific drugs to its formulary or to or eliminate prior authorization
requirements for specific drugs. If the MCO disputes the DEPARTMENT'S
determination, the MCO may exercise its rights pursuant to section 7.02 of this
Contract.

f. 
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.

1.
When the MCO deletes a drug from its formulary or imposes prior authorization
requirements on additional drug(s), the MCO shall identify to the DEPARTMENT
which of the affected drugs the MCO intends to treat as maintenance drugs.

2.
The DEPARTMENT may require the MCO to treat additional drugs as maintenance
drugs for purposes of this subsection and subsection (e).

3.
If the MCO treats all drugs affected by a formulary change as maintenance drugs
for purposes of this subsection and for purposes of subsection (g) below, the
MCO is not required to designate specific drugs as maintenance drugs.   In
such circumstances, the MCO shall notify the DEPARTMENT that all drugs affected
by the formulary change will be treated in the same manner.

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g.        
If a prescribing provider seeks authorization to continue a maintenance drug
that is being removed from the MCO's formulary or subjected to new prior
authorization requirements at any time prior to the effective date of the
change, the MCO shall conduct a medical necessity review.

1.
The MCO shall conduct the review, and, if the MCO does not approve the request,
the MCO shall issue a notice of action in accordance with the provisions of
subsection (i) below.

2.
If the MCO denies the prior authorization request for the maintenance drug, the
MCO shall issue a notice of action at least ten days in advance of the effective
date of the action.

3.
The MCO shall automatically continue authorization for the maintenance drug for
at least the medical necessity review period plus, if the MCO does not approve
the authorization, for the ten (10) day advance notice period, or the effective
date of the action, whichever is later.

4.
If a Member requests an appeal and administrative hearing concerning a denial or
termination that results from or relates to the imposition of new prior
authorization requirements for or removal of the maintenance drug from the
formulary, the MCO shall continue to authorize the drug for that Member pending
a hearing decision.

5.
If the prescriber does not initiate the prior authorization process prior to the
expiration of the existing authorization period, the Member shall receive a
temporary supply of the maintenance drug if the conditions described in
subsection (i) are met.

6.
If the MCO grandfathers some or all Members affected by the formulary changes
for a period of more than ninety (90) days, the MCO shall either:

 
a)
Send a second advance notice letter at least thirty (30) days prior to the end
of the extended authorization period or

b)
Ensure that if the Member's prescriber requests authorization prior to the end
of the existing authorization period, that if the request is denied and the
Member appeals, that the authorization will continue pending appeal.

h. 
The MCO shall require that its provider network of pharmacies adhere to the
provisions of Connecticut General Statutes § 20-619 (b) and (c) related to
generic substitutions for Medicaid recipients.

i.        
 If the MCO maintains 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.

1.        
The MCO shall develop a timely and efficient authorization process to obtain
information from providers on medical necessity for a non-Part II 30 formulary
drug, a formulary drug requiring prior authorization or a brand name drug where
a generic substitution is available.

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(Part II, 3.01-3.35) 07 HUSKY A 05/07

2.
The MCO shall make an individualized determination concerning medical necessity
and appropriateness in each instance when a Member's prescribing provider
requests a non-formulary drug, formulary drug requiring prior authorization or a
brand name drug including request made in relation to the provisions of (f)
above.

3.
If the MCO or the Pharmacy Benefits Manager (PBM) does not receive a request for
prior authorization prior to the submission of a prescription to a pharmacy, the
pharmacist may contact the prescribing physician and inform him or her of the
prior authorization requirement.

j.        
Except as provided in subsection (p) below, in the event that a provider
requests authorization for, or prescribes a non-formulary drug, a formulary drug
requiring prior authorization or a brand name drug where a generic substitution
is available but elects during the prior authorization process or in discussions
with the pharmacist to prescribe a formulary, generic or alternate formulary
drug that the provider agrees will be equally effective for the Member, the MCO
is not required to issue a notice of action and is not required to provide a
temporary supply of the drug for which the provider initially sought
authorization.

k.        
In the event that a provider requests authorization, or prescribes a
non-formulary drug, a formulary drug requiring prior authorization or a brand
name drug where a generic substitution is available the MCO must approve or deny
the request as expeditiously as the Member's health condition requires, but no
later than 14 calendar days following the MCO's receipt of the request.
 
An additional 14 calendar days will be allowed if: 1) the Member or the
requesting provider asks for the extension or 2) the MCO or its PBM documents
that the extension is in the Member's interest because additional information is
needed for the MCO to authorize the service and the failure to extend the
authorization timeframe will result in denial of the service. The DEPARTMENT may
request and review such documentation from the MCO.

 
l.
In the event that a provider certifies to the MCO or its PBM that the drug is
necessary to address an urgent or emergent condition or that the standard
authorization period could seriously jeopardize the Member's life or health or
ability to attain, maintain or regain maximum function, the MCO or its PBM must
make an expedited authorization decision and provide notice as expeditiously as
the member's health condition requires and no later than 3 working days after
receipt of the request for service. The MCO or its PBM may extend the 3 working
days time period by up to 14 additional calendar days if: 1) the Member or the
provider requests the extension, or 2) if the MCO or its PBM documents that the
extension is in the Member's interest because additional information is needed
for the MCO to authorize the service and the failure to extend the authorization
timeframe will result in denial of the service. The DEPARTMENT may request such
documentation from the MCO.

 
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m.       
The MCO or its PBM shall without delay authorize up to a thirty (30) day
temporary supply of the drug if the provider certifies to the MCO or its PBM
that the drug is necessary to address an urgent or emergent condition. The MCO
is also required to authorize a thirty (30) day temporary supply of the drug on
the day of submission of the prescription to the pharmacy if the MCO has been
unable to contact the provider to discuss an effective formulary drug during
normal business hours. The certification shall be in a manner to be specified by
the MCO, subject to the DEPARTMENT'S approval. If the original prescription was
for a period less then thirty (30) days, the temporary supply will be for the
period prescribed.

n.
 
If the Member, upon receipt of a termination, suspension or reduction notice of
action, timely requests an appeal and administrative hearing the MCO shall
continue to authorize the drug for the Member pending a hearing decision or
other resolution of the dispute concerning the prescription. As used within this
section, "timely" means filing on or before the later of the following: (1)
within ten (10) days of the MCO mailing of the notice of action; or (2) the
intended effective date of the MCO's proposed action. If the Member does not
request an appeal and administrative hearing, the MCO is not required to
authorize any further refills.

o.   
Notwithstanding anything to the contrary in the preceding, the MCO shall not
cover drugs used to treat sexual or erectile dysfunction, as set forth in
1927(d)(2)(K) of section 1903(i) of the Social Security Act as amended, unless
such drugs are used to treat conditions other than sexual or erectile
dysfunction and the uses have been approved by the Food and Drug Administration.

p.
The MCO shall, on a quarterly basis, submit the report at Appendix L.

q.        
If the DEPARTMENT or its agent determines that there is a pattern of denials for
requested authorization for particular drugs, or any other pattern suggesting
that the MCO's authorization process is one that does not appropriately consider
each Member's individualized medical needs, the DEPARTMENT may require notices
of action in circumstances other than those described above and/or may require
the addition of a particular drug or drugs to the MCO's formulary as drugs that
do not require prior authorizations.

3.17    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 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 CT BMP as
outlined in Appendix N.

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b.
The MCO may track utilization, including, but not limited to, primary
care behavioral health, laboratory, behavioral health pharmacy,
emergency department, 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 BMP as to whether a Member's
medical or behavioral health condition is primary, the MCO's 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.

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-Occurring 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;

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

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The MCO shall be responsible for primary care and other services provided 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 under CRT 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

 
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.

b.
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.

c.
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.

d.
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
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.

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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.

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 BHP non-medical
behavioral health specialist when necessary; and

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

2.
The CT BHP 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 CT BHP ASO will make telephonic
psychiatric consultation services available to primary care providers. Any
primary care provider that is seeking guidance on psychotropic prescribing for a
HUSKY A or HUSKY B member may initiate consultation.

3.
The CT BHP ASO will work with the MCO and provider organizations to sponsor
opportunities for joint training to promote effective coordination and
collaboration. MCO policies, procedures 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.

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l.         School Based Health Center Services

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

3.18    Children's Issues and EPSDT Compliance

In order to meet the requirements of the epsdt program as set forth in Sections
1902(a)(43) and 1905(r) of the Social Security Act, the MCO shall:

a.
Provide EPSDT screening services in accordance with the periodicity schedule
attached to this contract as Appendix C. Any changes in the periodicity 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 EPSDT screening services;

b.
Provide interperiodic screening examinations when medically necessary, or in
accordance with the provisions of Section 3.19(a), to determine the existence of
a physical or mental illness or condition, or to assist Members in meeting the
medical requirements for certification or recertification in WIC. Such
interperiodic screens shall include screens for anemia as recommended by the
Centers for Disease Control (CDC). The MCO shall not require prior authorization
of interperiodic screening examinations;

c.
Provide EPSDT screening services that at a minimum, include:

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 currently recommended by the Connecticut DEPARTMENT
of Public Health;

4.
Laboratory tests, as set forth in the periodicity schedule at Appendix C

5.
Vision and hearing screenings as set forth in the periodicity schedule at
Appendix C;

6.
Dental assessments as set forth in the periodicity schedule at Appendix C and

7.
Health education, including anticipatory guidance.

d.
Provide all medically necessary health care, diagnostic services, and treatment
for Members under twenty-one (21) covered under the federal

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Medicaid program and described in Section 1905(a) of the Social Security Act
regardless of whether the health care, diagnostic services, and treatment are
specified in the list of covered services at Appendix A of this contract and
regardless of any limitations on the amount, duration, or scope of the services
that would otherwise be applied.

e.
Take all necessary steps to ensure that its Members under the age of twenty-one
(21) receive EPSDT screening services and any necessary diagnostic and treatment
services, including, but not limited to:

1.
Providing assistance in arranging and scheduling appointments;

2.
Providing and arranging transportation;

3.
Following up on missed appointments; and

4.
Providing interpreters to Members with limited English proficiency and Members
who are hearing and visually impaired.

f.
No later than sixty (60) days after enrollment in the plan and
annually thereafter, 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 EPSDT screening, diagnostic and
treatment services;

2.
Inform its Members about the importance and benefits of EPSDT screening
services;

3.
Inform its Members about how to obtain EPSDT screening services; and

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

g.
Coordinate and enhance the services provided to Members under twenty- one (21)
through the development and execution of memorandums of understanding (MOUs)
with the following programs:

1.
Nurturing Families Network;

2.
Healthy Start;

3.
The Special Supplemental Food Program for Women, Infants, and Children (WIC);

4.
Birth-to-Three;

5.
Head Start;

6.
InfoLine's Maternal and Child Health Project; and

7.
Other programs operated by the DEPARTMENTS of Children and Families, Education,
Public Health, Mental Health and Addiction

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Services and Mental Retardation as designated by the DEPARTMENT.

The MCO shall cooperate with the DEPARTMENT and the entities listed above in
g.1-7 in the development and execution of the MOUs and any revisions or
amendments thereto.

h.   
Include in the MOUs developed and executed under subsection (g) of this section,
provisions that specify how the MCO will work with the program, including, but
not limited to:

1.
A description of the services provided by the program;

2.
Designation of a liaison at the MCO to work with the program on ensuring the
provision of medically necessary and appropriate covered services by the MCO and
the coordination of services provided by the MCO and the program;

3.
Protocols for referrals to the program by the MCO;

4.
Protocols for communication of information concerning individuals who are
Members of the MCO who are receiving services from the program;

5.
Protocols for the resolution of any issues that arise concerning the delivery of
services to HUSKY Members who are receiving services from the program;

6.
Compliance with HIPAA privacy rules if the agreement includes exchange of
members' protected health information; and

7.
Any other mutually agreed upon provisions.

i.
The MCOs shall require PCPs to obtain all available vaccines free of charge from
the DEPARTMENT of Public Health under the Vaccines for Children program.

j.        
 Cooperate with the Connecticut Immunization Registry and Tracking System to
track childhood immunizations of its Members.

k.       
 In order to carry out the responsibilities set forth in this section, the MCO
shall identify children who are overdue for EPSDT screening services, and those
who have missed EPSDT screening services. The MCO shall work to develop a plan
for ensuring that Members under twenty-one (21) years of age who are overdue or
late for screening examinations receive their EPSDT screening services and that
other Members continue to receive their examinations on a regular basis.

l.        
 The MCO shall attain an annual EPSDT participation ratio and an annual EPSDT
screening ratio of at least eighty (80) percent for the period from October 1,
2002 through September 30, 2003. The DEPARTMENT shall determine the MCO's
participation and screening ratio from the encounter data as reported to the
DEPARTMENT or its agent(s) in accordance with the methodology established by
HCFA or CMS for the HCFA-416 report.

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Sanction: Failure to achieve a participation and/or screening ratio of eighty
(80) percent may subject the MCO to a Class B sanction in accordance with the
provisions of Section 7.05. However, no sanction shall apply if the MCO's
participation and screening ratios, although less than eighty (80) percent, are
greater than the participation and screening ratios for the MCO for the
equivalent period one year earlier plus one half the difference between the
ratios for the earlier period and eighty (80) percent.

3.19    Specialized Outpatient Services for Children Under DCF Care

a.     
 The MCO shall pay for a comprehensive multi-disciplinary examination for
initial placement only, for each child entering DCF care, within thirty (30)
days of placement into out-of-home care.

1.
The multi-disciplinary examination that shall consist of a thorough assessment
of the child's functional, medical, developmental, educational, and mental
health status.

2.
Within each area of the assessment, the evaluation shall identify any additional
specialized diagnostic and therapeutic needs.

3.
Physicians and other medical and mental health providers specializing in the
assessment areas shall conduct the multi- disciplinary examination.

4.
Each multi-disciplinary examination shall occur at a single location.

5.
All components of the examination shall be performed on the same day, excluding
additional needed examinations, unless otherwise indicated.

6.
The provider shall report the findings and conclusions of the examination in a
form acceptable to DCF. The report must be received by DCF within fifteen (15)
days of the examination. The provider shall also provide for updates to DCF on
any additional examinations.

b   
The providers of the MCO shall provide for training of foster parents on the use
of special equipment or medications as needed.

c.
The MCO shall require regular collaboration between providers and DCF Regional
Offices and Central Office medical, mental health and social work staff and
consultants. The MCO shall assign staff to act as liaisons to identify, address
and resolve health care delivery issues, barriers to comprehensive care and
other problem areas. DCF shall specify the contact persons by name, title and
phone number who will be available for quarterly meetings between DCF and the
MCO and shall facilitate the initiation of these meetings with the MCO.

d.
In addition to standard prescription coverage, the MCO shall cover prescriptions
in compliance with DCF policy for "Placement Medications" that are additional
prescriptions that may be needed when children are placed or change placements.
The MCO shall cover "Home Visit Medications". Home Visit Medications are
additional prescriptions, which may be needed when children placed in
out-of-home settings leave the placement for a home visit. Home Visit
Medications should include only those doses that will be needed during the home
visit, plus one extra dose.

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e.        
The MCO shall deliver a notice of action to an identified person at the DCF
Central Office when a service is to be reduced, denied or terminated. DCF will,
in turn, distribute the notice of action to its appropriate regional and local
personnel.

3.20    Prenatal Care

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

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

b.
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 of postpartum;

c.
Refer enrolled pregnant women to the WIC program;

d.
Offer case management services for assistance with obtaining prenatal care
appointments, transportation, WIC, and other support services as necessary;

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

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

g.
Refer any pregnant Member who is actively abusing drugs or alcohol to CTBHP; and

h.
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.

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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 including access to the dental specialties that include endodontic,
oral surgical and orthodontic services;

2.
For the purpose of enrollment capacity a dental hygienist meeting the criteria
of Connecticut General Statutes Section 20-1261, with two (2) years of
experience, working in an institution (other than hospital), a community health
center, a group home, a preschool operated by a local board of education or head
start program, 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 diagnostic, restorative and treatment
services;

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.
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 every six (6) months and scheduling occurs no greater six (6)
weeks from the appointment;

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 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
pediatric or general dentist as appropriate;

7.
Implement specific outreach strategies to educate Members about the importance
of regular dental care, with a focus on accessing age appropriate preventive
care such as evaluations, cleanings and fluoride applications at least twice a
year;

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

9.
Devise mechanisms to avoid unnecessary PCP visits related to dental problems.

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Performance Measure: The MCO shall ensure that no less than eighty (80) percent
of continuously enrolled Members two (2) to twenty (20) years of age shall
receive one screening and dental cleaning per twelve (12) month period. On a
quarterly basis, the DEPARTMENT shall, through the encounter data submitted by
the MCO, review the MCO's performance under children's dental access.

Performance Measure: The MCO shall ensure that no less than eighty (80) percent
of continuously enrolled Members twenty-one (21) years of age and over shall
receive one screening and dental cleaning per twelve (12) month period. On a
quarterly basis, the DEPARTMENT shall, through the encounter data submitted by
the MCO, review the MCO's performance under adult dental access.

3.22   Other Access Features

a.        The MCO shall have systems in place to ensure access to medically
necessary and medically appropriate well care by its Members. The MCO shall
develop procedures to identify access problems and shall take corrective action
as problems are identified. These systems and initiatives shall include, but not
be limited to:

1.
Monitoring new Members to ensure that a well-care appointment is scheduled
within six (6) months of enrollment for those whose last well-care visit does
not fall within the recommended age and gender appropriate schedules;

2.
Monitoring and ensuring that Members receive well-care visits based on age and
gender appropriate schedules;

3.
Contacting and counseling Members who miss scheduled appointments;

4.
Coverage and provision of services to newborns from the time of birth;

5.
Assisting Members in accessing and locating linguistically and culturally
appropriate services, including but not limited to, appropriate accommodation
for Members with hearing disabilities;

6.
Assisting disabled Members in accessing and locating services and providers that
can appropriately accommodate their needs, for example wheelchair access to
provider's office;

7.
Development of special initiatives, case management, care coordination, and
outreach to Members with special or multiple medical needs, for example persons
with AIDS or HIV infected individuals;

8.
Development of goals and action plans for incremental increases in utilization
of services such as postpartum care, adolescent health, dental care and other
health care measures agreed upon between the MCO and the DEPARTMENT;

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9.
Encouraging providers to offer extended business hours and weekend (Saturday)
openings.

 
10.
Monitoring timely access to care as described in Section 3.14.

 
b.   
The MCO's access systems will be assessed as part of the annual performance
review of the MCO.

3.23            Pre-Existing Conditions

a.
The MCO shall assume responsibility for all covered services as outlined in
Appendix A for of each Member as of the effective date of coverage under the
contract regardless of the new Member's health status.

b.
As outlined in Appendix K, for new Members who have transferred enrollment from
another HUSKY MCO, coverage of services other than acute care hospitalization,
nursing home care or care in a long term chronic disease hospital shall be the
responsibility of the MCO as of the beginning of the month during which
enrollment becomes effective. Responsibility for acute hospitalization, nursing
home or long term chronic disease hospital care services at the time of
enrollment or disenrollment is described in Section 3.25.

3.24            Newborn Enrollment

Within six (6) months of a child's date of birth, the MCO must notify the
DEPARTMENT of newborns for which they have not received enrollment notification
from the DEPARTMENT. The MCO shall use the notification form made available by
the DEPARTMENT for this purpose. Should the MCO fail to report the child's
birth, the MCO shall reimburse the DEPARTMENT for any fee-for-service claims
paid for covered services that occurred for the newborn Members prior to
processing the newborn's enrollment into the MCO.

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

For acute care requiring inpatient stay at a hospital, nursing home or chronic
disease hospital, financial responsibility for covered services shall be
determined as follows:

a.          Inpatient at time of enrollment

1
Initial enrollment in HUSKY A should not commence during a recipient's inpatient
stay at a hospital, nursing home or subacute facility unless the recipient is a
newborn, born to a Member. Upon approval by CMS of a waiver amendment, this
exemption from enrollment will not apply to inpatient stays with a behavioral or
mental health diagnosis

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2.  
The MCO shall notify the DEPARTMENT within sixty (60) days of the MCO's
discovery of or from the date that the MCO receives information from which a
determination can be made that initial enrollment will take effect during the
course of a hospitalization. For those individuals who are inpatient in an MCO
participating facility, the time period in which an MCO must notify the
DEPARTMENT is limited to six (6) months from the enrollment effective date or
sixty (60) days of discovery, whichever comes first. Upon timely notification to
the DEPARTMENT by the MCO, the DEPARTMENT shall change the effective date to the
first of the month after discharge. If the MCO fails to notify the DEPARTMENT of
the inpatient status within the above specified time periods, the DEPARTMENT
shall be relieved of its responsibility to change the enrollment effective date
and the individual's initial enrollment effective date into the MCO shall be
retained.

b.            Hospitalization at time of disenrollment
 
Hospital costs for Members who are inpatient at the time of disenrollment from
the MCO shall remain the financial responsibility of the MCO until discharge
from the hospital. For purposes of this subsection, hospital costs shall include
the per diem hospital charge. Hospital costs shall not include charges related
to the inpatient stay, but performed and billed separately, such as the services
of the attending physician or a consulting specialist. Upon discovery of the
Member's disenrollment, the MCO shall notify the individual's new MCO of the
inpatient status and coordinate care and discharge planning with the new MCO.
The MCO shall assume financial responsibility for all non-hospital costs as of
the enrollment effective date for new Members who change MCOs while inpatient.
Individuals who are disenrolled due to recategorization of their Medicaid
coverage to a non-managed care category shall revert to fee-for-service upon
recategorization.

c.
Disenrollment during or resulting from a long-term chronic disease hospital or
nursing home stay

 
1. 
 Members who are inpatient in a long-term chronic disease hospital facility or a
nursing home will remain the responsibility of the MCO until they are discharged
from the facility or disenrolled from the MCO. If the MCO reports to DSS or its
agent, any patient in a subacute facility or a nursing home other than for the
purpose of behavioral health prior to the ninety (90) continuous days from the
date of admission, the DEPARTMENT will disenroll the Member at the end of the
month, that the Member has been inpatient in the facility for ninety (90)
continuous days. If the MCO reports to the DEPARTMENT beyond ninety (90) days,
the change will be effective the end of the month during which the change was
reported to DSS or its agent.   The facility's per diem (room and board) costs
for a Member who is inpatient in a subacute

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facility or a nursing home will remain the responsibility of the MCO until the
Member is discharged from the facility or disenrolled from managed care,
whichever comes first.

2.       
 Upon discovery of the Member's disenrollment resulting from a plan change, the
MCO shall notify the individual's new MCO of the inpatient status and coordinate
care and discharge planning with the new MCO. The MCO shall assume financial
responsibility for all non-room and board costs as of the enrollment effective
date for any new Member who changed MCOs while inpatient.

3.26           Open Enrollment

a.
The MCO shall conduct continuous open enrollment during which the MCO shall
accept clients eligible for coverage under this contract in the order in which
they are enrolled without regard to the need for health services, health status
of the client or any other factor(s).

b.
The MCO shall accept membership of newborns born to a Member upon the child's
date of birth with the exception of newborns that are placed for private
adoption or when the mother has indicated in writing that she does not wish
Medicaid coverage for the child. The enrollment effective date for newborns
shall be the first of the month in which the child was born.

c.
The MCO shall not discriminate against individuals eligible to enroll on
the basis of race, color, or national origin and will not use any policy
or practice that has the effect of discriminating on the any such basis. The MCO
shall not discriminate in enrollment activities on the basis of health status or
the client'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 Medicaid clients.

d.
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 comes first. Other than
the case of a newborn retroactively enrolled, failure to notify the DEPARTMENT
or its agent within the parameters defined in this section and within
established procedures will result in the retention of the Member by the MCO for
the erroneous period of enrollment.

3.27           Special Disenrollment

a.
The MCO may request in writing and the DEPARTMENT may approve disenrollment of
specific Members 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:

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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 Member or others; 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;

         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 effective date for an approved disenrollment shall be no later than
the first day of the second month following the month in which the MCO files the
disenrollment request. If the DEPARTMENT fails to make the determination within
this timeframe, the disenrollment shall be deemed approved.

e.
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, notices of action
and grievance/administrative hearing information in languages other than
English. The MCO shall notify its members that oral interpretation is available
for any language.

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 Members in any
county 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'S Eligibility Management System (EMS) to determine the percentage
of Members who speak alternative languages. The MCO shall inform

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members that written materials are available in these alternative languages.

c.        The MCO shall also take appropriate measures to ensure access to
services by persons with visual and hearing disabilities. This shall include the
provision of information in alternative formats and in an appropriate manner
that takes into consideration the special needs of Members with disabilities.
Information concerning Members with visual impairments and hearing disabilities
will be made available through the daily and monthly EMS enrollment data.

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 7.05.

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; website; newsletter; and other Member educational materials. The
MCO's written materials for members must be in a language and format that may be
easily understood. 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.
At the time of initial enrollment, the MCO shall provide a member handbook to
each Member. If a Member loses eligibility and re-enrolls in the MCO less than
ninety (90) days after losing eligibility, the MCO is not required to send a new
handbook. If the lapse in enrollment is more than ninety (90) days, the MCO
shall send a new handbook.   The MCO shall mail the Member handbook and provider
directory to Members within one week of enrollment notification. At least once a
year, thereafter, the MCO shall notify the Members of their right to request the
Member Handbook that shall address and explain, at a minimum, the following:

1.
The amount, duration and scope of covered services under the contract in
sufficient detail that the Member understands the benefits to which they are
entitled;

2.
Restrictions on services (including limitations and services not covered) and
circumstances in which the Member could be held liable for payment for services;

3.
Prior authorization process;

4.
Definition of and distinction between emergency care and urgent care and the
extent to which emergency coverage is available, including: the fact that prior
authorization is not necessary for emergency care, the procedures for obtaining
emergency services including the use of 911; the locations of emergency settings
which

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provide emergency services and post-stabilization services; the fact that the
Member can obtain emergency care in any hospital or other setting and the post
stabilization rules;

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

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

7.
Assistance with appointment scheduling;

8.
Member rights and responsibilities, as described in Section 3.03;

9.
Member services, including hours of operation;

10.
Enrollment/disenrollment/plan changes;

11.
Procedures for selecting and changing PCPs;

12.
Policies on referrals for specialty care and other benefits not furnished
by   the PCP;

13.
Availability of provider network directory and updates;

14.
An explanation of circumstances in which a Member is responsible for making
co-payments;

15.
Restrictions on the Member's freedom of choice among providers;

16.
Limited liability for services from out-of-network providers;

17.
Access and availability standards;

18.
Special access and other MCO features of the health plan's program;

19.
Family planning services and the availability of family planning from out-of
network providers;

20.
Case management services targeted to Members as medically necessary and
appropriate;

21.
The MCO's appeal and the DEPARTMENT'S administrative hearing process, including
the right to a hearing, the method for obtaining a hearing, the right to
representation; the right to file appeals and hearing requests and the time
frames for filing; the availability of assistance with filing; the toll-free
numbers for filing appeals; the circumstances in which services will be
continued pending a hearing; the MCO's provider appeal process;

22.
Procedures to request non-emergency transportation and transportation options;

23.
EPSDT services for children;

24.
Coordination of benefits and third party liability;

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

26.
Advance directives;

27.
Information on how to access services from the CT BMP; and

28.
How to obtain any other benefits that are available under the Connecticut
Medicaid Plan but are not covered under this contract.

Upon request, the MCO shall also provide Members with information on the
structure and operation of the MCO and physician incentive plans.

d.
The MCO's provider directory shall include, at a minimum, the names, location,
telephone numbers and non-English languages spoken by current contracted
providers in the Member's service area, including identification of providers
that are not accepting new patients. The provider directory shall include, at a
minimum, information on PCPs, specialists and hospitals.

e.
The MCO shall make a good faith effort to give written notice to members of
termination of a network provider within fifteen (15) days after receipt
or issuance of the provider termination notice. The notice to members
shall apply to those members whose designated PCP terminated from the Plan or
for those members who had an established relationship with any other provider
including but not limited to specialists or clinics.

f.
All Member educational materials for distribution beyond the MCO's membership
must be prior approved by the DEPARTMENT.

g.
The following Member materials must be prior approved by the DEPARTMENT Member
handbook; Membership card; introductory and other text language from the
provider directory; and all communication to Members that include HUSKY A
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. The DEPARTMENT reserves the right to request
revisions or changes in the material at any time.

h.  
The DEPARTMENT shall, to the extent feasible, notify the MCO more than thirty
(30) days in advance of any significant change to the HUSKY program, for example
a change in the scope of covered services resulting from legislation. The MCO
shall give each Member written notice of any significant change, at least 30
days before the intended effective date of the change.

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 start date. The MCO shall distribute
the Member handbook within six (6) weeks of receiving the DEPARTMENT'S written
approval.

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i.  
The MCO shall maintain an adequately staffed Member services office to receive
telephone calls and to meet personally with Members in order to answer Members'
questions, respond to Members' complaints and resolve problems informally.

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

k. 
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.

l.   
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, a staff Member shall answer ninety (90) percent of all incoming calls
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.

m.
 
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 appeal and administrative hearing processes and, upon request,
mail to them, within one business day, forms and instructions for filing a
grievance.

n.
 
The MCO shall maintain a grievance report in the format designated by the
DEPARTMENT pursuant to Section 6.01. These reports shall be made available to
the DEPARTMENT upon request

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

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

q.
 
The MCO will participate in 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.

r.
 
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.

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s. 
The MCO shall make appropriate referrals of Members who express the need for or
may require behavioral health services to the CT BHP. The MCO shall develop
appropriate procedures for managing urgent or crisis calls and communicating
client specific crisis management information to the CTBHP for effective
coordination of care.

Sanction: If either the incoming call response or call abandonment standards set
forth in paragraph h are not met for ninety (90) percent of the days during the
six (6) month review period, the DEPARTMENT may impose a strike towards a Class
A sanction pursuant to Section 7.05.

3.30            Information to Potential Members

Informational materials for potential members shall also be provided in a manner
and format that may be easily understood. The MCO shall make the following
information available to potential Members, upon request: the locations,
qualifications, non-English languages spoken by and availability of the MCO's
network providers. The MCO shall provide a summary of this information to the
DEPARTMENT, in a format to be approved by the DEPARTMENT. The DEPARTMENT shall
provide the summary information to all potential Members.

The MCO shall also provide oral interpretation services in all non-English
languages to potential Members.

3.31            Marketing Requirements

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
provisions of 42 CFR 438.104, guidelines and restrictions as set forth in this
section and Appendix D. DSS marketing restrictions apply to subcontractors and
providers of care and 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.

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.
The MCO shall prohibit any type of marketing activity that has not been clearly
specified as permissible under the guidelines in Appendix D. 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

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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 only approved marketing materials and such approved
materials shall be distributed on a statewide basis.

Sanction: If the MCO or its providers violate marketing guidelines, the
DEPARTMENT may impose a Class B or Class C sanction pursuant to Section 7.05 as
it deems appropriate.

Sanction: If the MCO engages in non-compliant marketing practices within one
year of a marketing related sanction, the DEPARTMENT may 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 statewide
default 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 that are
available and designed to prevent illness. The MCO must also offer periodic
screening programs that in the opinion of the medical staff would effectively
identify conditions indicative of a health problem. The MCO shall keep a record
of all activities it has conducted to satisfy this requirement.

3.33            Internal and External Quality Assurance

a.
The MCO is required to provide a quality level of care for all services that it
provides and for which it contracts. These services are expected to be medically
necessary and may be provided by participating providers. A Quality Assessment
and Performance Improvement program shall be implemented by the MCO 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 federal regulations and DEPARTMENT policies and
requirements concerning Quality Assessment and Performance Improvement and
utilization review set forth below. The MCO will develop and implement an
internal Quality Assessment and Performance Improvement program consistent with
the Quality Assessment and Performance program guidelines as provided
in Appendix E.

c.
The MCO shall comply with all applicable federal regulations concerning Quality
Assessment and Performance Improvement.

d.
The MCO shall operate a Quality Assessment and Performance Improvement system
that:

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1.
Is consistent with applicable federal regulations;

2.
Provides for review by appropriate health professionals of the process followed
in providing health services;

3.
Provides for systematic data collection of performance and participant results;

4.
Provides for interpretation of these data to the practitioners;

5.
Provides for making needed changes;

6.
Provides for the performance of at least one performance improvement project of
the MCO's own choosing;

7.
Provides for participation in at least one performance improvement project
conducted by the EQRO; and

8.
Has in effect mechanisms to detect both under utilization and over utilization
of services.

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

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

1.
A Quality Assessment and Performance Improvement plan.

2.
A full-time 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 of
all the MCO's providers, as well as the MCO's subcontractors.

3.
The Quality Assessment and Performance Improvement Director shall spend an
adequate percentage of time on Quality Assessment 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. A Quality Assessment and Performance Improvement
committee that includes representatives from the following shall
provide oversight of the program:

a)  
A variety of medical disciplines (e.g., medicine, surgery, mental health, etc.);

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b)
 
Administrative staff; and Board of Directors of the MCO.

4.
Make available case management training for PCPs designed by the DEPARTMENT or
its agent.

g.  
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.

h.
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.

i. 
The Quality Assessment and Performance Improvement activities of the MCO's
network 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 in-network 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 in-network providers and
subcontractors.

j. 
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.

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

I.
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.

m. 
Where 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.

n. 
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 Quality Assessment and
Performance Improvement contractor and shall provide access to the data and
records requested for this purpose.

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

p.       
 The MCO will be an active participant in at least one of the EQRO's quality
improvement focus studies each year and will cooperate with the DEPARTMENT in
other studies of mutual interest initiated by the DEPARTMENT.

q.
 
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,
encounter and medical data, and/or making data available to the review
organization.

r.  
 The MCO must conduct at least one performance improvement project that:

1.           Focuses on one of the following areas:
a)           Prevention and care of acute and chronic conditions;
b)           High volume services;
c)           Continuity and coordination of care;
d)           Appeals, grievances and complaints;
e)           Access to and availability of services; or
f)           Other projects subject to DEPARTMENT approval.

2.
Includes the measurement of performance and quality indicators that are:

a)           Objective;

b)           Clearly and unambiguously defined;

c)
Based on current clinical knowledge or health services research;

d)           Valid and reliable;

e)           Systematically collected; and

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

3.           Implements system interventions to achieve quality improvement;

4.           Evaluates the effectiveness of the interventions;

5.
Plans and initiates activities for increasing or sustaining improvement; and

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6.   
Represents the entire population to which the quality indicator is relevant.

s. 
The MCO shall maintain a health information system that collects, analyzes,
integrates and reports data. The system must provide information on areas
including but not limited to utilization, appeals and hearings.

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

u.
At the invitation of the CT BHP, 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 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

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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, Section 3.34.

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. Section 1320 d-2 et seq. and the implementing privacy regulations at
45 CFR pts. 160 and 164.

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, 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.
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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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 §§
1320d-2 et seq.. and the implementing privacy regulations at 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 NCQA or other national
accrediting body with a recognized expertise in managed care.

b.
The MCO shall also simultaneously maintain, with the medical record, a record of
all contacts with each Member that the MCO will maintain in a computerized
database and make available to the DEPARTMENT, at its request. Claims and
encounter records will be provided to the DEPARTMENT in an electronic medium as
specified by the DEPARTMENT, and its agent(s). The medical record shall
demonstrate coordination of Member care; for example, relevant medical
information from referral sources and out-of-network family planning providers
shall be reviewed and entered into Members' medical records. For those MCOs that
are governed under Connecticut General Statutes Chapter 705 Section 38a-975 et
seg., known as the "Connecticut Insurance Information and Privacy Act", such MCO
shall be required to observe the provisions of such Act with respect to
disclosure of personal and privileged information as such terms are defined
under the Act.

c.
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.

d.
The MCO shall share information and provide copies of medical records pertaining
to a Member to the BMP ASO 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 MCO's obligations
pursuant to this 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 DEPARTMENT all payments made under the
contract to which exception has been taken or which have been disallowed because
of such an exception.

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3.38   Clinical Data Reporting

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

Utilization reports shall cover the following areas:

1.      Inpatient Care;
2.      Preventive Care;
3.      Dental Care;
4.      Other Services;
5.      Maternal and Child Health;
6.      EPSDT, known as HealthTrack; and
7.      Immunization Information.

b.
The DEPARTMENT shall consult with the MCO, through a workgroup comprised of
DEPARTMENT and MCO representatives that meets on a periodic basis, or a similar
process, on the necessary data, methods of collecting the data and the format
and media for new reports or changes to existing reports.

c.
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 that
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.

d.
For each report the DEPARTMENT shall consider using any HEDIS standards
promulgated by the NCQA, which cover 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 A program can be
better served by using other methods.

e.
EPSDT (HealthTrack): The MCO shall submit to the DEPARTMENT reports on
compliance with screening requirements of the EPSDT program sufficient to enable
the DEPARTMENT to comply with its reporting obligations under federal and state
requirements and to assess and evaluate the performance of the MCO in the
screening requirements of the EPSDT program. These obligations include, but are
not limited to, submitting reports to federal and state agencies.
 

 f.   Maternal and Prenatal Care

          :

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The MCO shall report aggregate summary data on outcomes of maternal and prenatal
care to the DEPARTMENT no less frequently than quarterly. Such data will
include:

1.
Number of deliveries during the quarter to women enrolled in the MCO at the time
of delivery;

2.   Number of live births;

3.  Number of fetal deaths;

4.
Number of very low birth weight babies, defined as weighing less than one
thousand five hundred grams;

5.
Number of hospital inpatient/NICU days for very low birth weight babies;

6.
Number of moderately low birth weight babies, defined as weighing less than two
thousand five hundred grams;

7.
Number of hospital/NICU days for moderately low birth weight babies;

8.  Number of deliveries by cesarean section;

9.  Number of women who delivered and had no prenatal care;

10. Number of women with inadequate prenatal care;

11. Number of women with deliveries who have received a postpartum visit; and

12. Aggregate measures of weeks of pregnancy at the time of enrollment in the
plan.

          
           
The report will be due within six (6) months after the last day of the quarter
in which the deliveries occurred. The DEPARTMENT will specify the methodology
for preparing the report, no less than ninety (90) days prior to the end of the
quarter, which is the subject of the report and after consultation with the MCO.
If the change requires the collection of additional data elements not currently
being captured, the DEPARTMENT will notify the MCO no less than ninety (90) days
prior to the beginning of the first quarter affected by the change.

g.        Daily and Monthly Reports

1.  
The MCO shall provide to the BMP ASO daily and monthly reports and/or data of
services as mutually agreed upon. Such reports shall be produced in a format as
mutually agreed upon. Examples of the service subjects for reporting may include
but not be limited to 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

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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.

3.
The MCO shall report medical and behavioral transportation data and
transportation related complaints to the DEPARTMENT and shall distinguish
behavioral health non-emergency medical transportation from medical
non-emergency medical transportation.

h.        Encounter Data:

1.
The MCO shall provide the DEPARTMENT with an electronic record of every
encounter between a network provider and a Member within fifteen (15) days of
the close of the month in which the specific encounter occurred, was paid for,
or was processed whichever is later but no later than 180 days from the
encounter. Such encounters shall be coded and formatted in accordance with the
specifications outlined in the State's Encounter Submission and Reporting Guide.
The DEPARTMENT or its agent shall analyze each month's encounter submission
file. The DEPARTMENT or its agent will reject those records that contain invalid
or missing data and result in a critical edit failure as outlined in the
Encounter Submission and Reporting Guide.

2.
Encounter data and any other types of data submitted by the MCO that the
DEPARTMENT designates as data relied upon by the DEPARTMENT to set rates must be
certified by one of the following: the MCO's Chief Executive Officer or Chief
Financial Officer or an individual who has delegated authority to sign for and
who reports directly to either the Chief Executive Officer or Chief
Financial Officer.    The certification must attest, based on the
best knowledge, information and belief, as follows: 1) to the
accuracy, completeness and truthfulness of the data and 2) to the
accuracy, completeness and truthfulness of the reports required pursuant to this
section. The MCO shall submit the certification concurrently with the certified
data.

Performance Measure: The overall volume of rejected encounters shall not exceed
five (5) percent in any given month.

3 a.
The overall acceptance rate in any given month shall not be less than 95 % for
the initial submission of encounters.

3 b.
The overall acceptance rate (initial and corrected encounters) for any given
month shall not be less than 98% within 90 days of the initial submission.

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3.c.       The overall acceptance rate (initial and corrected encounters) for
any given month shall not be less than 99.6% within 120 days of the initial
submission.

4.
The DEPARTMENT or its agent shall also analyze the MCO's encounter submissions
for completeness. On a quarterly basis, no less than six (6) months from the
date of service on the encounter, the DEPARTMENT or its agent will compare
encounter data utilization levels to the MCO self-reported utilization levels in
the reports specified in Sections 3.38(a)-(f).

Performance Measure: Encounter data shall not be over or under the MCO
self-reported utilization levels for the same time period by ten (10) percent or
more.

5.
The DEPARTMENT or its EQRO, may choose a random sample of no more than one
hundred (100) encounters for each year. The MCO will make the medical records of
each encounter so chosen available to the DEPARTMENT or EQRO at a central
location upon reasonable notice. The EQRO shall review the medical records and
report to the DEPARTMENT on the extent to which the information in each field of
the encounter record corresponds to the information contained in the medical
record. Prior to making its report to the DEPARTMENT, the EQRO shall afford the
MCO a reasonable opportunity to suggest corrections to or comment upon the
EQRO's findings.

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 7.05.

3.39    Utilization Management

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

b.
The MCO and its subcontractors shall develop and adhere to written policies and
procedures for processing requests for initial and continuing authorizations of
services.   The MCO shall have mechanisms in place to ensure consistent
application of review criteria for authorization decisions. Authorization
decisions must be made by a health care professional who has appropriate
clinical expertise in treating the Member's condition or disease.

c.
The MCO must provide a written notice of action, as described in Section 6.02,
of any decision to deny a service authorization request or to authorize a
service in an amount, duration, or scope that is less than requested or any
decision to terminate, suspend or reduce a previously

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authorized Medicaid-covered service. The provider requesting authorization shall
also receive a copy of the notice of action,

d.
The MCO shall make authorization decisions and issue a written notice of action
and notice to the provider as expeditiously as the Member's health condition
requires, but not to exceed fourteen (14) calendar days following receipt of the
request for service.   This standard 14 day authorization period may be extended
one time only by an additional fourteen (14) days if:

1.           The Member or requesting provider asks for an extension; or

2.
The MCO documents that the extension is in the Member's interest because
additional information is needed to authorize the service and the failure to
extend the timeframe will result in the denial of the service. The DEPARTMENT
may request such documentation from the MCO.

3.
The MCO gives the Member written notice of the reason for the decision to extend
the timeframe and informs the Member of the right to file a grievance if he or
she disagrees with the decision to extend the timeframe.

e.
The MCO shall expedite its authorization decision if a provider indicates, or
the MCO determines that following the timeframe in subsection (d) of this
section could seriously jeopardize the Member's life or health or ability to
attain, maintain or regain maximum function. In such circumstances the MCO shall
issue a decision no later than three working days after receipt of the request
for service. This three-day period may be extended for an additional fourteen
days if either criteria in (d)(1) or (d)(2) above, are met.

f.
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 subcontracts will be subject to the provisions of Section 5.08 of this
contract. The DEPARTMENT will review and approve the subcontract, subject to the
provisions of Section 3.45, 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.

g.
The MCO shall not compensate any subcontractor or other entity performing
utilization management or utilization review functions to provide any incentive
for the individual to deny, limit or discontinue medically necessary services to
any Member.

h. 
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. If the issue remains unresolved, the DEPARTMENT
will conduct an expedited review of the issue at the request of the MCO.

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3.40    Financial Records

a.
Accounting: 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, for any subcontract that is a risk contract as defined in 42 CFR
438.2, any such subcontractors' 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 subsections (c) and (d) below or as otherwise directed by the
DEPARTMENT.

c.
Reports specific to the MCO's Medicaid line of business shall be provided in
formats developed by the DEPARTMENT. All reports described in Sections
3.40(c)(1) and 3.40(c)(2) shall contain separate sections for HUSKY A and HUSKY
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 with an income statement by 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. § 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.

 
2.
Unaudited financial reports, HUSKY line of business (formats shown in Appendix
F). 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.

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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 C.G.S. § 38a-53.
One copy of each statement shall be submitted to the DEPARTMENT in
accordance with the Department of Insurance submittal schedule.

4.
Claims Aging Inventory Report (format shown in Appendix F, or any other format
approved by the DEPARTMENT). The Claims Aging Inventory 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 Inventory 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.
Denied Claims Report. The MCO shall also submit a Denied Claims report, to
include all HUSKY provider claims denied as of the end of each quarter.

6. 
Claims Turn Around Time Report (format shown in Appendix F, or any other format
approved by the DEPARTMENT). For those claims processed in forty-six (46) days
or more, the report shall indicate if interest was paid in accordance with
Section 3.46 of this 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 in the required
format 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 that 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 the said
agency agrees that such information may be shared with the DEPARTMENT.

f.
The MCO shall submit to the DEPARTMENT on a quarterly basis, capitation income
and disbursement reports from mental health and dental subcontractors with whom
they have a risk arrangement. The report shall be in a format specified by the
DEPARTMENT and shall include total

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payment received for Medicaid members from the MCO and breakdown of payment by
categories as specified in Sec. 3.45 (j)(2).

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 should 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           Third Party Coverage

The DEPARTMENT is the payer of last resort when third party resources are    .
available to cover the costs of medical services provided to Medicaid
recipients. Pursuant to this requirement, the MCO is required to comply with
federal and state statutes and regulations regarding third party liability. The
MCO shall be responsible for making every reasonable effort to determine the
legal liability of third parties to pay for services rendered to Members under
this contract. The MCO shall be responsible for identifying appropriate third
party resources, and if questions arise they shall consult with the DEPARTMENT.
The MCO shall pursue, collect, and retain any monies from third party payers for
services to the MCO's Members under this contract, subject to the following
terms and conditions:

a. 
The DEPARTMENT hereby assigns to the MCO all rights to third party recoveries
from Medicare, health insurance, casualty insurance, workers' compensation,
tortfeasors, or any other third parties who may be responsible for payment of
medical costs for the MCO's Members.

The MCO may assign the right of recovery to their subcontractors and/or network
providers. Notwithstanding any such assignment of the right of recovery, the MCO
remains responsible for the effective and diligent performance of third party
recovery.

1.        Other Insurance, Cost Avoidance and Third Party Resources

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The MCO will have primary responsibility for cost avoidance through the
coordination of benefits relative to federal and private health insurance
resources including, but not limited to Medicare, individual health insurance,
employment-related group health insurance and self administered or self funded
health benefit plan, including ERISA (Employee Retirement and Income Security
Act) plans. The MCO shall avoid initial payments of claims, as permitted by
federal law, where federal or private health insurance resources are available.
When cost avoidance is not possible, the MCO may utilize post payment recovery.
If a third party insurer requires the Member to pay any co-payment, coinsurance
or deductible, the MCO is responsible for making any such payments to the extent
that the third party insurer's co-payment exceeds the co-payment applicable
under this contract.

The MCO or its assignee must initiate third party recoveries within sixty (60)
days after the end of the month in which the MCO learns of the existence of the
liable third party. The MCO or its assignees must maintain dated documentation
of all claims to third parties. The MCO must document initiation of recovery by
formal communication in written or electronic form to the liable third party,
specifically requesting reimbursement up to the legal limit of liability for any
services provided to the MCO's Member covered under the State Medicaid Plan.

The right to pursue, collect and retain recovery from claims not initiated and
documented within sixty (60) days as stated above, will revert to the DEPARTMENT
and the MCO or its assignees will lose any right of recovery.

2.        Tort Recoveries

The DEPARTMENT or the Department of Administrative Services shares the right
with the MCO to initiate recoveries from tortfeasors. The right to recover the
cost of medical services from a tortfeasor goes to the first party that makes a
valid and legal claim to recovery. The party making a claim to recovery must
request reimbursement up to the legal limit of liability for any services
provider to the MCO's Member covered under the State Medicaid Plan. Disputes
between the State of Connecticut and the MCO as to which party first initiated
recovery will be determined by written confirmation from the tortfeasor.

When the MCO seeks recovery from a third party for care provided to a Member
following an accident, the MCO may recover only its cost of care.

b. 
In pursing third party recovery, the MCO, network providers, and subcontractors
shall seek recovery of the cost of services actually

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rendered to the Member, notwithstanding the fact that the MCO may pay the
subcontractor on a capitated basis.

c.   
The MCO shall maintain records of recoveries of all third party collections,
including cost avoidance, and recovery actions. The DEPARTMENT will specify a
schedule and format for reporting such collections. The amounts avoided or
recovered by the MCO shall be considered in establishing future capitated rates
paid to the MCO.

d  
The MCO shall fully cooperate with the DEPARTMENT in all third party recovery
efforts.

e.
The DEPARTMENT shall supply the MCO with a monthly file of Members where third
party coverage has been identified. The information shall also be available to
the MCO and its assignees from the DEPARTMENT'S Automated Electronic Voice
Response System.

f.
The MCO shall notify the DEPARTMENT within thirty (30) days if the MCO or its
network provider or subcontractor discovers that a Member has become eligible
for coverage by a liable third party. The MCO shall notify the DEPARTMENT within
thirty (30) days if the MCO or its in-network provider or subcontractor
discovers that a Member has lost eligibility for coverage by a liable third
party. The MCO shall notify the Department in a format specified by the
Department.

3.43   Coordination of Benefits and Delivery of Services

a.
The MCO shall ensure that the rules related to the coordination of benefits in
Section 3.41 do not present any barriers to Members' access to the covered
services under this contract.

b.
The MCO shall educate its Members on how to access services when a third party
insurer covers a Member.

c.
If a third party insurer requires the Member to pay any co-payment, coinsurance
or deductible, the MCO is responsible for paying the portion of the third party
insurer's co-payment that exceeds the co-payment applicable under this contract,
not to exceed the amount allowed per the MCO's fee schedule, even if the
services are provided outside of the MCO's provider network.

d.
If a Member's third party insurer pays for only some services covered under this
contract or for only part of a particular service, the MCO shall be liable up to
the allowed amount in accordance with the MCO's fee schedule, for the full
extent of services covered under this contract, even if the services are
provided outside of the MCO's provider network.

e.
If a third party insurer covers a Member, the MCO is bound by any
prior authorization decisions made by the third party insurer.

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3.44           Passive Billing

a.
Capitation payments to the MCO shall be based on a passive billing system. The
MCO is not required to submit claims for the capitation payment for its HUSKY A
membership. Capitation payments will be based on MCO membership data as
reflected in the enrollment files provided by the DEPARTMENT to the MCOs. On a
monthly basis ACS will provide the MCO with a detailed capitation remittance
file.

3.45           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 their 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 the 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. Before delegating
any of the requirements of this contract, the MCO shall evaluate the prospective
subcontractor's ability to perform the activities to be delegated. 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,
including any reporting requirements. The subcontract shall also provide for
revocation or other sanctions if the subcontractor's performance is inadequate.
All subcontracts shall also provide for the right of the DEPARTMENT or other
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 3.34, Inspection of Facilities. All
subcontracts shall comply with the requirements of 42 CFR 438.6 that are
appropriate to the service or activity delegated under the subcontract.

c.
With the exception of subcontracts specifically excluded by the DEPARTMENT, all
subcontracts shall include verbatim the HUSKY A definitions of Medical
Appropriateness / Medically Appropriate and Medically Necessary/Medical
Necessity as set forth in Part II, General Contract Terms for the MCOs. 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 A
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 shall be providing through a subcontract and
copies of the contracts between the MCO and the subcontractor. The 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 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 A
Members for the provision of goods and services to HUSKY A 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 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 dental subcontracts which include the payment of claims on behalf of HUSKY A
Members for the provision of goods and services to HUSKY A members shall require
the submission of a capitation income and disbursement report in a format
specified by the DEPARTMENT. The report shall be submitted quarterly and shall
include the amount of payment received for Medicaid members; amount paid
directly to providers of health services on behalf of Medicaid
members; administrative costs and profits.

g.
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.

h.
 
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 (j)
below.

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i.  
The MCO shall monitor all subcontractors' performance on an ongoing basis and
subject the subcontractor to formal review once a year. AH subcontracts shall
provide that if the MCO identifies deficiencies or areas for improvement, the
MCO and the subcontractor shall take corrective action.

j.
 
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)(4) of this contract, with steps to ensure the resolution
of the outstanding amounts. This plan shall be submitted prior to the
DEPARTMENT'S approval of the replacement subcontractor.

k.  
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.

l. 
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.

m.
This section shall not be construed as restricting the MCO from entering into
contracts with participating providers to provide health care services to
Members.

3.46    Timely Payment of Claims

a.
The MCO shall pay providers in group or individual practices or who practice in
shared health facilities within the following time limitations unless the MCO
and its providers stipulate to an alternative schedule in their provider
contracts:

1.
Ninety (90) percent of all clean claims within thirty (30) days from the date of
receipt;

2.
Ninety-nine (99) percent of all clean claims within ninety (90) days from the
date of receipt.

b.
If the MCO or any 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 otherwise as stipulated by a provider contract.

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c.  
In accordance with Section 3.40 (c)(4), Financial Records, the MCO shall provide
to the DEPARTMENT information related to interest paid beyond the forty-five
(45) day timely filing limit or otherwise stipulated by a provider contract.

3.47           Member Charges For Noncovered Services

A provider shall be permitted to charge an eligible Member for goods or services
which are not coverable only if the Member 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 noncovered
services are services not covered under the Medicaid state plan, services which
are provided in the absence of appropriate authorization, and services which are
provided out-of-network unless otherwise specified in the contract, policy or
regulation (e.g., family planning, mental health or emergency room services).

3.48           Insolvency Protection

Unless the MCO is (or is controlled by) one or more federally qualified health
care centers and meets the solvency standards established by the DEPARTMENT for
those centers, the MCO shall meet the solvency standards established by the
State of Connecticut for private health maintenance organizations, or be
licensed or certified by the State as a risk bearing entity. 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.

3.49           Acceptance of DSS Rulings

In cases where there is a dispute between the MCO and an out-of-network provider
about whether a service is medically necessary, is an emergency, or is an
appropriate diagnostic test to determine whether an emergency condition exists,
the DEPARTMENT will hear appeals, filed within one year following the date of
service and make final determinations. The DEPARTMENT will accept written
comments from all parties to the dispute prior to making the decision, and order
or not order payment, as appropriate. The MCO shall accept the DEPARTMENT'S
determinations regarding appeals.

3.50           Fraud and Abuse

a.
The MCO shall not knowingly take any action or fail 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 program.

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c.
The MCO acknowledges that the 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 program.

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 applies
to the MCO's subcontractors.

g.
The MCO shall have administrative and management procedures and a mandatory
compliance plan to guard against fraud and abuse. The MCO's compliance plan
shall include but not necessarily be limited to, the following efforts:

1.
The designation of a compliance officer and a compliance committee, responsible
to senior management;

2.
Written policies, procedures and standards that demonstrate commitment to comply
with all applicable Federal and State standards;

3.
Effective lines of communication between the compliance officer and MCO
employees;

4.
Conducting regular reviews and audits of operations to guard against fraud and
abuse;

5.
Assessing and strengthening internal controls to ensure claims are submitted and
payments are made properly;

6.
Effectively training and educating employees, providers, and subcontractors
about fraud and abuse and how to report it;

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7. 
Effectively organizing resources to respond to complaints of fraud and abuse;

8   
Establishing procedures to process fraud and abuse complaints; and

9. 
Establishing procedures for prompt responses to potential offenses and reporting
information to the DEPARTMENT.

h.
The MCO shall examine publicly available data, including but not limited to the
CMS Medicare/Medicaid Sanction Report and the CMS 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 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.

k. 
On or before January 1, 2007, the MCO's compliance plan shall meet the
requirements of Section 6033 of the Deficit Reduction Act of 2005, P.L. 109-171,
and any implementing regulations or guidance on those requirements issued by the
federal government.

Sanction: The DEPARTMENT may impose a sanction, up to and 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 7 of this contract, including terminating
or refusing to renew this contract or any other Sanction or remedy allowed by
federal or state law.

3.51    Persons with Special Health Care Needs

a.  
The DEPARTMENT will provide to the MCO information to identify Members who are:

     

1. Eligible for Supplemental Security Income;

2.  Over sixty-five (65) years of age;

3.
Children who are receiving foster care or otherwise in an out of home placement
or receiving Title IV E foster care or adoption services; and

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4.   
Children who are enrolled in Title V's Children with Special Health Care Needs
program.

b.
The MCO shall conduct an assessment of these individuals and other persons with
special health care needs and make a referral to the Member's PCP to develop a
treatment plan, as appropriate.

c.
The MCO shall report to the DEPARTMENT, in a format specified by the DEPARTMENT,
on quality indicators such as utilization of specialty services and case
management to be developed jointly between the DEPARTMENT and the MCOs.

3.52    Behavioral Health Payment Adjustment

a.
The DEPARTMENT will seek reimbursement from the MCO for the behavioral health
portion of capitation payments for HUSKY A members for service months of January
2006 through the final date that the Department's capitation payment included
behavioral health services

b.
The MCO will reimburse the DEPARTMENT the portion of its capitation payment
reflected in Appendix I - Capitation Amount - for behavioral health services per
the following schedule:

1.
Upon execution of this amendment for those payments the MCO received between
January 1, 2006 and June 30, 2006;

2.
By March 31, 2007 for those payments the MCO received between July 1, 2006 and
September 30, 2006, and

3.
By June 30, 2007 for those payments the MCO received between October 1, 2006 and
the final date that the Department's capitation payment included behavioral
health services

c.
The Department within one month from the execution of this amendment will reduce
the HUSKY A capitation rate to reflect the removal of payments for behavioral
health services.

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4.  FUNCTIONS AND DUTIES OF THE DEPARTMENT

4.01            Eligibility Determinations

The DEPARTMENT will determine the initial and ongoing eligibility for medical
assistance of each individual enrolled under this contract in accordance with
the DEPARTMENT'S continuous and guaranteed eligibility policies.

4.02            Populations Eligible to Enroll

Appendix G contains a list of the Medicaid groups currently eligible for managed
care enrollment. New eligibility groups may be added to the managed care
population. The DEPARTMENT will notify the MCO of any changes in the eligibility
categories to be included. Additional groups included by the DEPARTMENT may be
served at the MCO's option.

4.03            Enrollment/Disenrollment

a.
The DEPARTMENT through a central enrollment broker contract will handle
enrollment, disenrollment and initial selection of PCP.

b.
Coverage for new Members will be effective the first of the month and coverage
for disenrollments will terminate at the end of the month.

c.
Members remain continuously enrolled throughout the term of this contract,
except in situations where clients

1.      Change health plans,
2.      Lose their Medicaid eligibility,
3.      Receive Medicare, or
4.     Are recategorized into a Medicaid category not included in the managed
care initiative.
 
d.
Disenrollments due to a Member's change in health plans will occur on the last
day of the month in which the Member makes a plan change and the Member's
enrollment in a new plan will occur on the first day of the following month. The
MCOs shall coordinate care to assure continuity in accordance with applicable
DEPARTMENT policies.

e.
Disenrollments due to loss of eligibility become effective upon on the last day
of the month in which the Member looses eligibility.

f.
Disenrollments due to receipt of Medicare become effective the month following
the month in which DSS receives information of the existence of the Medicare
coverage.

g.
The Department will exempt adults who receive SSI form managed care. The
Member's enrollment in managed care will end on the last day of the month, and
the exemption from managed care will occur the first day of the following month.

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h.  
The DEPARTMENT determines Medicaid eligibility, and periodically the DEPARTMENT
may reclassify a Member's Medicaid status from mandatory managed care coverage
to non-managed care coverage. When the DEPARTMENT reclassifies a Member's
coverage to non-managed care coverage, the Member's enrollment in managed care
will end on the last day of the month.

i. 
The DEPARTMENT will notify the MCO of enrollments and disenrollments specific to
the MCO via a daily data file. 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).

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.

4.04            Default Enrollment

The DEPARTMENT shall, on a rotating basis among all of the participating MCO's
and as the MCO's enrollment capacity allows, assign default Members to the MCO.

The default assignment methodology is structured to evenly distribute families
among all the participating MCOs. However, due to variability in MCO service
area and enrollment capacity, family size and loss of Medicaid eligibility, the
outcome of the default assignment may not result in an even net default
distribution among all the MCOs.

4.05            Capitation Payments to 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, as amended.   The actuarial basis for the capitation rates, as
approved by CMS, is also attached at Appendix I.

b.
Upon validation of client eligibility and MCO membership, the DEPARTMENT will
pay the capitation payments in the month following the month to which the
capitation payments apply or for retroactive enrollments, the month following
the enrollment-processing month in accordance with Connecticut General Statutes
Section 4a-71 through 4a- 72.

c.
Payment to the MCO shall be based on the enrollment data transmitted from the
DEPARTMENT to the Enrollment Broker each month. The MCO will be responsible for
detecting the source of any inconsistency in capitation payments. 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

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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 (representing reinstated recipients) for each month of coverage shall be
included in the next monthly capitation payment, based on updated MCO enrollment
information for that month of coverage.

d. 
Any retrospective adjustments to prior payments will be made in the form of an
addition to or subtraction from the current month's capitation payment. Positive
adjustments are particularly likely for newborns, because the MCO may be aware
of births before the DEPARTMENT.

4.06            Retroactive Adjustments

a.
When a Member loses Medicaid eligibility and managed care enrollment but regains
coverage within sixty (60) days, and the coverage is made retroactive such that
the entire coverage gap is eliminated, the DEPARTMENT shall reinstate enrollment
into the MCO retroactive to the time of disenrollment. The MCO will remain
responsible for the cost of in- network covered services and the cost of
emergency and family planning services received by the Member during this sixty
(60) day period.

b.
In instances where enrollment is disputed between two (2) MCOs or the MCO and
Medicaid fee-for-service program, 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 be
made to the MCO pursuant to rules outlined in Section II, 4.05(d), Capitation
Payments to MCO.

4.07            Information

The DEPARTMENT will make known to each MCO complete and current information that
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.

4.08            Ongoing MCO Monitoring

a.
To ensure access and the quality of care, the DEPARTMENT or its agent shall
undertake plans to conduct monitoring activities, including but not limited to
the following:

1.  
Analyze the MCO's access enhancement programs, financial and utilization data,
and other reports to monitor the value the MCO is providing in return for the
State's capitation payments. Such efforts shall include, but not be limited to,
on-site reviews and audits of the MCO and its subcontractors and network
providers.

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2.
Conduct regular recipient surveys of Members to address issues such as
satisfaction with plan services to include administrative services, satisfaction
with treatment by the plan or its providers, and reasons for disenrollment and
access.
 

 3.  Review the MCO certifications on a regular basis

 
4.
Analyze encounter data, actual medical records, correspondence, telephone logs
and other data to make inferences about the quality of and access to specific
services.

5.
Sample and analyze encounter data, actual medical records, correspondence,
telephone logs and other data to make inferences about the quality of and access
to MCO services.

6.
Test the availability of and access to MCO services by attempting to make
appointments.

7.
At its discretion, commission or conduct additional objective studies of the
effectiveness of the MCO, as well as the availability of, quality of and access
to its services.

4.09   Utilization Review and Control

The DEPARTMENT shall waive, to the extent allowed by law, any current DEPARTMENT
requirements for prior authorization, second opinions, co-payment, or other
Medicaid restrictions for the provision of contract services provided by the MCO
to Members.

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5.   DECLARATION AND MISCELLANEOUS PROVISIONS

5.01           Competition Not Restricted

In signing this contract, the MCO asserts that no attempt has been made or will
be made by the MCO to restrict competition by inducing any other person or firm
to submit or not to submit an application to provide services.

5.02           Nonsegregated 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 Part 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).

5.03           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 DEPARTMENT may terminate the contract 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.

5.04           Employment/Affirmative Action Clause

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.

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5.05            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 consent of
the Contract Administrator, except as specified in this contract and as
permitted by applicable law.

5.06            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.

5.07            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 that arise during implementation and operation of the
contract.

5.08            Freedom of information

a.
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's subcontractor believes that any portions of the materials submitted to the
DEPARTMENT are proprietary or confidential or constitute commercial or financial
information, given in confidence, those portions or pages or sections the 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

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are submitted to the DEPARTMENT. The rationale and explanation must be stated in
terms of the prospective harm to the MCO's or subcontractor's competitive
position that would result if the identified material were to be released and
the reasons why the materials are legally exempt from release pursuant to the
above cited statue. The final administrative authority to release or exempt any
or all material so identified by the MCO or the 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.

b.    
The MCO understands the DEPARTMENT'S need for access to eligibility and paid
claims information and is willing to provide such data relating to the MCO to
accommodate that need. The MCO is committed to providing the DEPARTMENT access
to all information necessary to analyze cost and utilization trends; to evaluate
the effectiveness of Provider Networks, benefit design, and medical
appropriateness; and to show how the HUSKY population compares to the MCO's
enrolled population as a whole. The MCO and the DEPARTMENT each understand and
agree that the systems, procedures and methodologies and practices used by the
MCO, its affiliates and agents in connection with the underwriting, claims
processing, claims payment and utilization monitoring functions of the MCO,
together with the underwriting, Provider Network, claims processing, claims
history and utilization data and information related to the MCO and its agents,
may constitute information which is proprietary to the MCO and/or its affiliates
(collectively, the "Proprietary Information"). Accordingly, the DEPARTMENT
acknowledges that the MCO shall not be required to divulge Proprietary
Information if such disclosure would jeopardize or impair its relationships with
providers or suppliers or would materially adversely affect the MCO's or any of
its Affiliates' ability to service the needs of its customers or the DEPARTMENT
as provided under this Contract unless the DEPARTMENT determines that such
information is necessary in order to monitor contract compliance or to fulfill
Part II Sections 3.33 and 3.34 of Part II of this contract. The DEPARTMENT
agrees not to disclose publicly and to protect from public disclosure any
proprietary or trade secret information provided to the DEPARTMENT by the MCO
and/or its Affiliates' under this contract to the extent that such information
is exempted from public disclosure under the Connecticut Freedom of Information
Act.

5.09   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,

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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.

5.10            Force Majeure

The MCO shall be excused from performance hereunder for any period that it 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.

5.11            Financial Responsibilities of the MCO

a.
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.

b.
The MCO's physician incentive plans must comply with the requirements of
1903(m)(2)(a)(x) of the Social Security Act and 42 CFR 422.208 and 42 CFR
422.210.

c.
The DEPARTMENT reserves the right to inspect any physician incentive plans.

d.
If the MCO is not a federally qualified MCO or Competitive Medical Plan, the MCO
must complete a HCFA Section 1318 Financial Disclosure Report, prior to the
start of the contract.

5.12            Capitalization and Reserves

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

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 Department
of Insurance.

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
sequestered 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

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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.

5.13    Provider Compensation

a.
The MCO shall comply with CMS's Physician Incentive Plan (PIP) requirements in
42 CFR 422.208 and 42 CFR 422.210. The MCO may operate a PIP only if:

1.
No specific payment can be made directly or indirectly under a PIP to a
physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an individual Member; and

2.
The stop-loss protection, Member survey, and disclosure requirements of 42 CFR.
422.208 and 42 CFR 422.210 are met.

b.
The MCO shall disclose to the DEPARTMENT the following information on PIPs in
sufficient detail to determine whether the incentive plan complies with the
regulatory requirements of 42 CFR 422.208. The disclosure must contain:

1.
Whether services not furnished by the physician or physician group are covered
by the PIP. If only the services furnished by the physician or physician group
are covered by the incentive plan, disclosure of other aspects of the plan need
not be made.
 

2.  The type of incentive arrangement (i.e. withhold, bonus, capitation).

 
3.
The percent of the withhold or bonus if the incentive plan involves a withhold
or bonus,.

4.
Proof that the physician or physician group has adequate stop-loss protection,
including the amount and type of stop-loss protection.
 

5. The panel size and, if patients are pooled, the method used.

 
6.
In the case of those MCOs that are required by 42 CFR. 422.208(h) to conduct
Member surveys, the survey results.

c.
The MCO shall disclose this information to the DEPARTMENT (1) prior to approval
of its contract as required by federal regulation and (2) upon the contract
anniversary or renewal effective date. The MCO shall provide the capitation data
required (see (6) above) for the previous contract year to the DEPARTMENT three
(3) months after the end of the contract year. The MCO will provide to the
Member upon request information regarding whether the MCO uses a physician
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referral services, the type of incentive arrangement, whether stop-loss
protection is provided, and the survey results of any Member survey conducted.
See Appendix J for the applicable regulations and disclosure forms.

d. 
The DEPARTMENT may impose Class C sanctions pursuant to Section 7.05 for failure
to comply with 42 CFR 422.208 and 422.210

5.14           Members Held Harmless

a.        The MCO shall not hold a Member liable for:
 

1.
 The debts of the MCO in the event of the MCO's insolvency;
 

2.
The cost of Medicaid-covered services provided pursuant to this contract to the
Member if the DEPARTMENT does not pay the MCO or the DEPARTMENT or the MCO does
not pay the health care provider that furnishes the services under a
contractual, referral, or other arrangement; and/or

3.
Payments for covered services furnished under a contract, referral, or other
arrangement, to the extent those payments are in excess of the amount that the
Member would owe if the MCO directly provided the service.

5.15         Compliance with Applicable Laws, Rules, Policies, and Bulletins

The MCO in performing this contract shall comply with all applicable federal and
state laws, regulations, provider bulletins and written policies, as set forth
in the Department's provider manuals or issued as policy transmittals to the
MCOs. This shall include but not be limited to compliance with licensing
requirements. In the provision of services under this Contract, the MCO and its
subcontractors shall comply with all applicable federal and state statutes and
regulations, and all amendments thereto, that are in effect when the agreement
is signed, or that come into effect during the term of the Contract. This
includes, but is not limited to Title XIX of the Social Security Act and Title
42 of the Code of Federal Regulations.

5.16           Advance Directives

a.
The MCO shall comply with the provisions of 42 CFR 422.128 relating to written
policies and procedures for advance directives. The MCO shall:

1.
Maintain written policies and procedures that meet the requirements for advance
directives in Subpart I of 42 CFR pt. 489;

2.
Maintain policies and procedures for all adults receiving medical care through
the MCO;

3.
Provide each adult Member with written information on advance directives
policies, including a description of Connecticut General Statutes §§ 19a-570 -
19a-580d; and

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4.       Provide each adult Member with information on changes in Connecticut
law regarding advance directives as soon as possible, but no later than ninety
(90) days after the effective date of the change.

5.17   Federal Requirements and Assurances
 
General

a.
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 and assurances are applicable to the MCO. Copies of the form are
available from the DEPARTMENT.

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

c.
The MCO shall comply with all applicable provisions of 45 CFR 74.48 and all
applicable requirements at 45 CFR 74.48 Appendix A.

Lobbying

a.
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.

b.
The MCO shall submit to the DEPARTMENT a disclosure form as provided in 45 CFR
93.110 and Appendix B to 45 CFR Part 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.

Balanced Budget Act and Implementing Regulations

The MCO shall comply with all applicable provisions of 42 U.S.C. Section 1396u-2
, 42 U.S.C. Section 1396b(m) and 42 CFR Parts 431 and 438.

Clean Air and Water Acts

The MCO and all subcontractors with contracts in excess of $100,000 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 section 508 of the Clear
Water Act (33 U.S.C. 1368), Executive Order 11738, and 40 CFR Part 15).

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Energy Standards
 
The MCO shall comply with all applicable standards and policies relating to
energy efficiency that are contained in the state energy plan issued in
compliance with the federal Energy Policy and Conservation Act, 42 USC §§ 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, 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.

Maternity Access and Mental Health Parity

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

5.18    Civil Rights Federal Authority

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

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.

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

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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 seg., must provide
for equal employment opportunities in its employment practices.

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) and Conn. Gen. Stat. § 17b-90. 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.

5.19           Statutory Requirements

a.
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 § 1395aa et seq.

5.20           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.

5.21           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.

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The MCO may disclose material and information to subcontractors and vendors, as
necessary to fulfill the obligations of this contract.

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.

5.22            Changes Due to a Section 1115 or 1915(b) Freedom of Choice
Waiver

The conditions of enrollment described in the contract, including but not
limited to enrollment and the right to disenrollment, are subject to change as
provided in any waiver under Section 1115 or 1915(b) of the Social Security Act
(as amended) obtained by the DEPARTMENT.

5.23            Hold Harmless

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.

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. 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.

5.24            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 Agreement 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 subsection (b).

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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 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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6.   GRIEVANCE SYSTEM AND PROVIDER APPEALS

The MCO shall establish and maintain a grievance system that meets all statutory
and regulatory requirements. The MCO's grievance system shall include a
grievance process, an appeal process and access to and participation in the
DEPARTMENT'S administrative hearings process.

6.01            Grievances

a.
The MCO shall have a system in place to handle grievances. Grievances are
expressions of dissatisfaction about any matter, other than those matters that
qualify as an action. The subject matters of grievances may include, but are not
limited to, quality of care, rudeness by a provider or MCO staff person or
failure to respect a Member's rights.

b.
The MCO shall maintain adequate records to document the filing of a grievance,
the actions taken, the MCO personnel involved and the resolution. The MCO shall
report grievances in a mutually agreed upon format.

c.
A Member, or a provider acting on a Member's behalf, may file a grievance either
orally or in writing. The MCO shall acknowledge the receipt of each grievance
and provide reasonable assistance with the process, including but not limited to
providing interpreter services and toll free numbers with TTY/TTD and
interpreter capability.

d.
If the grievance involves a denial of expedited review of an appeal or some
other clinical issue, the grievance must be reviewed by a health
care professional with appropriate clinical expertise.

e.
The MCO shall dispose of each grievance as expeditiously as the member's health
requires. If the Member filed the grievance orally, the MCO may resolve the
grievance orally, but shall maintain documentation of the grievance and its
resolution. If the Member filed a written grievance, the resolution shall be in
writing. If applicable, each grievance shall be handled by an individual who was
not involved in any previous level of decision-making. Each grievance shall be
disposed of in ninety (90) days or less.

6.02            Notices of Action and Continuation of Benefits

 
a.        The MCO or its subcontractor (as duly authorized by the MCO) shall
mail a notice of action to a Member when the MCO takes action upon a request for
medical services from the Member's treating PCP, or other treating provider,
functioning within his or her scope of practice as defined under state law. For
purposes of this requirement, an "action" includes:

 
1.        The denial or limited authorization of a requested service, including
the type or level of service;

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2.
The reduction, suspension or termination of a previously authorized service;
 

3. The denial, in whole or in part, of payment for a service;

 
4.
The failure to act within the timeframes for utilization review decisions, as
described in Section 3.39; and

5.
The failure to provide access to services in a timely manner as required by
3.14(c)(1) through (c)(6) and 3.21 (a)(4) or the failure to provide access to
consultations and specialist referrals within three (3) months.

The notice of action requirements shall apply to all categories of covered
medical services including transportation to medically necessary appointments.

The CT BMP will issue notices of action for behavioral health utilization review
decisions. When a Member has both medical and behavioral health conditions and
an MCO action affects both conditions, the MCO shall, as necessary, consult with
the ASO in preparation for the hearing.   If the MCO issues a notice of action
related to a request for pharmacy services and the prescription at issue was
written by a Medicaid enrolled behavioral health prescribing provider, the MCO
shall send the notice of action to the Member and the prescribing provider.

The MCO is required to issue a notice for actions described in (a)(3) above if
the denial of payment for services already rendered may or will result in the
Member being held financially responsible. Such circumstances include, but are
not limited to, the provision of emergency services that do not appear to meet
the prudent layperson standard, the provision of services outside of the United
States, and the provision of non-covered services with the Member's written
consent as described in 3.47. The MCO is not required to issue a notice of
action for the denial of payment for covered services that have already been
provided to the Member if the denial is based on a procedural or technical
issue, including but not limited to a provider's failure to comply with prior
authorization rules for services that the Member has already received, incorrect
coding or late filing by a provider for services that the Member has already
received. In these circumstances, coverage of the service is not at issue and
the Member may not be held financially liable for the services. Nothing herein
shall relieve the MCO from its responsibility to issue a notice of action in all
circumstances in which a provider requests prior authorization for a service and
the request is denied in whole or in part, as required in (a)(1) above. Nothing
herein shall relieve the MCO from its responsibility to hold a Member harmless
for the cost of Medicaid covered services and

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its responsibility to ensure that the MCO's network providers hold a Member
harmless for the cost of Medicaid covered services.

The MCO is required to issue a notice of action for actions described in (a)(5)
above, only if the Member notifies the MCO of his or her inability to obtain
timely access to services. In such instances, the MCO shall provide the Member
with immediate assistance in accessing the services. If the Member has been
unable to access emergency services, the MCO shall issue a notice of action
immediately. For non-emergent services, if a Member contacts the MCO concerning
the inability to access a covered service within the timeframes referenced in
(a)(5) above, and three (3) business days later the Member has not accessed or
made arrangements for receiving the service that are satisfactory to the Member,
the MCO shall issue a notice of action.

b.
The MCO shall issue a notice of action if the MCO approves a good or service
that is not the same type, amount, duration, frequency or intensity as that
requested by the provider, consistent with current DSS policy.

c.
The MCO shall identify if the Member reads only a language other
than English.   For Members who do not read English, the notice of action
shall be provided in accordance with Sections 3.28(a) and 3.29(h).

d.
Except as provided in (h) below, the MCO shall mail an advance notice of action
for a termination, suspension or reduction of a previously authorized service to
a Member at least ten (10) days before the date of any action described in (a)
above, consistent with current DSS policy. The MCO may shorten the period of
advance notice to five (5) days before the date of action if: 1) the MCO has
facts indicating that the action should be taken because of probable fraud by
the Member; and 2) the facts have been verified, if possible, through secondary
sources.

e.
All notices related to actions described in (a) above shall clearly state
or explain:

 

1. 
The action the MCO intends to take or has taken;
 

2.
The reasons for the action;
 

3.
The statute, regulation, the DEPARTMENT'S Medical Services Policy section, or
when there is no appropriate regulation, policy or statute, the HUSKY A contract
provision that supports the action;

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

5.
The Member's right to challenge the action by filing an appeal and requesting an
administrative hearing;

6.
The procedure for filing an appeal and for requesting an administrative hearing;

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7.
How the Member may obtain an appeal form and, if desired, assistance in
completing and submitting the appeal form;

8.
That the Member will lose his or her right to an appeal and administrative
hearing if he or she does not complete and file a written appeal form with the
DEPARTMENT within sixty (60) days from the date the MCO mailed the initial
notice of action;

9.
That the MCO must issue a decision regarding an appeal by the date that the
administrative hearing is scheduled, but no more than thirty (30) days following
the date the DEPARTMENT receives it;

10.
That, if the Member files an appeal he or she is entitled to meet with or speak
by telephone with the MCO representative who will decide the appeal, and is
entitled to submit additional documentation or written material for the MCO's
consideration;

11.
That the Member may proceed automatically to an administrative hearing if he or
she is dissatisfied with the MCO's appeal decision concerning the denial of
coverage of goods or services or a reduction, suspension, or termination of
ongoing goods or services, or if the MCO fails to render an appeal decision by
the date the administrative hearing is scheduled;

12.
That at an administrative hearing, the Member may represent himself or herself
or use legal counsel, a relative, a friend, or other spokesperson;

13.
That if the Member obtains legal counsel who will represent the Member during
the appeal or administrative hearing process, the Member must direct his or her
legal counsel to send written notification of the representation to the MCO and
the DEPARTMENT;

14.
That if the circumstances require advance notice, the Member's right to
continuation of previously authorized goods and services, provided that the
Member files a appeal/request for administrative hearing form with the
DEPARTMENT on or before the intended effective date of the MCO's action or
within ten (10) calendar days of the date the notice of action is mailed to the
Member, whichever is later;

15.
The circumstances under which expedited resolution is available and how to
request expedited resolution; and
 

16. Any other information specified by the DEPARTMENT.

 
f.
In the case of a child who is under the care of the Department of Children and
Families (DCF), the MCO must send the notice of action to the child's foster
parents and the DCF contact person specified by the DEPARTMENT.

g.           The NOA shall be mailed within the following timeframes:

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1.
For termination, suspension, or reduction of previously authorized Medicaid
covered services, 10 days in advance of the effective date;

2.
For standard authorization decisions to deny or limit services, as expeditiously
as the Member's health condition requires, not to exceed fourteen (14) calendar
days following receipt of the request for services;

3.
If the MCO extends the fourteen day time frame for denial or limitation of a
service as permitted in Section 3.39d (1) and (2), as expeditiously as the
Member's condition requires and no later than the date the extension expires;

4.
For service authorization decisions not reached within the timeframes in 3.39
(which constitutes a denial and thus is an adverse action), on the date the
timeframe expires;

5.
For expedited service authorization decisions as expeditiously as the Member's
health condition requires and no later than three (3) business days after
receipt of the request for services;

6.
For denial of payment where the Member may be held liable, at the time of any
action affecting the claim

7.
For failure to provide timely access to services as expeditiously as the
Member's health requires, but no later than three (3) business days after the
Member contacts the MCO.

h.
 
The ten (10) day advance notice requirements do not apply to the circumstances
described in 42 CFR 431.213. Notice of action need not be sent to the Member ten
(10) days in advance of the action, but may be sent no later than the date of
action and will be considered an exception to the advance notice requirement, if
the action is based on any of the following circumstances:

1            A denial of services;

2
The MCO has received a clear, written statement signed by the Member that:

a)
The Member no longer wishes to receive the goods or services; or

b)
The Member gives information which requires the reduction, suspension, or
termination of the goods or services, and the Member indicates that he or she
understands that this must be the result of supplying that information; and

3
The Member has been admitted to an institution where he or she is ineligible for
the goods or services. In this instance, the Member must be notified on the
notice of admission that any goods or services being reduced, suspended, or
terminated will be

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reevaluated for medical necessity upon discharge, and the Member will have the
right to appeal any post-discharge decisions.

If the circumstances are an exception to the advance notice requirement as set
forth above the Member does not have the automatic right to continuation of
ongoing goods or services. In these circumstances, however, and in any instance
in which the MCO fails to issue an advance notice when required, the reduced,
suspended, or terminated goods and services must be reinstated if the Member
files a written appeal form with the DEPARTMENT within ten (10) days of the date
the notice is mailed to the Member.

i.  
The MCO shall follow the requirements for continuation of services set forth in
42 CFR 438.420. The right to continuation of ongoing goods or services applies
to the scope of services previously authorized. The right to continuation of
services does not apply to subsequent requests for approval that result in
denial of the additional request or re-authorization of the request at a
different level than requested. For example, the right to continuation of
services does not apply:

1
When a prescription (including refills) runs out and the Member requests a new
prescription for the same medication; or

2
To a request for additional home health care services following the expiration
of the approved number of home health visits

The MCO shall treat such requests as a new service authorization request and
provide a denial notice.

j.
Notice of action is not required if the member's treating physician or PCP,
using his or her professional judgment, refuses to prescribe (or prescribes an
alternative to) a particular service sought by a member. Notice of action is
also not required if the Member's treating physician or PCP, using his or her
professional judgment, orders the reduction, suspension, or termination of goods
or services.   Such decisions do not constitute an action by the MCO.   If,
however, the Member disagrees with the provider and contacts the MCO to request
authorization for the service the MCO shall conduct an expedited review of the
request, according to the timeframe in 3.39(e).   If the MCO affirms the
provider's action to deny, terminate, reduce or suspend the service, the MCO
shall issue a notice of action. If the Member requests an appeal and hearing,
the MCO shall continue authorization for the services, to the extent services
were previously authorized, unless the MCO determines that continued provision
of the services could be harmful to the Member.    The MCO shall also advise the
Member of his or her right to a second opinion from another provider.   Because
only a licensed health care provider, and not the MCO, may prescribe or provide
medical services, the Member may not be able to receive some or all of the
requested goods or services while the appeal is pending.    If the MCO approves
the Member's request for the

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good or service, the MCO shall inform the Member of the approval and shall
inform the Member of the right to a second opinion.

k.   
The DEPARTMENT will provide standardized notice of action forms to be used by
the MCO and its subcontractors. The DEPARTMENT will also provide standardized
appeal/hearing request forms to be used by the MCO and its subcontractors. The
MCO and its subcontractors shall not alter the standard format of either form
without prior, written approval of the DEPARTMENT.

I.
The DEPARTMENT will conduct random reviews and audits of the MCO and its
subcontractors, as appropriate, to ensure that Members are sent accurate,
complete and timely notices of action.

Sanction: If the DEPARTMENT determines during any audit or random monitoring
visit to the MCO or one of its subcontractors that a notice of action fails to
meet any of the criteria set forth herein, the DEPARTMENT may impose a strike
towards a Class A sanction. If the deficiencies which give rise to a Class A
sanction continue for a period in excess of ninety (90) days, the DEPARTMENT may
impose a Class B sanction.

6.03   Appeals and Administrative Hearing Processes

a.
The MCOs shall have a timely and organized appeals process. The appeals process
shall be available for resolution of disputes between the MCO and its Members
concerning the MCO's actions as defined in 6.02.

b.
The MCO shall develop written policies and procedures for its appeals process.
Those policies and procedures must be approved by the DEPARTMENT in writing and
must include the elements specified in this contract. The MCO shall not be
excused from providing the elements specified in this contract pending the
DEPARTMENT'S written approval of the MCO's policies and procedures.

c.
The MCO shall maintain a record keeping system for appeals that shall include a
copy of the appeal, the response, the resolution and supporting documentation.

d.
The MCO must clearly specify in its Member handbook/packet the procedural steps
and timeframes for filing an appeal and administrative hearing request,
including the timeframe for maintaining benefits pending the conclusion of the
appeal and administrative hearing processes. The Member handbook/packet shall
also list the addresses, office hours, and toll-free telephone numbers for the
Member Services office.

e.
The MCO shall ensure that network providers and subcontractors are familiar with
the appeal process and shall provide information on the process to providers and
subcontractors. The MCO shall provide information on the appeal process to its
providers and subcontractors at the time it enters into contracts or
subcontracts. The MCO must ensure that appeal forms are available at each
primary care site. At a minimum,

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appeals assistance must include providing forms on request, assisting the Member
in filling out the forms upon request, and sending the completed form to the
DEPARTMENT upon request.

f.
The MCO shall develop and make available to Members and potential Members
appropriate foreign language versions of appeals materials, including but not
limited to, the standard information contained in notices of action and appeals
forms. Such materials shall be made available in Spanish, English, or any other
languages if more than five (5) percent of the MCO's Members in any county of
the State served by the MCO speak the alternative language. The DEPARTMENT must
approve such foreign language materials, in writing.

g.
A Member may request an appeal either orally or in writing. When requesting an
appeal orally, unless the member is seeking an expedited appeal review, the
Member must follow up an oral request in writing. The MCO shall advise any
member who requests an appeal orally, that the Member must file a written appeal
within sixty (60) days of the notice of action in order to receive an
administrative hearing and the member must file an appeal within ten (10) days
of the mailing of the notice of action or the effective date of the intended
action in order to continue previously authorized services pending the appeal
and hearing.   In all other respects, the process for pursuing an appeal and for
requesting an administrative hearing shall be unified. The MCO and the
DEPARTMENT shall treat the filing of a written appeal as a simultaneous request
for an administrative hearing. The MCO shall attempt to resolve appeals at
the earliest point possible. If the MCO is not able to render a decision by
the time the administrative hearing is scheduled, the Member will automatically
proceed to the administrative hearing.

h.
The Member, the Member's authorized representative, or the Member's conservator
may file an appeal on a form approved by the DEPARTMENT. A provider, acting on
behalf of the member and with the Member's written consent, may file an appeal.
A provider may not file an administrative hearing request on behalf of a Member
unless the authorized representative requirements in DSS Uniform Policy Manual
Section 1525.05 are met. The MCO shall request a copy of the written consent
from the Member.   Appeals shall be mailed or faxed to a single address within
the DEPARTMENT. The appeal form must state both the mailing address and fax
number at the DEPARTMENT where the form must be sent. If the MCO or its
subcontractor receive an appeal directly from a Member or the Member's
authorized representative or conservator, the MCO shall date stamp and fax the
appeal to the appropriate fax number at the DEPARTMENT within two (2) business
days.

i.  
Upon receipt of a written appeal, the DEPARTMENT will schedule an administrative
hearing and notify the Member and MCO of the hearing date and location. If a
Member is disabled, the hearing may be scheduled for the Member's home, if
requested by the Member.

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j. 
The DEPARTMENT will date stamp and forward the appeal by fax to the MCO within
two (2) business days of receipt. The fax to the MCO will include the date the
Member mailed the appeal to the DEPARTMENT. The postmark on the envelope will be
used to determine the date the appeal was mailed.

k.  
An individual or individuals having final decision-making authority must conduct
the MCO's review of the appeal. Any appeal stemming from an action based on a
determination of medical necessity or involving any other clinical issues must
be decided by one or more physicians who were not involved in making that
medical determination.

l. 
The MCO may decide an appeal on the basis of the written documentation available
unless the Member requests an opportunity to meet with the individual or
individuals making that determination on behalf of the MCO and/or requests the
opportunity to submit additional documentation or other written material. The
Member shall have a right to review his or her MCO record, including medical
records and any other documents or records considered during the appeal process.
The Member's right to access medical records shall be consistent with HIPAA
privacy regulations and any applicable state or federal law.

m.
If the Member wishes to meet with the decision maker, the meeting can be held
via the telephone or at a location accessible to the Member, including the
Member's home if requested by a disabled Member or any of the Department's
office locations through video conferencing, subject to approval of the
DEPARTMENT'S Regional Offices, The MCO must invite a representative of the
DEPARTMENT to attend any such meeting.

n.
The MCO must mail to the Member a written appeal decision, described below, with
a copy to the DEPARTMENT, by the date of the DEPARTMENT'S administrative hearing
as expeditiously as the Member's health condition requires, but no later than
thirty (30) days from the date on which the appeal was received by the
DEPARTMENT. If the Member is dissatisfied with the MCO's decision regarding the
denial, reduction, suspension, or termination of goods or services, or if the
MCO does not render a decision by the time of the administrative hearing, the
Member may automatically proceed to the administrative hearing.

o.
The MCO's written appeal decision must include the Member's name and address;
the provider's name and address; the MCO name and address; a complete
description of the information or documents reviewed by the MCO; a complete
statement of the MCO's findings and conclusions, including the section number
and text of any contractual provision or DEPARTMENTAL policy provision that is
relevant to the appeal decision; and a clear statement of the MCO disposition of
the appeal.

p. 
Along with its written appeal decision, the MCO must remind the Member, on a
form approved by the DEPARTMENT, that:

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1.
If the Member is dissatisfied with the MCO's appeal decision, the DEPARTMENT has
already reserved a time to hold an administrative hearing concerning that
decision;

2.
That the Member has the right to automatically proceed to the administrative
hearing, and that the MCO must continue previously authorized goods and services
pending the administrative hearing decision;

3.
If the appeal pertains to the suspension, reduction, or termination of goods or
services which have been maintained during the appeals process, and the MCO's
appeals decision affirms the suspension, reduction, or termination of goods or
services, those goods or services will be suspended, reduced, or terminated in
accordance with the MCO's appeals decision unless the Member proceeds to an
administrative hearing; and

4.
If the Member fails to appear at the administrative hearing, the Member's
reserved hearing time will be cancelled and any disputed goods or services that
were maintained will be suspended, reduced, or terminated in accordance with the
MCO's appeals decision.

q.
If the Member proceeds to an administrative hearing, the MCO must make its
entire file concerning the Member and the appeal, including any materials
considered in making its decision, available to the DEPARTMENT.

r.
 
If the MCO fails to issue an appeal decision by the date that an administrative
hearing is scheduled, but no later than thirty (30) days following the date the
appeal was received by the DEPARTMENT, an administrative hearing will be held as
originally scheduled. At the hearing, the MCO must prove good cause for having
failed to issue a timely decision regarding the appeal. Good cause for the MCO's
failure to issue a timely decision shall include, but not be limited to,
documented efforts to obtain additional medical records necessary for the MCO's
decision on the appeal and the Member's refusal to sign a release for medical
records necessary for the decision on the appeal.
 
The MCO's inability to prove good cause shall constitute a sufficient basis for
upholding the appeal, and the hearing officer, in his or her discretion, may
uphold the appeal solely on that basis.
 
If the MCO proves good cause for having failed to issue a timely appeal
decision, the hearing officer may order a continuance of the hearing pending the
issuance of the appeal decision by a certain date, or the hearing officer may
proceed with the hearing.

s.    A representative of the MCO shall prepare the summary for the
administrative hearing, subject to approval by the DEPARTMENT prior to the
hearing, and shall present proof of all facts supporting its initial action

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if the administrative hearing proceeds in the absence of an appeal decision. The
MCO shall submit a final, signed hearing summary to the DEPARTMENT no later than
five (5) business days prior to the scheduled hearing date. The MCO's
representative shall also present any provisions of this contract or any
DEPARTMENT policies that support its decision.

t. 
If the Member is represented by legal counsel at the hearing and has not
notified either the DEPARTMENT or the MCO of the representation, the MCO may
request a continuance of the hearing or may ask the hearing officer to hold the
hearing record open for additional evidence or submissions. The decision as to
whether a continuance will be granted or the record will be held upon is within
the hearing officer's discretion.

u.   
If a representative of the MCO fails to attend a scheduled session of an
administrative hearing, the MCO's failure to attend shall constitute a
sufficient basis for upholding the appeal, and the hearing officer, in his or
her discretion may close the hearing and uphold the appeal solely on that basis.
This provision shall not apply unless the MCO receives notice of the hearing at
least seven (7) business days prior to the administrative hearing.

v. 
If the DEPARTMENT is advised that the Member does not intend to proceed to an
administrative hearing, the DEPARTMENT will fax such notice to the MCO.

w.  
The MCO must designate one primary and one back-up contact person for its
appeal/administrative hearing process.

x.
 
If the DEPARTMENT'S hearing officer reverses the MCO's decision to deny, limit
or delay services that were not furnished while the appeal was pending, the MCO
shall authorize or provide the disputed services promptly, and as expeditiously
as the Member's health condition requires.

6.04    Expedited Review and Administrative Hearings

a.
Subject to Section 6.02 above, the appeal process must allow for expedited
review. If the appeal contains a request for expedited review, it will be
forwarded by fax to the MCO within one business day of receipt by the
DEPARTMENT. The fax will include the date the Member mailed the appeal. The
postmark on the envelope will be used to determine the date the appeal was
mailed. If the MCO receives an oral request for expedited appeal, the MCO shall
notify the DSS liaison by fax or telephone within one business day of the oral
request.

b.
The MCO must determine, within one business day of receiving the appeal which
contains a request for an expedited review from the DEPARTMENT, or within one
business day of receiving an oral request for an expedited appeal, whether to
expedite the appeal or whether to perform it according to the standard
timeframes. If the Member's provider indicates or the MCO determines that the
appeal meets the criteria for

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expedited review, the MCO shall notify the DEPARTMENT immediately that the MCO
will be conducting the appeal on an expedited basis.

 
1.  
 An expedited appeal must be performed when the standard timeframes for
determining an appeal could seriously jeopardize the life or health of the
Member or the Member's ability to attain, maintain or regain maximum function.
The MCO must expedite its review in all cases in which the Member's provider
indicates, in making the request for expedited review on behalf of the Member or
supporting the member's request, that taking the time for a standard appeal
review could seriously jeopardize the Member's life or health or ability to
attain, maintain, or regain maximum function and if the DEPARTMENT requests the
MCO to conduct an expedited review because the DEPARTMENT believes a specific
case meets the criteria for expedited review.

d.
If the MCO denies a request for expedited review, the MCO shall perform the
review within the standard timeframe and make reasonable efforts to give the
Member prompt oral notice of the denial and follow up within two calendar days
with a written notice.

e.
An expedited review must be completed and an appeal decision must be issued
within a timeframe appropriate to the condition or situation of the Member, but
no more than three (3) business days from the DEPARTMENT'S receipt of the
written appeal or three (3) business days from an oral request received by the
MCO.

f.
The MCO may extend the timeframe for decisions in paragraph e by up to 14 days
if: 1) the Member requests the extension or 2) MCO can demonstrate that the
extension is in the member's interest because additional information is needed
to decide the appeal and if the timeframe is not extended, the appeal will be
denied. The DEPARTMENT may request this documentation from the MCO.

g.
The MCO shall ensure that no punitive action is taken against a provider who
requests an expedited appeal or supports a Member's appeal.

h.  
The MCO shall issue a written appeal decision for expedited appeals. The written
notice of the resolution must meet the requirements of 6.03(o) and (p). The MCO
shall also make reasonable efforts to provide the Member oral notice of an
expedited appeal decision.

i.
 
The DEPARTMENT also provides expedited administrative hearings for HUSKY A
Members, where required. The DEPARTMENT shall issue a hearing decision as
expeditiously as the Member's health condition requires, but no later than three
(3) working days after the DEPARTMENT receives from the MCO, the case file and
information for any appeal that meets the requirements for an expedited hearing.
A Member is entitled to an expedited hearing for the denial of a service if the
denial met the criteria for expedited appeal but was not resolved within the
expedited appeals timeframe or was resolved within the

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expedited appeals timeframe, but the appeals decision was wholly or partially
adverse to the Member.

Sanction: If the MCO fails to provide expedited appeals in appropriate
circumstances, the DEPARTMENT may impose a Class B sanction pursuant to Section
7.05.

6.05    Provider Appeal Process

a.
The MCO shall have an internal appeal process through which a health care
provider may appeal the MCO decision on behalf of a Member.

b.
The health care provider appeal process shall not include any appeal rights to
the DEPARTMENT or any rights to an administrative hearing.

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7.    CORRECTIVE ACTION AND CONTRACT TERMINATION

7.01           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. The DEPARTMENT will keep
written minutes of such meetings. 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 Article
7.02, 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.

7.02           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.

7.03           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 erroneous 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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7.04           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.)

7.05           Monetary 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:

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

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 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

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$2,500 after the first three (3) 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:

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 required (under law or under this contract) to be provided to an Member
covered under this contract;

b)
Imposing a premium or charge on Members except as specifically permitted under
provisions of the approved Medicaid State Plan and the provisions of this
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 Title XIX, 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;

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

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e)
Failing to comply with the physician incentive requirements under Section
1903(m)(2)(A)(x) of the Social Security Act and 42 CFR 422.208 and 422.210;

f)
Distributing directly or through any agent or
independent contractor      marketing materials that have not been approved by
the DEPARTMENT or containing false or misleading information; and

g)
Failing to comply with any other requirements of 42 U.S.C. 1396b(m)or 42 U.S.C.
1396u~2.

2.
Class C sanctions for noncompliance with the contract under this subsection
include 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, makes misrepresentations or false statements to Members,
potential Members or health care providers, engages in marketing violations or
fails to comply with the physician incentive plan requirements, 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 or DEPARTMENT,
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;

4)
For a determination that the MCO has imposed premiums or charges on Members in
excess of the premiums or charges permitted, double the excess amount but not
more than $25,000. The excess amount charged in such a circumstance must
be deducted from the penalty and returned to the Member concerned;

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

d)
Appointment of temporary management as described in 7.06.

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 that 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.

d.           CMS Sanctions

Pursuant to 42 CFR 438.730, the DEPARTMENT may recommend the imposition of
sanctions to CMS and CMS may sanction the MCO as described in that section. In
the alternative, CMS may independently initiate the sanction process described
in 42 CFR 438.730(a) through (d). The MCO shall comply with all applicable
sanction provisions set forth in 42 CFR 438.730. CMS may deny payment to the
DEPARTMENT for new Members under the circumstances described in 42 CFR
438.730(e) and capitation payments to the MCO will be denied so long as payment
for those Members is denied by CMS.

7.06   Temporary Management

The DEPARTMENT may impose temporary management upon a finding by the DEPARTMENT
that: 1) there is continued egregious behavior by the MCO; 2) there is a
substantial risk to the health of the Members or 3) temporary management is
necessary to ensure the health of the MCO's members while improvements are made
to remedy the violations or until there is an orderly

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termination or reorganization of the MCO. For purposes of this section,
"egregious behavior" shall include but not be limited to any of the violations
described in 7.05b(ii)(2) or any other MCO behavior that is contrary to Sections
1903(m) and 1932 of the Social Security Act. After a finding pursuant to this
subsection, individuals 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 imposing temporary management. If however, the DEPARTMENT chooses
not to first terminate the contract and repeated violations of substantive
requirements in section 1903(m) or 1932 of the Social Security Act occur, the
DEPARTMENT must than impose temporary management and allow individuals to
disenroll without cause. The Department may impose temporary management without
a hearing.

7.07           Payment Withhold, Class C Sanctions or Termination for Cause

The DEPARTMENT may withhold capitation payments, impose sanctions including
Class C Sanctions set forth in Section 7.05 retain monies collected in pursuit
of fraud or abuse, whether by the MCO, its providers, subcontractors or any
other entity; 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 A program and this contract and 2) failure to detect
fraud or abuse and to notify the Department of fraud or abuse, as required by
Section 3.51 and 3) if a civil action or suit in federal or state court
involving allegations of health fraud or violation of 18 U.S. C. Section 1961 et
seq. is brought on behalf of the DEPARTMENT.

7.08           Emergency Services Denials

If the MCO has a pattern of inappropriately denying payments for emergency
services as defined in Part II, Definitions, the MCO 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.)

7.09           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."

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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.
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 or that the MCO's
failure to perform or make progress in performance was due to causes beyond
control and without the error or negligence of the MCO, or any subcontractor,
the notice of termination shall be deemed to have been issued as a termination
for convenience pursuant to Section 7.09 and the rights and obligations of the
parties shall be governed accordingly.

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

e.
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.

f.
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.

g.
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 4.06 and Part II 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.

7.10   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 recipients through the termination of the contract.

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7.11           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.

7.12           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 Medicaid 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 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 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 sixty (60) day determination and notification period had not been
completed, and the MCO will be held to the terms of the executed contract.

7.13           Termination for Collusion in Price Determination

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

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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.

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.

7.14   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 contract The DEPARTMENT shall
give the MCO written notice of its intent to terminate, the reason for the
termination and the date and time of the hearing. After the hearing, the
DEPARTMENT shall give the MCO written notice of its decision affirming or
reversing the proposed termination. In the event of a decision to affirm the
termination, the DEPARTMENT'S written notice shall include the effective date of
termination. The 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 Medicaid claims.

c.
Where this contract is terminated due to cause or default by the MCO: 1) 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
and 2) the MCO shall notify all providers and be responsible for all expenses
related to notification to providers and members.
 

d.  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 to members;

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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.

7.15   Waiver of Default

Waiver of any default shall not be deemed 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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8.           OTHER PROVISIONS

8.01           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.

8.02           Effective Date

This contract is subject to review for form and substance by the U.S. Department
of Health and Human Services Centers for Medicare and Medicaid Services and the
DEPARTMENT, and will not become effective until it is approved by those
agencies.

8.03           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.

8.04           Correction of Deficiencies

This contract does not release the MCO from its obligation to correct all
outstanding certification deficiencies. Failure to correct all outstanding
material deficiencies may cause the MCO to be determined in Default of this
contract.

8.05           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.

9.0    APPENDICES

The following appendices are attached and incorporated as part of this Purchase
of Service Contract between the MCO and the DEPARTMENT:
Appendix A   HUSKY A Covered Services
Appendix B   Provider Credentialing and Enrollment Requirements;
Appendix C   EPSDT Periodicity & Immunization Schedules,
Appendix D   DSS Marketing Guidelines;
Appendix E   Standards for Internal Quality Assurance Programs for Health Plans;
Appendix F   Claims Inventory, Aging and Unaudited Quarterly Financial Reports;

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Appendix G  HUSKY A Medicaid Coverage Groups
Appendix I   Capitation Payment Amount
Appendix K  Inpatient/Eligibility Recategorization Chart.
Appendix L   Pharmacy Reports
Appendix M  Rate Charts
Appendix N   HUSKY Behavioral Health Carve-Out Coverage and Coordination of
Medical and Behavioral Services
Appendix O   CTBHP Master Covered Services Table
 

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APPENDIX A

HUSKY A COVERED SERVICES

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Appendix A - MCO Contract 05/07

 
HUSKY A      Covered Services

For purposes of this contract, the information contained in the Department's
Medical Services Policy Manuals and Departmental regulations has been summarized
to provide an overview for reference of the goods and services covered by the
Medicaid program (see attached list of Medical Assistance Program policies and
regulations). Any limitations or exclusions to these covered goods and services
are also overviewed.

Plans should be advised that, notwithstanding the following summary overview,
guidance issued by the Department in the form of policy transmittals,
regulations, provider bulletins, provider manuals, letters, and other written
correspondence is the final authority regarding covered goods and services. The
intent of the summary is to provide a quick working guide. These policies are
available at the Connecticut Medical Assistance Program website:
www.ctmedicalprogram.com. Whenever any questions regarding Medicaid policy
occur, health plans should consult with the Department's Medical Administration
Policy Unit for clarification.

Health plans are required to cover identical goods and services that are covered
under the Medicaid program. Health plans do not have the option of adding or
subtracting from the 'benefit package'. These goods and services are included in
plans' capitation rates.. Health Plans may provide unlisted support services
when such services lead to either a better health outcome or result in a less
restrictive and patient preferred treatment milieu.

Under current Medicaid Fee-For-Service (FFS) reimbursement methodology, various
administrative procedures related to payment for covered goods and services are
in place. These procedures are not incumbent upon health plans under Medicaid
Managed Care (MMC). For example, currently Medicaid FFS has administrative
procedures related to physical therapy provided in the home. When physical
therapy exceeds two (2) sessions per any consecutive seven (7) day period, prior
authorization is required.

Whether or not a given health plan requires prior authorization prior to
physical therapy being provided in the home, or requires prior authorization
after a certainnumber of visits, or does not require prior authorization at all
is not prescribed. The management of the "benefit" is at the discretion of the
health plan. However, a health plan cannot decide to limit a covered good or
service (e.g., cut off all physical therapy home visits after a certain number
of visits). The number of medically necessary visits will vary by member, and
the health plan cannot set a limit for members unless the Medicaid "benefit"
itself is specifically limited in Medical Services Policy.

The Behavioral Health Partnership ("BHP") is responsible for providing services
for behavioral health conditions. Appendix N, CT BHP Master Covered Services
Table outlines the respective coverage responsibilities of the MCO and the
Behavioral Health Partnership. No provision in this Appendix is intended to
negate, supercede or contradict any provision of the HUSKY A contract or

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Appendix N. In the event of any such inconsistencies, the provisions of the
HUSKY A Contract or Appendix N shall control.

The summary overview is divided into three (3) sections. Section A contains a
listing of covered goods and services included in the capitation rates. It also
lists the major limitations and exclusions to these covered goods and services.
Section B contains a listing of covered goods and services not included in the
capitation rates. Section C contains a listing of noncovered services.

SUMMARY DESCRIPTION OF BENEFITS

A.       Covered Services included in the Capitation Payment

1.
Hospital Inpatient Care (acute care hospitals) - Medically necessary
and medically appropriate hospital inpatient acute care, procedures,
and services, as authorized by the responsible physician(s) or dentist,
and covered under Department of Social Services (DSS) policies and regulations.
The responsibilities of the MCO and the BHP for inpatient care are outlined in
detail in Appendix N. In general, the MCO is responsible for inpatient hospital
care when the medical diagnosis is primary.

a.
Administratively Necessary Days (AMDs) are covered when a nursing home placement
delay is due to unavailability of beds. However, a patient is required to accept
the first available, medically appropriate bed.

b.
Organ transplants are covered if they are of demonstrated therapeutic value,
medically necessary and medically appropriate, and likely to result in the
prolongation and the improvement in the quality of life of the applicant. The
DEPARTMENT has developed, and continues to develop, medical criteria relating to
particular organ transplant procedures. These criteria are available for use by
health plans. The criteria are guidelines. However, a final decision to deny a
transplant request is not to be rendered without considering the medical
opinion of a qualified organ transplantation expert(s) in the community.

2.
Chronic Disease Hospital Inpatient Care - Such medically necessary
care, procedures, and services as covered under DSS policy and regulation.

3.
Nursing Facility (Skilled Nursing and Intermediate Care) Inpatient Care - Such
medically necessary care is covered while the patient remains in a managed care
coverage group.

4.
Intermediate Care Facility (Mentally Retarded) Inpatient Care - Such medically
necessary care is covered while the patient remains in a managed care coverage
group.

5.
Christian Science Sanitoria Service - Such medically necessary care is covered
while the patient remains in a managed care coverage group.

 
.

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Appendix A- MCO Contract
 
05/07

 
6.
Hospital Outpatient Care (General Hospital,, and Chronic Disease Hospital and
freestanding Medical/Primary Care Clinics) - Preventive, diagnostic,
therapeutic, rehabilitative, or palliative medical services provided to an
outpatient by or under the direction of a physician or dentist in a licensed
hospital facility. Section 3.17 and Appendix N outline the responsibilities of
the MCO and the CT BHP. The MCO is responsible for coverage for all primary care
and other medical services at hospital outpatient clinics, regardless of
diagnosis and including all medical specialty and ancillary services. The MCO
will maintain responsibility for primary care and other medical services
provided by freestanding clinics, regardless of diagnosis.

7.
Physician Services - Primary and specialty services provided by a licensed
physician or doctor of osteopathy and performed within the scope of practice of
medicine or osteopathy as defined by State law. As outlined in Section 3.17 and
Appendix N, the MCO retains responsibility for all primary care services and
charges regardless of diagnosis.

8.
Nurse-Midwifery Services - Services provided by a licensed,
certified nurse-midwife that are related to the care, and to the management of
the care, of essentially normal mothers and newborns (only throughout
the maternity cycle) and well woman gynecological care, including
family planning services.

9.
Nurse Practitioner Services - Services that are provided by a licensed Advanced
Practice Registered Nurse (APRN) and that are within his or her scope of
practice as defined by State law.

10.
Chiropractor Services - Manual manipulation of the spine performed by a licensed
chiropractor within the scope of chiropractic practice. Noncovered services:

a.
Prescription or administration of any medicine or drug or the performance of any
surgery;

b.      X-rays furnished by a chiropractor.

c.
Manipulation of other parts of the body (e.g., shoulder, arm, knee, etc.) even
when for subluxation of the spine; and

d.      Lab work ordered by a chiropractor.

e.
Chiropractor services provided by independently enrolled chiropractors for
individuals who are 21 years of age or older.

 
11.
 
Naturopathic Services - Services provided by a licensed naturopath that conform
to accepted methods of diagnosis and treatment and that are within the scope of
naturopathic practice.

 
Naturopathic services provided by independently enrolled naturopaths are not
covered for individuals who are 21 years of age or older.

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12.
Podiatrist Services - Services provided by a licensed podiatrist that conform to
accepted methods of diagnosis and treatment and that are within the scope of
podiatric practice.

a.      Limitations of Coverage

 
i.    Orthotic and/or corrective arch supports for recipients under five years
of age; and

 
ii.   Orthotic and/or corrective arch supports only once every two (2) years.

b.      Noncovered Services

i.   Services of assistants at surgery;

 
ii.   Simplified tests requiring minimal time or equipment and employing
materials nominal in cost such as Clinitest, testape, Hematest, Bumintest,
Dextrostix, nonphotolitric hemogloblin, etc.;

iii.
Simple foot hygiene; and

 
iv. Repairs to devices judged to be necessitated by willful or malicious abuse
on the part of the patient.

 
v.   Podiatrist services provided by independently enrolled podiatrists are not
covered for individuals who are 21 years of age or older.

13.
Laboratory Services - Laboratory services: a) ordered by a duly
licensed physician or other licensed practitioner of the healing arts; and
b) performed in a laboratory that is certified according to the
applicable provisions of the Clinical Laboratory Improvement Amendments of
1988 (CLIA) and meets all applicable licensing, accreditation and
certification requirements for the specific services and procedures it provides.
The MCO maintains coverage responsibilities for ancillary services such
as laboratory, regardless of diagnosis.

14.
Outpatient Medical Rehabilitation Services - Medically necessary and medically
appropriate outpatient rehabilitation services provided by a licensed or
certified practitioner. Such services include: physical therapy, occupational
therapy, speech therapy, audiology, inhalation therapy, social services,
psychological services, traumatic brain injury (T.B.I.) day treatment,
neuropsychological evaluation, electronystagmography, and early childhood
intervention services.

a.  Limitations include:

 
i.   Sheltered workshop services for individuals who are primarily
developmentally disabled are covered only if their need for this type of program
stems from an etiology readily identifiable as medical or psychological in
origin;

 
ii.   T.B.I, treatment programs are limited to individuals who have sustained
injury from interaction of any external forces resulting in

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Appendix A - MCO Contract
05/07

the central nervous system (brain) dysfunctions. Developmental impairment
primarily contributing to brain dysfunction is not included. The impairment must
be readily identifiable as having been sustained through injury;

 
iii. The T.B.I, program is primarily a medical rehabilitation program, however,
vocational, social, and educational services may be covered only when these
services are: a) related to the individual's injury, b) are reasonable and
necessary for the diagnosis or treatment of the injury, and c) are a part of the
recipient's written individual plan of care; and

 
iv. Programs relating to the learning of basic living skills, or other
activities of daily living, are limited to individuals who have lost or had
impaired functions of daily living and require retraining to maximize
restoration of these skills.

b.  Noncovered Services include:

i.   Services that are related solely to specific employment opportunities, work
skills, work settings, and/or academic skills and are not reasonable or
necessary for the diagnosis or treatment of an illness or injury;

 
ii.   Speech services involving nondiagnostic, nontherapeutic, routine,
repetitive, and reinforced procedures or services for the patient's general good
and welfare; and

 
iii. Services ordinarily covered are not covered if an individual's expected
restoration potential would be insignificant in relation to the extent and
duration of rehabilitation services required to achieve such potential.

 
iv. Services provided by independently enrolled physical therapists,
audiologists and speech pathologists for individuals who are 21 years of age or
older.

15.      Vision Care - Services performed by a licensed ophthalmologist,
optometrist, or optician that conform to accepted methods of diagnosis and
treatment.

a.  Limitations of Coverage

 
i.    Contact lenses are covered when such lenses provide better management of a
visual or ocular condition than can be achieved with spectacle lenses,
including, but not limited to the diagnosis of Unilateral Aphakia, Keratoconus,
Corneal Transplant, and High Anisometropia;

 
ii.   Prescription sunglasses are covered when light sensitivity that will
hinder driving or seriously handicap the outdoor activity of a patient is
evident;

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Appendix A- MCO Contract 05/07

 
iii. Trifocals are covered when the patient has a special need due to job
training program or extenuating circumstances;

 
iv. Extended wear contact lenses are covered for aphakia and for members whose
coordination or physical condition make daily usage of contact lenses
impossible;

 
v. Oversize lens are covered only when needed for physiological reasons, and not
for cosmetic reasons; and

vi.
 A spare pair of eyeglasses is not covered.

16. 
Dental Care - Services performed by a licensed dentist or dental hygienist that
conform to accepted methods of diagnosis and treatment.

a. The categories of covered services are as follows:

 
1). Diagnostic Services are the procedures needed to diagnose the oral
condition.

      a). Radiographs:
i     Full mouth series or panoramic radiograph;
ii    Bitewing films and
iii   Periapical films,
 
b) Oral examinations:
i.   Initial comprehensive oral examination, which includes a complete
evaluation including medical history;
ii.   Periodic oral exams and
iii. Emergency oral examination.

 
2). Preventive Services are the procedures used to help avoid oral disease.

a)   Prophylaxis;
b)   Fluoride treatment for children under 21;
c)   Sealants for adult (secondary) teeth;
d)   Space maintainers and
e)   Night guards.

 
3). Restorative Services are the procedures performed to remove disease or
repair broken teeth.

a)      Amalgam (silver) fillings;
b)      Composite (white) fillings and
c)      Crowns.

 
4). Endodontic Services are the procedures used to treat infections or repair
trauma that has reached deep into the tooth structure.

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05/07
 
a)      Pulpotomy in primary teeth;
b)      Root canal therapy in adult teeth;
c)      Apicoectomy in adult teeth and
d)      Apexification in adult teeth

 
5). Periodontal Services are those procedures used to treat diseases of he
gingival (gum) and supporting structures (periodontal ligament and bone) of the
teeth.

a)      Gingivectomy and

b)      Gingivoplasty.

 
6). Prosthodontic Services are the procedures used to repair teeth when a great
deal of tooth structure is lost due to disease or trauma or and/replaces missing
teeth.

a)      Crowns;
b)      Removable complete upper and/or lower dentures and
c)      Removable partial upper and or lower dentures.

 
7). Oral Surgery is the surgical and non surgical procedures used to restore the
health of the mouth and surrounding structures.

a)      Edxoodontia (extractions);
b)      Biopsy;
c)      Lesion and tissue removal
d)      Surgery for trauma, and e.Fracture reduction

 
8). Orthodontics are the procedures used to realign teeth in the proper position
when the teeth are determined to be in a severe handicapping malocclusion.

 
a) Active treatment may extend up to but not exceeding thirty months per
recipient.

 
9). Miscellaneous Services are procedures required for oral care utilized in
conjunction with dental services.

a)
Patient Management - in connection with dental services to individuals with
cognitive disabilities as determined by the Department of Mental Retardation.

b)      General Surgical Anesthesia;
c)      Home visits.
 
b.
The categories of Program Limitations are as follows:
 
1). Diagnostic Services:

 
 

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Appendix A - MCO Contract 05/07

a). Radiographs:

i. 
Full mouth series or panoramic radiograph once every three years;

ii.   Bitewing films once every six months;

iii.
Periapical films the single first film is not    covered on the same date of
service as bitewings, panoramic, or lateral jaw films.

b). Oral examinations:

i. 
Initial oral complete examination includes a complete history workup and is
limited to one time per patient per three year (3) period;

ii.
Periodic oral exams once six months after the initial oral exam and every six
months thereafter;

 
iii. Emergency oral examination.
 
2). Preventive Services:
 
a)      Prophylaxis once every six months;

 
i.     Prophylaxis includes supra and sub gingival scaling and polishing by
rotary, ultrasonic or other mechanical means as described as standard procedure
by the American Dental Association.

 
ii.   "Toothbrush" prophylaxis is not a Medicaid covered procedure in children
over 48 months of age.

b)
Fluoride treatment for children under 21 every six months (prior authorization
is required for members over 21 years of age);

c)
Sealants for adult (secondary) teeth for all molar teeth and for premolar teeth
on children who are at moderate or severe risk for caries as assessed by the
Caries Assesment Tool. A sealant may be placed from ages 5 through 16, only one
time in a five year period per tooth.

d)      Space maintainers cannot be unilateral and removable in form.
 
e)      Occlusal guards. 
 
3). Restorative Services:

a)
Amalgam and composite fillings are limited to one per year to the same surface
per tooth by the same provider unless prior authorization is obtained.

b)
More than one amalgam filling on a single surface will be considered a single
filling. Anterior or composite fillings involving more than one surface will be
considered as a single

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Appendix A - MCO Contract 05/07

filling. Only those fillings involving the incisal corner will be considered a
two filling procedure.

c) 
Crowns may be used only in those cases where the breakdown of tooth structure is
excessive or root canal therapy has been performed. Suitable types of crowns
include:

 
i.   Stainless steel, may be used for deciduous or permanent, anterior or
posterior teeth.

 
ii.   Preformed plastic may be used on anterior deciduous or permanent teeth.

iii. Acrylic or porcelain veneer, permanent anterior teeth only

iv. Porcelin fused to metal on permanent teeth only.

4). Endodontic Services:

a)
Performed in anterior upper and lower six teeth only when the retention of the
tooth in site is necessary to maintain the integrity of the dentition and when
the prognosis is favorable.

b)
Performed in the eight posterior teeth only in cases where there is a full
dentition or when the tooth is the only source for an abutment tooth or the
integrity of the bite would be seriously affected.

c)
Apexification does not include root canal treatment but includes all visits to
complete the service.

5). Periodontal Services:
 
a)      Limited to givoplasty and
b)      Limited to givectomy. 
 
6). Prosthodontic Services:
 
a)      Crowns (refer to Section 3b Restorative, Crowns);

b)
Removable complete upper and/or lower dentures will be approved if the patient
can tolerate and is expected to use them on a daily basis.

c)
Removable partial upper and/or lower dentures will be approved if the patient
can tolerate them and is expected to use them on a daily basis. There must less
than eight posterior teeth in occlusion with missing anterior teeth.

d)
Replacement of existing complete or partial dentures, may be reconstructed in
any five (5) year period. Prior authorization must be requested with a
documented need of medical necessity if the removable complete or partial
denture(s) must be remade or replaced for any reason within the date of
delivery of the initial prosthesis.

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Appendix A - MCO Contract 05/07

e)
Relining or rebasing of existing complete or partial dentures may be performed
one time in a two year period.

f)
Denture labeling may be performed for patients residing in long term care
facilities.

7).  Oral Surgery:

a)
Suturing of lacerations of the mouth is covered in accident cases only and not
cases incidental to and connected with dental surgery.

b)
The following services are not covered unless the procedure is used in
conjunction with orthodontic therapy:

 
i.    Uncovering of impacted or un-erupted teeth for orthodontic reasons;

 
ii.   Ostoplasty/osteotomy of facial bones for midface hypoplasia or mandibular
progngaathism without bone graft.

c)
Reimplantation of an avulsed anterior tooth may not be billed in conjunction
with root canal therapy on the same tooth.

d)
Bone grafts of the mandible are restricted to the replacement of bone previously
removed by a radical surgical procedure.

8). Orthodontics:

a)
In cases where a severe handicapping malocclussion exists under the Early
Periodic Screening, Diagnosis and Treatment (EPSDT) and is limited to recipients
under the age of 21.

 
i.    Services must be rendered by providers who are qualified by Section 184.B
in regulations.

b)
Screening may be performed one time per provider for the same recipient

c)
Consultation may be performed one time per provider for the same recipient;

d)      Diagnostic Assessment:

 
i.    Preliminary casts/study models one time per provider per recipient;

 
ii.   Comprehensive casts/study models one time per provider per recipient.

e)      Appliance:

i.    Initial appliance is limited to one per provider per recipient;

 
ii.   Retainer appliance is limited to one replacement per dental arch for each
recipient regardless of the reason.

9). Miscellaneous Services

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Appendix A - MCO Contract 05/07

a)
Services covered under Husky are limited to the Department's fee schedule, which
can be found on www.ctmedicalprogram.com;

b)
Patient management - in conjunction with dental services when the provider has
documented the specific diagnosis in the patient's chart. A diagnosis of
moderate, severe, or profound mental retardation will satisfy the diagnosis
requirement.

i.   The provider's record of the patient must contain the
signature of the physician or a professional staff member of the Department of
Mental Retardation attesting to the authority of the diagnosis.

c. 
 The categories of dental services that have noncovered procedures are as
follows:

 
1)      Preventive Services:
i.    Unilateral Removable Appliances.
2)      Restorative Services:
i.    Cosmetic dentistry;
ii.   Unilateral Removable Appliances;
iii. Procedures to teeth nearing exfoliation (ready to fall out).
3)      Periodontal Services:
i.   Any surgical periodontal procedure; ii.   Any non surgical periodontal
therapies; iii. Scaling and root planning.
 
4)
Prosthodontic Services: 

i.   Cosmetic dentistry;
ii.Dentures (partial) where there are more than 8 posterior teeth in occlusion
and no missing anterior teeth;
iii. Fixed Partial Dentures (Bridges);
iv. Implants and associated abutments and /or attachments;
iv. Implant sustained crowns;
v. Office visits to obtain a prescription where the need for such prescription
has already been ascertained and
vi. Unilateral removable appliances.
5)      Oral Surgical Services:
i.   Alveoplasty in conjunction with extraction (s);
ii.   Cosmetic surgery;

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Appendix A - MCO Contract 05/07
iii. I.V. Sedation (conscious sedation);
iv. Implant placement;
v.   Nitrous Oxide (inhalation conscious sedation);
vi. Vestibuloplasty.
 
6) Miscellaneous:
 
i.    Broken or cancelled appointments;
 
17.
Durable Medical Equipment - equipment that: 

a   Can stand repeated use;
b   Is primarily and customarily used to serve a medical purpose;
c   Is generally not useful to a person in the absence of an illness or injury;
and
d   Excludes items that are disposable.

Equipment covered includes: wheelchairs and accessories, walking aids, bathroom
equipment (e.g., commode and safety equipment), hospital beds and accessories,
inhalation therapy equipment (e.g., IPPR machines, suction machines, nebulizers,
and related equipment), enteral/parenteral therapy equipment, and the repair and
replacement of durable medical equipment (DME) and related equipment.

18.
Orthotic and Prosthetic Devices - Mechanical appliances and devices for the
purpose of providing artificial replacement of missing parts, and/or prevention
or correction of disorders in involving physical deformities and impairments.

a.
Devices covered include: braces, corsets, collars, arch supports, footplates,
orthopedic shoes, orthopedic prostheses, hearing aids (including batteries,
earmolds, and cords).

b.
Limitations: i) orthotic and/or corrective arch supports are not provided for
recipients under five years of age; ii) Metatarsus Adductus Shoes are limited to
a congenital metatarsus adductus condition and are limited to children through
age four as medically necessary.

19.
Oxygen Therapy - oxygen, equipment, supplies, and services related to the
delivery of oxygen.

20.
Respiratory Therapy - services include: intermittent positive
pressure breathing, ultrasonography, aerosol, sputum induction, percussion
and postural drainage, arterial puncture, and withdrawal of blood for diagnosis.

21.
Dialysis - hemodialysis and peritoneal dialysis services are covered, including
the treatment of end stage renal disease.

22.
School-Based Clinics - services provided at a facility: a) located on
the grounds of a public school; b) serving enrolled recipients on a scheduled

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Appendix A - MCO Contract 05/07

basis or for an emergency situation; and c) licensed as an outpatient medical
facility to provide comprehensive care.

a.
Covered services include: health assessments; family planning services;
diagnosis and/or treatment of illness or injuries; laboratory testing (performed
by the School-Based Health Clinic); follow-up visits; EPSDT services; one-on-
one health education, medical social work services, and nutritional counseling;.
The MCO is responsible for primary care services provided by school-based
clinics, regardless of diagnosis, except for services described in Appendix N.

b.
Noncovered services include: mandated school health screenings, simple
intervention of a health problem such as nonmedical personnel could render,
visits where the presenting health problem does not require a health or mental
health assessment/evaluation, visits for the sole purpose of administering or
monitoring medications, services that are not part of the written individual
plan of care.

23.
Family Planning and Abortion - medically approved diagnostic
procedures, treatment, counseling, drugs, supplies, or devices that are
prescribed or furnished by a provider to individuals of child bearing age for
the purpose of enabling such individuals to freely determine the number and
spacing of their children.
 
Noncovered services include: a) sterilizations for patients who are under age
twenty-one (21), mentally incompetent, or institutionalized; and b)
hysterectomies performed solely for the purpose of rendering an individual
permanently incapable of reproducing.

 
24.
Ambulatory Surgery - Services include preoperative examinations, operating and
recovery room services, and all required drugs and medicine.

25.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
(HealthTrack Services)- Comprehensive child health care services to recipients
under twenty-one (21) years of age, including all medically necessary
prevention, screening, diagnosis, and treatment services listed in Section
1905(r) of the Social Security Act.

EPSDT Covered Services are described below:

a.  
Initial and Periodic Comprehensive Health Screenings - includes the following
services provided at the intervals recommended in the Periodicity Schedule
consistent with the standards of the American Academy of Pediatrics and Center
for Disease Control:

 
i.   A comprehensive health and developmental history, including physical and
nutritional assessments and mental health development screening;

ii.   A comprehensive unclothed physical examination;

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Appendix A - MCO Contract 05/07

 
iii. Appropriate immunizations according to age and health history, unless
medically contraindicated at the time;

 
iv. Appropriate laboratory tests (including blood lead level assessments
appropriate for age and risk factors);

 
v.   Health education (including anticipatory guidance and risk assessment);

vi. Diagnosis and treatment of problems found during the screening;

vii. Vision screenings - an objective vision screening is indicated beginning at
three years of age as indicated in accordance with the Periodicity Schedule;

 
viii. Hearing screenings - an objective hearing screening is indicated beginning
at four years of age according to the Periodicity Schedule; and

 
ix. Dental screenings are recommended in the Periodicity Schedule, for example,
an initial direct referral to a dentist beginning at age two.

b.
Dental Services - includes those dental services provided by or under the
direction of a dentist, in addition to the dental screening, that
are recommended in the Periodicity Schedule. Dental services also include relief
of pain and infections, restoration of teeth, and maintenance of dental health.

c.
Administration and Medical Interpretation of Developmental Tests - objective
standardized tests, recognized by the Connecticut Birth-To- Three Council, for
further diagnosis and treatment of problems found during a periodic
comprehensive health screen or interperiodic encounter. Such tests include, but
are not limited to, the Battelle, the Mullen, and the Bayley.

d.
Case Management Services - The following services are determined to be necessary
when a child evidences a need for such services as a result of a periodic
comprehensive health screening or interperiodic encounter:

 
i.    Initial case management assessment and periodic reassessment, including
development of the plan of services and revision as necessary.

ii.   Ongoing case management, including, at a minimum:

 
A) Assistance in implementing the plan of services, which includes: facilitating
referrals, providing assistance in scheduling needed health or health-related
services, and helping to identify and link with the child's health and social
service providers. Particularly, the case management provider shall identify the
child's health

 

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Appendix A - MCO Contract 05/07

home or, if necessary, participate in linking the child with a quality health
home, and encourage continuity of care;

B)
Monitoring the delivery of and facilitating access to a periodic comprehensive
health screening at the intervals recommended in the Periodicity Schedule, and
other screening, diagnosis, and treatment services. Such activities also include
follow-up on missed appointments, and, if necessary, assistance with arranging
medical transportation, child care, and interpreter services;

C)
Coordinating and integrating the plan of services, as necessary, through direct
or collateral contacts with the family and members of their team of direct
service providers, as appropriate;

D)
Monitoring the quality and quantity of needed services that are being provided,
and evaluating outcomes and assessing future needs which might support changes
in the plan of services, including completing a quarterly progress note;

E)
Providing health education, as needed, and in coordinating with a direct service
provider, interpreting and reinforcing the service provider's recommendations
for the health of the child; and

F)
Providing client advocacy to ensure the smooth flow of information between the
child, the child's representative, providers, and agencies, to minimize conflict
between service providers, and to mobilize resources to obtain needed services.

e.  Interperiodic Encounters

 
i.   An encounter or visit to determine if there is a problem, or to treat a
problem that was not evident at the time of the regularly scheduled periodic
comprehensive screening but needs to be addressed before the next periodic
comprehensive screening;

 
ii.   Any screening, in addition to the screenings recommended in the
Periodicity Schedule, to determine the existence of suspected physical, mental,
or developmental conditions;

iii.
An encounter or follow-up visit in the case of a child whose physical, mental,
or developmental illness or condition has already been diagnosed prior to the
child being Medicaid eligible (e.g., a pre- existing condition), but needs to be
addressed before the next scheduled screening interval recommended in the
Periodicity Schedule, if there are indications that the illness or condition may
have become more severe or changed sufficiently so that further examination is
medically necessary; and

 
iv.  An encounter necessary to provide immunizations, vision, and/or hearing
screenings (e.g., which had been deemed medically

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Appendix A - MCO Contract 05/07

contraindicated at the time of the periodic comprehensive health screening).

f.
Personal Care Services - services for a child who has a diagnosed disability and
is judged to be able to benefit from one (1) or more personal care service
activities as the result of a periodic comprehensive health screen or
interperiodic encounter performed by a primary care provider.

 
i. Covered personal care services include all tasks to assist a child with major
life activities of self-care and instrumental activities as identified in the
personal care services plan of care:

A)
Covered major life activities include, but are not limited to, dressing,
bathing, eating, and personal health care maintenance; and

B)
Covered instrumental activities include, but are not limited to, cooking,
cleaning, travel, and shopping.

ii.   The following services are not covered:

A)
Personal care services provided to an individual who does not reside at home;

B)           Personal care services provided by a family member;

C)
Home health services which duplicate personal care services (e.g., home health
aide services are not covered when personal care services are appropriate);

D)
Transportation of the personal attendant to and from the child's home to provide
services;

E)
Acute health care services that are covered under other DSS regulations;

F)
Personal care services when the child is eligible for or receiving comparable
services from another agency or program; and

G)
Personal care services for the care or assistance that would routinely be given
to a child in the absence of a disability.

g.
EPSDT Special Services - other medically necessary and medically appropriate
health care, diagnostic services, treatment, or other measures necessary to
correct or ameliorate disabilities and physical and mental illnesses and
conditions discovered as a result of a periodic comprehensive health screening
or interperiodic encounter, whether or not the good or service is included in
the Connecticut Medicaid Program State Plan as a good or service available to
all other Medicaid recipients. Such services include, but are not limited
to, medically necessary and medically appropriate over-the-counter drugs and
personal care services.

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Appendix A - MCO Contract 05/07

h.
All medically necessary diagnosis and treatment services available to all
Medicaid recipients under the Connecticut Medical Assistance Program.

26.
Diagnostic Services - Medical procedures (e.g., radiology, cardiology, EEC, and
ultrasound procedures) or supplies recommended by a physician or other licensed
practitioner of the healing arts, within the scope of his/her practice under
State law, to enable the identification of the existence, nature, or extent of
illness, injury, or other health deviation. The MCO retains the
responsibility for ancillary services such as radiology, regardless of diagnosis

27.
Home Health Care - Medically necessary home health services ordered by the
licensed practitioner and provided by a licensed home health agency on
a part-time or intermittent basis to members who reside at home, as defined
by Departmental policy, for the purpose of enabling the patient to remain
at home or to provide a less costly alternative to institutional care. The MCO
and BHP share responsibilities for home health services, as outlined in
Section 3.17 and Appendix N. In general, the MCO must provide home
health services for the treatment of medical diagnoses alone, and when a client
has both medical and behavioral diagnosis, but the medical diagnosis is primary.

28
 
Mental Health/Substance Abuse Services - As outlined in Section 3.17 and
Appendix N, the BHP assumes coverage responsibility for most behavioral health
services. The MCO retains responsibility for all primary care services and
associated changes, regardless of diagnosis. This includes, but is not limited
to behavioral health prevention and screening.

29.      Medical Transportation Services
 
a.
Emergency and Nonemergency Ambulance Service is covered when: 
 
i    The patient's condition requires medical attention during transit; or

 
ii The patient's diagnosis indicates that the patient's condition might
deteriorate in transit to the point where medical attention would be needed; or

iii   The patient's condition requires hand and/or feet restraints; or iv  The
ambulance is responding to an emergency; or

 
v .  No alternative less expensive means of transportation is available.
Ambulance trips to an emergency room, regardless of the outcome, nor ambulance
trips in response to a 911 call, cannot be subject to prior authorization. The
MCO is responsible for emergency medical transportation regardless of diagnosis.
Hospital to hospital transportation of members with a medical condition is also
covered.

b.
Air Transportation - when a medical condition or time constraint dictates its
use.

c.
Critical Care Helicopter - when a medical condition or time constraint dictates
its use.

 

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Appendix A - MCO Contract 05/07

d.
Other Nonambulance Transportation [Livery, Wheelchair van, Commercial Carrier,
Taxi, Private Transportation, Service bus - when needed to obtain necessary
medical services covered by Medicaid including behavioral health services, and
when it is not available from volunteer organizations, other agencies, personal
resources, etc. To administer this benefit, DSS currently employs the following
limitations on services:

i.    Requirement of prior authorization;

 
 ii.   Requirement of the use of the nearest appropriate provider of medical
services when a determination has been made that traveling further distances
provides no medical benefit to the patient; and

.
iii.   Requirement of the use of the least expensive appropriate method of
transportation, depending on the availability of the service and the physical
and medical circumstances of the patient.

e.
Transportation for relatives, guardians, or foster parents of a
Medicaid recipient - only under the following circumstances:

 
i.   The person needs to be present at and during the medical service being
provided to the patient (for example, in parent/child situations); and

 
ii. The person needs to be trained by hospital staff to provide unpaid health
care in the home to the patient, and without this health care being provided the
patient would not be able to return home.

 
iii. Children under twelve (12) years of age shall be escorted to medical
appointments. Either the child's parent, foster parent, caretaker, legal
guardian or the Department of Children and Families (DCF), as appropriate, shall
be responsible for providing the escort.

 
iv. For children between the ages of twelve (12) to fifteen (15) years, a
consent form signed by a parent, caretaker or guardian shall be required in
order for a child to be transported without parental consent as specified by
state statute (i.e., for family planning and mental health treatment).

For children sixteen (16) years or older, no consent form shall be required.

f.
The MCO is not responsible for transportation to non-Medicaid services such as
respite or DCF services that are designed to be provided at the client's
location, such as home.

g.
Out-of-State Transportation Services - when out-of-state- medical services are
needed because of the following:

i.   A medical emergency;
 

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Appendix A - MCO Contract 05/07

 
ii.  The patient's health would be endangered if required to travel to
Connecticut; and

iii. Needed medical services are not available in Connecticut.

 
30.      Medical Surgical Supplies - those items that are prescribed by a
physician to meet the needs or requirements of a specific medical and/or
surgical treatment. They are generally disposable and not reusable.

 
a.  Covered services include: gauze pads, surgical dressing material, splints,
tracheotomy tube, diabetic supplies, elastic hosiery, sterile gloves,
incontinence supplies, thermometers, blood pressure kit (aneroid type including
stethoscope, but limited to use in the home for patient's diagnosed to have
complicated cardiac conditions and labile hypertension), enteral/parenteral
feeding therapy supplies including solutions and manufacturing materials,

b. Items considered first aid supplies such as, bandages, solutions, vaseline,
etc., are not covered services.

34.      Pharmacy Services
 
a.      Covered services

 
i.    Drugs prescribed by a licensed authorized practitioner. The MCO maintains
responsibility for all pharmacy services and associated charges, regardless of
diagnosis The MCO may use a prescription drug formulary as is described in
Section 3.15, Pharmacy Access of the contract. CT BMP providers are required to
follow the MCO's pharmacy program requirements

 
ii. Over-The-Counter (OTC) Drugs on the State of Connecticut's OTC Formulary,
including liquid generic antacids, birth control products, calcium preparations,
diabetic-related products, electrolyte replacement products, heratinics,
nutritional supplements and vitamins (prenatal, pediatric, high potency).

b.      Noncovered Services

 
i. Drugs included in the Food and Drug Administration's Drug Efficacy Study
Implementation Program;

ii.   Alcoholic liquors;
iii. Items used for personal care and hygiene or cosmetic purposes;
iv. Drugs solely used to promote fertility;

 
v. Drugs not directly related to the patient's diagnosis, when diagnosis is
required by the DEPARTMENT to be written on the prescription;

 
vi. Any vaccines and/or biologicals which can be obtained free of charge
from   the CT. State Department of Health Services. The DEPARTMENT will notify
pharmacists of such vaccines or biologicals;

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Appendix A - MCO Contract 05/07

 
vii. Any drugs used in the treatment of obesity unless caused by a medical
condition;

 
viii. Controlled substances dispensed to HUSKY members that are in excess of the
product manufacturer's recommendation for safe and effective use for which there
is no documentation of medical justification in the pharmacy's file; and,

ix. Drugs used to promote smoking cessation.

x.   Drugs used to treat sexual or erectile dysfunction,

35.
Emergency Services - such inpatient and outpatient services in and out of the
health plan's service area are covered services. As described in Section 3.05
and Appendix N, in general, the MCO maintains coverage responsibility for
emergency department services, including emergent and urgent visits and al
associated charges, regardless of diagnosis.

36.
Dental Hygienist Services - Services that are provided by a licensed dental
hygienist and that are within his or her scope of practice as defined by State
Law.

B.           Covered Services Not Included In the Capitation Payment

1.
School-Based Child Health Services - Medically necessary special education
related diagnostic and treatment services provided to children by or on behalf
of school districts pursuant to the Individuals with Disabilities Education Act
(IDEA) and Connecticut General Statutes (CGS). Diagnostic services must be
ordered by a Planning and Placement Team and treatment services must be
prescribed in a child's Individualized Education Program (lEP)--and verified by
a physician's signature.

2.
Connecticut Birth to Three Program Services - The Connecticut Birth to Three
Program, pursuant to the Individuals with Disabilities Education Act (IDEA ) and
Connecticut General Statutes (CGS), provides a range of early intervention
services for eligible children from birth to three years of age with
developmental delays and disabilities. Eligibility of children is determined by
Department of Mental Retardation (DMR) staff or entities with which DMR
contracts. Services are authorized in an Individualized Family Service Plan
(IFSP) and verified by a physician's signature.

3.
All Medicaid covered behavioral health and behavioral health related services
described, Appendix N, and the HUSKY contract, are the responsibility of the
BHP.

C.           Noncovered Services

 
1.        Institutions for Mental Disease (IMD) - The federal definition of an
IMD is a hospital, nursing facility, freestanding alcohol treatment center, or
other institution of more than sixteen (16) beds that is primarily engaged in
providing diagnosis, treatment, or care of persons with mental diseases.

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Appendix A - MCO Contract 05/07

a.
IMD Exclusion - Medicaid does not cover IMD services (i.e., these services are
excluded). States, rather than the Federal Government, have principle
responsibility for funding inpatient psychiatric services; therefore, State
funding of IMD)s is not through the Medicaid program.

b.
Exceptions - certain individuals are not part of the IMD exclusion (i.e.,
they are covered by Medicaid for services in IMDs):

i.    inpatient psychiatric services for individuals under age 21;

 
ii.   individuals 65 years of age or older who are in hospitals or nursing
facilities that are IMDs.

2.
Services and/or procedures considered to be of an unproven, experimental, or
research nature or cosmetic, social, habilitative, vocational, recreational, or
educational.

3.
Services in excess of those deemed medically necessary to treat the patient's
condition.

4.
Services not directly related to the patient's diagnosis, symptoms, or medical
history.

5.
Any services or items furnished for which the provider does not usually charge.

6.
Medical services or procedures in the treatment of obesity, including gastric
stapling. When obesity is caused by an illness (hypothyroidism, Cushing's
disease, hypothalamic lesions) or aggravates an illness (cardiac and respiratory
diseases, diabetes, hypertension) services in connection with the treatment of
obesity could be covered services.

7.
Services related to transsexual surgery or for a procedure which is performed as
part of the process of preparing an individual for transsexual surgery, such as
hormone therapy and electrolysis.

8.           Services for a condition that is not medical in nature.

9.
Routine physical examinations requested by third parties, such as employers or
insurance companies.

10.
Drugs that the Food and Drug Administration (FDA) has proposed to withdraw from
the market in a notice of opportunity for hearing.

11.           Tattooing or tattoo removal.
 
12.           Punch graft hair transplants.
 
13.           Tuboplasty and sterilization reversal.
 
14.           Implantation of nuclear-powered pacemaker.
 
15.           Nuclear powered pacemakers.
 
16.           Inpatient charges related to autopsy.

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

Appendix A - MCO Contract 05/07

17.
All services or procedures of a plastic or cosmetic nature performed
for reconstructive purposes, including but not limited to lipectomy,
hair transplant, rhinoplasty, dermabrasion, and chernabrasion.

18.           Drugs solely used to promote fertility.

19.           Drugs used to promote smoking cessation.

20.
Services that are not within the scope of a practitioner's practice under state
law.

21.           Drugs used to treat sexual or erectile dysfunction,
 
 

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

Appendix A - MCO Contract

MEDICAL ASSISTANCE PROGRAM POLICIES AND REGULATIONS BY PROVIDER AREA
 
Provider Area
Policy or Regulation Sections
Birth to Three
Sections 1 7b-262-597 through 17b-262-605 of the Regulations of Connecticut
State Agencies
Case Management Services to Persons Under 21
Proposed Regulations
Chiropractic Services
Sections 1 7b-262-535 through 17b-262-545 of the Regulations of Connecticut
State Agencies
Clinics
Sections 171 through 171 B. XI of Medical Services Policy and Sections 1 7-1
34d-7 through 17-134d-8, 17-134d-56 and 17-134d-70 through 17-134d-78 of the
Regulations of Connecticut State Agencies
Rehabilitation Clinics
Sections 171.2 through 171.2l.lll.k.of Medical Services Policy
Dental Clinics
Sections 171 .3 through 171.3l.lll.f. of Medical Services Policy
Medical Clinics
Sections 171 .4 through 171.4I.IIU. of Medical Services Policy
Dental Services
Sections 184 through 184l.lll.h. of Medical Services Policy and Section 1 7-1
34d-35 of the Regulations of Connecticut State Agencies
Dialysis
Sections 17b-262-651 through 17b-262-660 of the Regulations of Connecticut State
Agencies
Early and Periodic Screening, Diagnostic and Treatment Services (Health Track
Services)
Included in Regulations with Other Providers
Family Planning, Abortions and Hysterectomies
Sections 173 through 1731. of Medical Services Policy
Home Health Services
Sections 185 through 1851. III. b.4. of Medical Services Policy and Sections
17-134d-37, 17»134d-48, 17-134d-60, 17-134d-62 and 17b-262-1 through 17b-262-9
of the Regulations of Connecticut State Agencies

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

05/07

Appendix A - MCO Contract

Hospital Inpatient Services
Sections 150.1 through 150.1I.VI.d of Medical Services Policy and Sections
19a-630, 17b-225, 1 7b-238 through 17b-247, 17b-262, 19-1 3D, 19a-490 through
19a-493, 19a-495 of the Regulations of Connecticut State Agencies
Hospital Outpatient Services
Sections 150.2 through 150.2J.V.n of Medical Services Policy and Sections
4-67c(fees), 17-311 (payments), 17-312 (payments), 19a-490 (licensing), 19a-493
(licensing) of the Connecticut General Statutes and Sections 19-1 3D, 17-134d-2
(Medical Care), 17-134d-40 (payments - clinic), 17-134d-63 (out-of-state
hospitals), 17-134d-86 (emergency room) of the Regulations of Connecticut State
Agencies.
Intermediate Care Facility
Sections 156 through 156l.l.b.6. of Medical Services Policy and Section
17-134d-47 of the Regulations of Connecticut State Agencies.
Independent Radiology and Ultrasound Centers
Sections 17b-262-51 2 through 17b-262-520 of the Regulations of Connecticut
State Agencies.
Independent Therapy Services
Sections 17b-262-630 through 17b-262-640 of the Regulations of Connecticut State
Agencies.
Laboratory Services
Sections 1 7b-262=641 through 17b-262-650 of the Regulations of Connecticut
State Agencies.
Medical Equipment, Devices and Supplies (MEDS)
See Below.
Medical Surgical Supplies
Sections 188 through 188J. of Medical Services Policy
Durable Medical Equipment
Sections 17b-262-672 through 17b-262-682 of Medical Services Policy
Orthotic and Prosthetic Devices
Sections 190 through 190l.iii.k. of Medical Services Policy
Oxygen Therapy
Section 196 of Medical Services Policy and 17-134d-83through 17-134d-85 of the
Regulations of Connecticut State Agencies

 
 

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

 
Appendix A - MCO Contract

05/07
 
Natureopathic Services
Sections 17b-262-547 through 17b- 262-557 of the Regulations of Connecticut
State Agencies
Nurse-Midwifery Services
Sections 17t>262-573 through 17b- 262-585 of the Regulations of Connecticut
State Agencies
Nurse Practitioner Services
Sections 17b-262-607 through 17b- 262-618 of the Regulations of Connecticut
State Agencies
Pharmacy
Sections 174 through 174H.IV.a.4. of Medical Services Policy and
Section 17-134d-81 of the Regulations of Connecticut State Agencies
Physician's Services
Sections 17b-262-337 through 17b- 262-449 of the Regulations of Connecticut
State Agencies
Podiatric Services
Sections 179 through 1791.II.b. of Medical Services Policy
Provider Participation
Sections 17b-262-522 through 17b- 262-533 of the Regulations of Connecticut
State Agencies
School Based Child Health Services
Sections 17b-262-213 through 17b- 262-224 of the Regulations of Connecticut
State Agencies
Skilled Nursing Facility
 
Sections 154 through 1541.1.b.6. of Medical Services Policy and
Sections 17-134d-46, 17-134d-68and 117- 134d-79 of the Regulations
of Connecticut State Agencies
Transportation Services
Section 17b-134d-33 of the Regulations of Connecticut State Agencies
Vision Care Services
 
Sections 17b-262-559 through 17b- 262-571 of the Regulations of Connecticut
State Agencies, DSS Policy Transmittal MS 93-18 and DSS Policy Bulletin 98-19.

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

 
 
APPENDIX B
Provider Credentialing and Enrollment Requirements

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

 
Appendix B

05/07                                                      

HUSKY 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

Credenting 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.

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

Appendix B

05/07                                                      

HUSKY PROVIDER CREDENTIALING AND ENROLLMENT 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;
HUSKY B 3 .42 "Subcontracting for Services".)

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

Appendix B

05/07                                                      

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 are used to
establish enrollment ceiling or cap (currently summarized by plan submittals of
provider tables);

b)
to provide accurate information 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.

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

  Appendix B

05/07                                                    

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.

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

Appendix B

05/07                                                      

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.

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

APPENDIX C

EPSDT Periodicity & Immunization Schedules

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

 
Appendix C - MCO Contract (document 1 of 3)

HEALTHRACK/EPSDT PERIODICITY SCHEDULE OF PREVENTIVE HEALTH SERVICES Department
of Social Services05/07

 
INFANCY
EARLY CHILDHOOD
AGE
NB
2-4 DAYS
 (1)
2 Weeks
2 mo.
4 mo.
6 mo.
9 mo.
12 mo.
15 mo.
18 mo.
24 mo.
3yr.
4yr.
'5yr.
Screening Components
                           
History: Initial/Interval
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Physical Examination (2)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Height/Weight
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Head Circumference
X
X
X
X
X
X
X
X
X
X
X
 
   
Blood Pressure
                     
X
X
X
Health Education (3) Anticipatory Guidance
SEE ATTACHED RECOMMENDATIONS
Developmental / Beh. Assessment (4)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Immunizations (5)
SEE ATTACHED IMMUNIZATION SCHEDULE
Hereditary Metabolic Screening (6)
X →
                     
Lead Screening (7)
           
X →
 
 
X
     
Hematocrit/ Hemoglobin
           
X →
W-HR
W-HR
X
W-HR
W-HR
W-HR
Cholesterol Screening
                   
HR
HR
HR
HR
Tuberculin Test
             
HR
HR
HR
HR
HR
HR
HR
Hearing Screening
O
S
S
S
S
S
S
S
S
S
S
S
O*
O
Vision Screening
S
S
S
S
S
S
S
S
S
S
S
O*
O
O
Initial Dental Referral (9)
                   
X →
   
Evaluate Dental Fluoride Access
         
X
X
X
X
X
X
X
X
X

Key:   X = To be performed; HR = To be performed for patients at risk; S =
Subjective, by history; O = By Objective Standardized Test (SNELLEN;
AUDIOMETRIC); ← → = The range during which a service may be provided, * If child
uncooperative, re-screen within 6 months. W-HR= Required by WIC. Covered for WIC
clients or high risk clients. Footnotes:   (1) For Newborns discharged less than
48 hours after delivery; (2) At each visit, a complete physical examination is
essential, with infant totally unclothed, older child undressed and suitably
draped; (3) Age appropriate/patient specific health education and counseling
should be part of every visit; (4) By history and appropriate physical
examination; if suspicious, by specific objective developmental testing; (5)
Childhood immunizations are based on age and health history, and should be
screened each visit. (6) Metabolic Screening (e.g., thyroid, hemoglobinopathies,
PKU,

EPSDT2001.DOC

1

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

Appendix C - MCO Contract (document 1 of 3)
HEALTHTRACK/EPSDT PERIODICITY SCHEDULE OF PREVENTIVE HEALTH SERVICES
Department of Social Services05/07

galactosemia) should be done according to State law. Sickle Cell Screening if
appropriate; (7) Further venous blood level measurement is required for children
showing elevated lead level (greater than or equal to 10 ug/deciliter of whole
blood); Children aged 2-5 should be screened at annual exam if there is no
record of a negative lead screen. (9)Earlier referral should be made if problem
indicated.
 

 
MIDDLE CHILDHOOD
ADOLESCENCE
Age:
6 yr.
7-8 yr. (b)
9-10 yr. (b)
11 yr.
12 yr.
13 yr.
14 yr.
15 yr.
16 yr.
17 yr.
18 yr.
19 yr.
20 yr.
21 yr.
*
Screening Components
 
 
 
                     
History: Initial/Interval
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Physical Examination (2)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Height/Weight
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Blood .iPressure
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Health Education    (3) Anticipatory Guidance
SEE ATTACHED RECOMMENDATIONS
Developmental / Ben. Assessment (4)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Immunizations (5)
SEE ATTACHED IMMUNIZATION SCHEDULE
Hematocrit / Hemoglobin
     
← (9) →
 
 
 
Urinalysis
     
← (10) →
Cholesterol Screening
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
Tuberculin Test
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
HR
Pelvic 'Exam/PAP Smear
     
← (11)
STD Screenings
       
← (12)
Healing Screening
0(8)
0(8)
O
S
O
S
S
O
S
S
O
S
S
S
Vision Screening
0(8)
0(8)
O
S
O
S
S
O
S
S
O
S
S
S
Evaluate Dental Fluoride Access
X
X
X
X
               
 
 

 
Key:   X = To be performed; HR = To be performed for patients at risk; S =
Subjective, by history; O = By Objective Standardized Test; <—» = The range
during at which a service may be provided; * Appropriate provision of EPSDT
services is required through age 20, up to, but not including, the 21st
birthday, (b) Biannually, at 2 year intervals. Footnotes:(2) At each visit, a
complete physical examination is essential with infant totally undressed and
older child undressed and suitably draped; (3) Age appropriate and patient
specific health education and counseling should be a part of every visit; (4) By
history and appropriate physical examination, if suspicious, by specific
objective developmental testing; (5) Childhood Immunizations are based on age
and health history and should be screened each visit. (8) State law requires
screening at school. Screening should be done if there is evidence it was not
done at school. (9) Hemoglobin or Hematocrit to be administered xl during
adolescence, annually for menstruating females that are at risk for anemia; (10)
Urinalysis to be administered xl during adolescence, annually for
sexually active clients at risk for STD's (i.e. gonorrhea, syphilis/serology,
chlamydia, HIV, etc.); (11) All sexually active females should have a pelvic
examination and a routine pap smear annually. A pelvic examination and routine
pap smear should be offered as part of preventive health maintenance between
18-21 years. (12) All sexually active patients should be screened for sexually
transmitted diseases (STD's) EPSDT2001.DOC

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

Appendix C - MCO Contract
Document 2 of 3
05/07

State of Connecticut
Department of Social Services
Health Care Financing Division
25 Sigourney Street
Hartford, CT 06106-5033

PB 2001-18   Policy Transmittal 2001-07 March 20,2001
 
Michael P. Starkowski Deputy Commissioner
Contact: James Linnane (860) 424-5111
Effective Date:  July 1. 2001

TO:   Physicians, Clinics, Hospitals, Managed Care Plans, Nurse Practitioners,
Home Health Agencies, Nurse Midwives, Dentists and Dental Hygienists

 
SUBJECT:     New EPSDT (Early, and Periodic Screening. Diagnosis and Treatment
Services)PeriodicityScheduleand Immunization Schedule

The Department of Social Services is revising the EPSDT Periodicity Schedule to
follow the recently issued American Academy of Pediatrics (AAP) guidelines. This
Policy Transmittal contains the EPSDT Periodicity Schedule that is to be
effective as of 7/1/2001 and a revised immunization schedule.   Please replace
the enclosed pages in Chapter 8 of your Connecticut Medical Assistance Provider
Manual. Changes to the periodicity schedule include the following:
 
-
A   newborn   hearing   screening   is   now   required  by   Connecticut   law   and   is
recommended by the AAP.    Therefore, this screening is being changed from a
subjective to objective screen on the periodicity schedule.

-
Infants at high risk for tuberculosis should receive a tuberculin test at 12
months, 15

-
months and 18 months.

-
Infants who have anemia at 1 year should be retested for it at 15 and 18 months.
a   A hematocrit/hemoglobin test has been added at age 2 in accordance with AAP
guidelines. The hematocrit/hemoglobin test should be repeated for high-risk
clients and WIC clients at age 3, 4, and 5.

-
The 3-year-old vision screening has been changed from subjective to objective.
An asterisk has been added indicating that if the child is uncooperative, he or
she should be rescreened within six months.

 

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

 
Appendix C - MCO Contract
Document 2 of 3 
05/07
-
Objective hearing and vision screenings have been added to the periodicity
schedule for ages 6 and 8. Section 10-214 of the Connecticut General Statutes
requires local or regional boards of education in Connecticut to provide these
screenings in kindergarten through sixth grade. Objective hearing and vision
screenings should be done by the Primary Care Provider (PCP) at age 6 and 8 if
there is reason to believe that the screenings were not done at school.

-
A note has been added that the screenings given at age 7-8 and age 9-10 should
be performed at two-year intervals.

The American Academy of Pediatrics recommends a prenatal visit to a pediatrician
for high-risk parents. Such a visit is medically necessary for the well-being of
a yet-to-be-born child and is a covered EPSDT service under Connecticut
Medicaid.

The new Recommended Childhood Immunization Schedule recommends administering
four doses of pneumococcal conjugate vaccine at age 2 months, 4 months, 6 months
and 12-15 months The immunization schedule recommends administration of "DTaP"
not "DTP" at age 2 months, 4 months, 6 months, 15-18 months and 4-6 years.
Hepatitis A appears on the immunization schedule as recommended in some parts of
the United States, but is not a recommended vaccine in Connecticut.

A new Women, Infants and Children (WIC) Coordinators contact sheet is also
included.

Posting Instructions: Holders of the Connecticut Medical Assistance Program
Provider Manual should replace the current EPSDT Periodicity Schedule,
Immunization Schedule and WIC Coordinators contact sheet with the attached
schedules and contact sheet for use effective 7/1/2001. Policy transmittals can
also be downloaded from EDS' Web site at www.ctmedicalprogram.com.

Distribution: This policy transmittal is being distributed to holders of the
Medical Services Policy Manual by EDS, and the Medicaid Mailing List by the
Department of Social Services. Managed Care Organizations are requested to send
this information to their network providers and subcontractors.

Responsible Unit: DSS, HUSKY, James Linnane, Manager, Program Analysis and
Enrollment at (860) 424-5111.

Date Issued: March 20, 2001

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

Connecticut Department of Social Services
Medical Assistance Program
Provider Bulletin

PB 2005-59                                                            November
2005

TO:                     Physicians, Nurse Practitioners, Freestanding Clinics,
Hospitals and Managed Care Organizations (MCOs)

SUBJECT:    Revised Immunization Schedule

This bulletin is being sent to inform you that the Department of Social Services
has revised the Childhood Immunization Schedule in the Provider Manual for
Providers listed above to be consistent with the latest immunization schedule of
the American Academy of Pediatrics, the American Academy of Family Physicians
and the Centers for Disease Control.

Changes to the Immunization Schedule include:

1)
Influenza immunizations are now recommended for all children age 6-23 months,
and all older children who are in households with children age 0-23 months or at
risk for complications from influenza.

2)         The recommendations for the timing of the Hepatitis B Series have
changed.

3)
Administration of PPV (pneumococcal polysaccharide vaccine) is now
recommended in addition to PCV (pneumococcal conjugate vaccine) for certain high
risk groups.

Further information about these changed recommendations is available at
http://www.cispimmunize.org.

MCOs are requested to send this information to their network providers and
subcontractors.

This bulletin and other program information can be found at
www.ctmedicalprogram.com.  Questions regarding this bulletin may be directed to
the EDS Provider Assistance Center - Monday through Friday from 8:30 a.m. to
5:00 p.m. at: In-state toll free 800-842-8440 or Out-of-state or in the local
New Britain, CT area 860-832-9259.  EDS Hartford, PO Box 299 CT 06104
                                                                                   

 

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[huskyimmunizationgraph.jpg]

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)
 

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Appendix D

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

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05/07

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 MCOoptions

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.

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05/07

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

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05/07

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
 
 

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05/07

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
   

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APPENDIX E
Standards for Internal Quality Assurance Programs

For Health Plans

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Appendix E - MCO Contract 05/07

STANDARDS FOR INTERVAL 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 overtime.

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.

Page l of 13(9/06)

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Appendix E - MCO Contract
05/07

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.

Page 2 of 13(9/06)

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Appendix E - MCO Contract
 
 
05/07

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.

Page 3 of 13(9/06)

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Appendix E - MCO Contract
05/07

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 l-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.

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Appendix E - MCO Contract
05/07

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.

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Appendix E - MCO Contract
05/07

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

Page 6 of 13 (9/06)

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Appendix E - MCO Contract
05/07

 
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.

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Appendix E - MCO Contract
 
05/07

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.

/.         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.

Page 8 of 13 (9/06)

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Appendix E - MCO Contract
05/07

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.

Page 9 of 13(9/06)

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Appendix E - MCO Contract
05/07

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

Page 10 of 13 (9/06)

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

Appendix E - MCO Contract
05/07

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; andherapies 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.

Page 11 of 13(9/06)

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Appendix E - MCO Contract
05/07

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, information sources and the process used to review and
approve the provision of medical 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.

Page 12 of 13(9/06)

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Appendix E - MCO Contract
05/07
 
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.

Page 13 of 13 (9/06)

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

APPENDIX F

Claims Inventory, Aging and Unaudited Quarterly
Financial Reports

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

Appendix F - MCO Contract
0507
(document 1 of 5)
Report #1
HUSKY A & B Unprocessed Claims in Dollars
Plan Name
Qtr. Ending:

 
Claims In Process During Qtr. (In Dollars) (1)
Claims Type
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
Mental Health
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 infonnation 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.

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

Appendix F - MCO Contract
(document 2 of 5)
Report #2
HUSKY A & B Volume of Unprocessed Claims
Plan Name
Qtr. Ending:

 
Claims In Process During Qtr. (# of claims) (1)
Claims Type
1-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Claims in Process During Qtr.
UB92 Claims
HCFA 1500 Claims
Subtotal MCO Claims
Pharmacy
Dental
Vision
Mental Health
Subtotal Vendor Claims
Total
                                       
323
             

 
Unpaid adjudicated (# of claims) (2)
Claims Type
1-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Total Unpaid Adjudicated Claims (# of claims) At the End of The Qtr.
UB92 Claims
HCFA 1500 Claims
Subtotal MCO Claims
Pharmacy
Dental
Vision
Mental Health
Subtotal Vendor Claims
Total
                         
0
                           

Claims Inventory
EQUAL TO OR  less than 45 days
Greater than 45 Days
     
MCO Claims
   
Pharmacy
   
Dental
   
Vision
   
Mental Health
   
Total
   

 
Estimated Claims Received but not in system (# of claims) (4)
Claims Type
1-30 Days
31-45 Days
46-60 Days
61-90 Days
91-120 Days
>120 Days
Estimated Claims Received but not in system
UB92 Claims
HCFA 1500 Claims
Subtotal MCO Claims
Pharmacy
Dental
Vision
Mental Health
Subtotal Vendor Claims
Total
                         
0
                           

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).

05/07

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

 
Appendix F - MCO Contract
(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
Mental Health
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
Mental Health
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
Mental Health
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
%
%

This report includes only paid claims, therefore it excludes denied claims.

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

05/07
Appendix F - MCO Contract
(document 4 of 5)
Report #4
HUSKY A & B - Claims paid in excess of 45 Days

Plan Name Qtr. Ending:

 
Claims older than 45 days paid during the Qtr.
Vendor(Pay To)
Claim #
Pay Amount
Allowed Amount*
Interest
Age of Claim (in Days)
   

Claim Count                                Pay Amount

Interest < 1.00

The following should be noted about this report:
It includes only paid claims and excludes denied or rejected claims.
It is sorted by provider, alphabetically
If an amount is used other than
* Allowed amount column has been Included in the report as a column, only if it
used to calculate interest.

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

05/07   

Appendix F - MCO Contract
(document 5 of 6)
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 1 2 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
     

page 1 of 4

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

05/07  

Appendix F - MCO Contract
(document 5 of 6)
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 1 1 from overflow page
 
1199
TOTALS: (items 1101 through 1 1 05 plus 1 1 98 page 3, item 1 1 )
 
 
   
 
Details of Write-ins Aggregated at item 21 for Other Net Worth Items
 
2101
   

page 2 of 4

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

05/07 

Appendix F - MCO Contract
(document 5 of 6)
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 8-1 5)
   
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
     

page 3 of 4

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

05/07  

Appendix F - MCO Contract
(document 5 of 6)
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)
 

page 4 of 4

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

APPENDIX G
HUSKY A MEDICAID COVERAGE GROUPS

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

05/07

Appendix G - MCO Contract

HUSKY A Medicaid Coverage Groups

Eligibility Code
Description
F01
Temporary Assistance to Needy Families (TANF)
F03
Transitional Work Extension
F04
Child Support Extension
F05
Work Supplementation
F07
Family Coverage (150 % FPL)
F08
Special Child Care Deduction
F09
Eligible for TANF except for Non-Medicaid Requirements
F10
Newborn Coverage
F11
Newborn Children
F12
CN Ribicoff Children
F13*
Children < 1, under 185 9 of the Federal Poverty Level (FPL)
F20*
Children 1-6, under 185 % of the Federal Poverty Level (FPL)
F25
Children under 185 % of the Federal Poverty Level (FPL)
   
F95
Children under 18, 18-21, and caretaker Relatives
P01
Pregnant Women -who meet TANF Financial Requirements
P02
Pregnant Women under 185 % of the Federal Poverty Level (FPL)
P95
Pregnant Women Coverage
M 01/M 02
Pregnant Women Extension (Post-Partum)
D01, D02, D 03, D 04
DCF Children

MCO Contract 1/06

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

APPENDIX H
BLANK
Reserved for Possible Future Use

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

APPENDIX I
CAPITATION PAYMENT AMOUNT

Table 1 – HUSKY A Capitation Rates Effective 010106-063006

Table 2 – HUSKY A capitation Rates effective 070106-063007

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

State of Connecticut   WellCare   Confidential

 
HUSKY A Capitation Rates (1/01/06 - 6/30/06)
Fairfield
Hartford
Litchfield
Middlesex
New Haven
New London
Tolland
Windham
All Counties
WellCare
<1 Male and Female
$         574.44
$        652.05
$        650.10
$        773.55
$           647.74
$              644.47
$        781.92
$        624.10
$         630.87
1-14 Male and Female
$           96.22
$         105.18
$         104.84
$         126.82
$           104.44
$              103.83
$         128.32
$         102.15
$         102.68
15-39 Male
$         123.65
$         135.99
$         135.56
$         162.53
$           135.08
$              134.35
$         164.36
$         132.42
$         132.95
1 5-39 Female
$        212.38
$        238.50
$        237.76
$        285.08
$           236.86
$              235.59
$        288.32
$        229.24
$         231.87
40+ Male
$        233.93
$        263.57
$        262.74
$        315.28
$           261.75
$              260.35
$        318.84
$        253.04
$         256.84
40+ Female
$        224.22
$         252.45
$        251.65
$        302.09
$           250.70
$              249.34
$        305.53
$        242.42
$         245.16
 
Total *
$          157.99
$         176.42
$        170.86
$         219.74
$           179.60
$             173.06
$        215.20
$        173.10
$         173.49

*Totals weighted on January 2006 through June 2006 member months

APPENDIX I
TABLE 1
HUSKY A Capitation Rates effective 010106 - 063006

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

State of Connecticut WellCare   Confidential

WELLCARE
Husky A Capitation Rates for SPY 2007 ( 7/01/2006 - 6/30/2007]
   
Fairfield
Hartford
Litchfield
Middlesex
New Haven
New London
Tolland
Windham
Under One
$         598.53
$         679.15
$         677.13
$         805.36
$         674.67
$         671.27
$         814.07
$         650.12
Ages 1 to 14
$          101.92
$         111.23
$         110.88
$          133.70
$         110.46
$         109.82
$         135.27
$         108.08
Male – Ages 15 to 39
$          130.17
$         142.99
$         142.54
$          170.56
$          142.05
$         141.29
$         172.46
$         139.29
Female – Ages 15 to 39
$         222.35
$         249.48
$         248.71
$         297.87
$         247.78
$         246.46
$         301.23
$         239.86
Male – Ages 40 and over
$         244.64
$         275.43
$         274.56
$         329.14
$         273.54
$         272.08
$         332.84
$         264.49
Female – Ages 40 and over
$         234.55
$         263.88
$         263.04
$         315.44
$         262.06
$         260.64
$         319.01
$         253.46

APPENDIX I
TABLE 2
HUSKY A Capitation Rates effective 070106 - 063007

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

APPENDIX J

BLANK

Reserved for Possible Future Use

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

APPENDIX K

INPATIENT/ELIGIBILITY RECATEGORIZATION CHART

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

0507
Appendix K - MCO Contract
HUSKY A&B

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
Θ
A1
HUSKY B to disenrolled due to loss of eligibility (Out of Program)
B1
Θ
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
Θ = Disenrolled due to loss of eligibility

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

APPENDIX L

PHARMACY REPORTS

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

05/07

 
Appendix L - MCO Contract (document 1 of 2)
 
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8 (cell description col 3)
 
Pharmacy Report #1
Prescription Request Process (Revision 10/05)
   
Name of MCO
Quarter Ending:
1.0
Total Prescriptions Filled by the MCO this Quarter
#
 
2.0
Total Member Months This Quarter
#
3.0
Number of Prescriptions filled Per Member Per Month
#VALUE!
 
Calc. field=total scripts/mm1.0/2.02
 
4.0
Requests for Prior Authorization
 
% of total prescription filled
   
4.1.
Total requests for Prior Authorization
#VALUE!
#VALUE!
Calc field: = 4.2+4.3+4.5.
4.2.
No Temporary Supply Dispensed
#VALUE!
#VALUE!
Calc field: = 4.2.2+4.2.3.
4.2.2.
No Temporary Supply - PA Approved
#!
#VALUE!
 
4.2.3.
No Temporary Supply - PA Denied
#
#VALUE!
4.3.
Temporary Supply Dispensed
#VALUE!
#VALUE!
Calc field 4.3.1+ 4.3.2.
4.3.1
Temporary Supply dispensed for PA of script with refill
#VALUE!
#VALUE!
Calc field: 4.3.1.1. + 4.3.1.2.
4.3.1.1.
TS for PA of script with refill - PA approved
#
#VALUE!
 
4.3.1.2.
TS for PA of script with refill - PA denied
#
#VALUE!
4.3.2.
Temporary Supply Dispensed for PA of script without refill
#
#VALUE!
Subset of 4.3
4.4.
Total requests for Prior Authorization that REQUIRE PA
#VALUE!
#VALUE!
Calc field:= total requests minus temp
Supply dispensed without refill; =4.1-4.3.2
4.5.
Other (refers to Prior Authorization disruption where "approve" or "deny" are
not applicable, i.e. prescriber provides a member a replacement script and the
original script remains unfilled, the member changes his or her plan membership.
#
#VALUE!
   
5.0.
Turn Around Time to Approve or Deny PA Request
           
5.1.
No Temporary Supply Dispensed
Less than 4 days
4-7 days
8-14 days
14+ days
5.1.1.
Approved PA request without Temporary Supply
#
#
#
#
5.1.2.
Denied PA Request without Temporary Supply
#
#
#
#
5.2.
Temporary Supply
#
#
#
#
5.2.1.
Approved PA request with Temporary Supply
#
#
#
#
5.2.2.
Denied PA request with Temporary Supply
#
#
#
#
   
6.0.
Turn around Time to approve Temporary Supply
Same Day
Next Day
More than the Next Day
 
6.1.
Urgent / emergent
#
#
#
6.2.
Unable to reach the provider within time limit
#
#
#
 
Directions - Definitions
   
This report is formatted in Excel. Enter amounts for each cell identified with
"#." The spreadsheet will calculate values in shaded cells.
 
Prior Authorization
Refers to those instances where an MCO requires a prescriber to obtain
authorization for reimbursing the cost of the drug when the drug is not on  the
MCO's formulary or the MCO requires prior authorization for a particular drug on
the MCO's formulary.
Temporary Supply
Refers to those drugs that require prior authorization that a pharmacist
provides a member when the pharmacist is unable to contact the prescriber for
justification or the prescriber claims the drug is urgent when the pharmacist
contacts the prescriber. Temporary Supply anticipates a PA decision on a script.
"With Refill" means the script has a refill. "With Refill" does not apply to the
temporary supply. "Without refill" applies to the script and not the temporary
supply.
Turn Around Time (TAT)
For PA - refers to the time between the time when the Pharmacist enters the
script in the system and the time when the PBM authorizes the script.
For Temporary Supply - refers to the time between the time when the Pharmacist
enters the script in the system and the time when the Pharmacist dispenses the
temporary supply.

 
 

Appendix L - MCO Contract - document 2 of 2 05/07
Pharmacy Report # 2
Top 30 Drugs - by Number of PA Requests Denied Revision 10/05

Name of MCO:
Quarter Ending:
     
Directions: This report is formatted in Excel. Enter the MCO name, quarter
ending and blank cells, as appropriate for each drug listed. The spreadsheet
will calculate the shaded cells.
Number of Authorization Reviews Completed this Quarter
Percent of Authorization Reviews Completed this Quarter
 
Reason for Denial
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
Rank
Name of Drug
Therapeutic Class
Total
Number Approved
Number Denied
Percent Approved
Percent Denied
Number of Temporary Supply
Inappropriate Diagnosis
Equally Effective Alternative on Formulary
Medical Necessity not Established
Lack of Information
Other
1
         
#DIV/0!
#D!V/0!
           
2
         
#DIV/0!
#DIV/0!
           
3
         
#DIV/0!
#DIV/O!
           
4
         
#DIV/0!
#DIV/0!
           
5
         
#DIV/0!
#DIV/0!
           
6
         
#DIV/0!
#DlV/0!
           
7
         
#DIV/0!
#DIV/0!
           
8
         
#DIV/0!
#DIV/0!
           
9
         
#DIV/0!
#DIV/0!
           
10
         
#DIV/0!
#DIV/0!
           
11
         
#DIV/0!
#DIV/0!
           
12
         
#DIV/0!
#DIV/0!
           
13
         
#DIV/0!
#DIV/0!
           
14
         
#DIV/0!
#DIV/0!
           
15
         
#DIV/0!
#DIV/0!
           
16
         
#DIV/0!
#DIV/0!
           
17
         
#DIV/0!
#DIV/0!
           
18
         
#DIV/0!
#DIV/0!
           
19
         
#DIV/0!
#DIV/0!
           
20
         
#DIV/0!
#DIV/0!
           
21
         
#DIV/0!
#DIV/0!
           
22
         
#DIV/0!
#DIV/0!
           
23
         
#DIV/0!
#DIV/0!
           
24
         
#DIV/0!
#DIV/0! .
           
25
         
#DIV/0!
#DIV/0!
           
26
         
#DIV/0!
#DIV/0!
           
27
         
#DIV/0!
#DIV/0!
           
28
         
#DIV/0!
,.#DIV/0!
           
29
         
#DIV/0!
 #DIV/0!
           
30
         
#DIV/0!
#DIV/0!
             
Subtotal
0
0
0
#DiV/0!
WDIV/0!
0
0
0
0
0
0
All other requests for PA
     
#DIV/0!
#DIV/0!
           
Total of all requests for PA
0
0
0
#DIV/0!
#DIV/0!
0
0
0
0
0
0

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

APPENDIX M

RATE CERTIFICATION

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

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

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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

State of
Connecticut                                                             Page
6                                                           01/26/06

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

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

State of
Connecticut                                                             Page
7                                                           01/26/06

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

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

State of Connecticut                        Page 9                     01/26/06

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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

1 of 11 HUSKY A B Appendix O - BHP Master Covered Services Table 05/01/07]

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

 
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

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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*

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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

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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

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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

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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

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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

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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 11HUSKY A B Appendix O - BMP 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
 
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 11HUSKY A B Appendix 0 - BHP Master Covered Services Table 05/01/07]